Uncertainty, Isomorphism, and the Birth of a New Industry

Abstract

The regulation of assisted living in the United States calls out for the attention of policy researchers, particularly in light of projected demographic changes reflecting dramatic increases in the nation’s senior population, the industry’s continued strong presence, and persistent concerns over related quality and consumer protection issues. Despite these factors, few comprehensive studies have been done on the development of regulatory policy for this relatively young industry that is a vibrant part of the health care services area in the United States. To address this issue, this article provides a systematic accounting and investigation of the regulatory environment and related policy development surrounding assisted living across the United States during a decade of formidable growth in the industry. Drawing on theories of institutional dynamics and policy formation, the findings reveal that, in terms of adopting regulatory schemes addressing key issues of quality and consumer protection, states do not always follow patterns that would be predicted under current models. Unanticipated patterns illustrating resistance to or movement away from isomorphism appear linked with a number of organizational pressure mechanisms that have evolved to limit the actual extent of this homogeneity. The findings lead to assertions that some mechanisms typically posited as contributing to isomorphism may actually work against this process under certain conditions, a result not currently evident in the literature.