The Dictatorship of the Precariat?

We are witnessing an intensifying and transformative battle over the sick-care factors of production.

Traditionally, economists define the four factors of economic production as land, labor, capital, and entrepreneurship. History is replete with wars, conflicts, and political shifts that reflect those on the right battling for control with those on the left i.e, the rulers and the privileged classes versus the working classes. This year marks another anniversary of the beginning of the Spanish Civil War (1936-39), the warm-up for World War II.

Sick care is in the midst of a battle between those who want to run medicine and those who actually deliver the care. In Marxist sociopolitical thought, the dictatorship of the proletariat refers to a state in which the proletariat, or the working class, has control of political power. The term, coined by Joseph Weydemeyer, was adopted by the founders of Marxism, Karl Marx and Friedrich Engels, in the 19th century. In Marxist theory, the dictatorship of the proletariat is the intermediate system between capitalism and communism, when the government is in the process of changing the ownership of the means of production from private to collective ownership.

Some have identified a new class, the precariat In sociology and economics, as a social class formed by people suffering from precarity, which is a condition of existence without predictability or security, affecting material or psychological welfare. Unlike the proletariat class of industrial workers in the 20th century who lacked their own means of production and hence sold their labor to live, members of the Precariat are only partially involved in labor and must undertake extensive “unremunerated activities that are essential if they are to retain access to jobs and to decent earnings.” Specifically, it is the condition of lack of job security, including intermittent employment or underemployment and the resultant precarious existence.

Physicians and other sick care workers, be they full time or members of the sick-care gig economy, independent or employed, are overburdened with administrivia and rules imposed by second-guessing bureaucrats and managers and policy wonks who are intent on justifiably controlling costs that threaten not just the national treasury, but the social fabric of communities. Recently announced double-digit health insurance premium hikes for individual policies, for example, in many rural and mountain communities force residents to make choices between rent, food, or medicine or leave where they and their families live.

I believe that the battle lines will continue to evolve because of the following forces:

1. Doctors as knowledge technicians will evolve into physician entrepreneurs and leaderpreneurs not just to add move value, but to survive.

2. Clinical decision support systems will get faster, smarter, and cheaper.

3. Clinical decision support systems will morph into administrative and fintech (financial technology) support systems to relieve knowledge workers of some of the non-value added heavy lifting.

4. The health data problems will be solved

5. Patients will get smarter and help solve some of their own problems through the widespread adoption, dissemination, and democratization of DIY medical technologies.

6. Power shifts and conflicts will intensify and be a battle between multiple forces, including rule makers, sick-care workers, patients, payers, and other members of the medical-industrial complex will intensify. Understanding the shifting forces will be as hard as understanding who is righting whom in present day Syria.

7. As resources shrink and the demand for medical services intensifies, so will the war for control

8. Present day recruits, i.e. medical students and residents, who are eager to man the barricades are ill prepared and under-armed to fight.

9. No battle plan will survive the first shot.

10. There will be no clear victor, rather an uneasy, precarious alliance, which, in many instances, will consist of strange bedfellows.

Much like the dictatorship of the proletariat, a dictatorship of the precariat is unlikely to be successful. In the new war, those who can control, secure, analyze, and produce value through the other factor of production, information, and decision making, will have a strategic advantage and that should come as no tactical surprise.