Bureaucracy As Active Ingredient

By Scott Alexander

Commenters on yesterday’s post brought up an important point: sometimes bureaucracies aren’t just inefficient information gathering and processing mechanisms. Sometimes they’re the active ingredient in a plan.

Imagine there’s a new $10,000 medication. Insurance companies are legally required to give it to people who really need it and would die without it. But they don’t want somebody who’s only a little bit sick demanding it as a “lifestyle” drug. In principle doctors are supposed to help with this, but doctors have no incentive to ever say no to their patients. If the insurance just sends the doctor a form asking “does this patient really need this medication?”, the doctor will always just check “yes” and send it back. Even if the form says in big red letters PLEASE ONLY SAY YES IF THERE IS AN IMPORTANT MEDICAL NEED, the doctor will still check “yes” more often than a rational central planner allocating scarce resources would like. And insurance companies are sometimes paranoid about refusing to do things doctors say are important, because sometimes the doctor was right and then they can get sued.

But imagine it takes the doctor an hour of painful phone calls to even get the right person from the insurance company on the line. Now there’s a cost involved. If your patient is going to die without the medication, you’ll probably groan and start making the phone calls. But if your patient doesn’t really need it, and you just wanted to approve it in order to be nice, now you might start having a heartfelt talk with your patient about the importance of trying less expensive medications before jumping right to the $10,000 one.

Organizations have a legal incentive not to deny people things, because the people involved can sue them. But they have an economic incentive not to say yes to every request they get. Seeing how much time and exasperation people are willing to put up with in order to get what they want is an elegant way of separating out the needy from the greedy if every other option is closed to you.

This story makes sense and would help explain why bureaucracy gets so bad, but I’m not sure it really fits the evidence. Some of the worst bureaucracy is around places like the Department of Motor Vehicles, which doesn’t lose anything by giving you a drivers license and isn’t interested in separating out people who really want licenses from people who only want them a little. If the DMV can be as bureaucratic as it is without any conspiratorial explanation, maybe everything is as bureaucratic as it is without any conspiratorial explanation.

But this sort of thing does explain rituals like doctor’s notes for back pain or ADHD diagnoses for stimulants. Maybe it fits better with metaphorical bureaucracy than with literal ones. Or maybe it’s a factor that disincentivizes existing bureaucracies from getting better. I’m not sure and I don’t want to extend the idea further than it will go. It just seems kind of plausible.