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“I’m hearing more about getting more people covered,” he said. “I think they should do what they need to do to get elected, [but] . . . getting the costs down is the most important thing.” (Voters have big health worries…. Washington Post)

The concept of “the commons” is not an easy one for Americans to grasp. The concept of the commons originated in England. Sheep were (and are) owned by people but the grazing area was (and is) owned by the community. It was pointed out by William Lloyd that while there was an advantage to the individual to have a bigger herd (more money from wool), collectively the community would suffer as the land was overgrazed. Garret Hardin pointed out the problem of individuals acting in rational self-interest by claiming that if all members in a group used common resources for their own gain and with no regard for others, all resources would still eventually be depleted. Writing in the journal Science, he felt that relying on conscience as a means of policing commons was problematic as it favors selfish individuals – often known as free riders – over those who are more altruistic.

The median American spends under $300 on health related expenses in a given year. However, the average American spends $10,000.  How is this? It is because  5% of the population account for half of all health spending. The 5% of people who spend the most on health care spend an average of around $50,000 annually; people in the top 1% have average spending of over $109,750.  Getting into the top 1% is kind of a random thing. You get bad cancer…you are there. You have a baby, you are not there but you move from $300 to $11,000 for that year. If you have the unfortunate luck of having your baby early…boom, your baby just hit $1,000,000.

So, in the The Affordable Care Act was designed, in part, to address the “free rider” problem in health care. Turns out almost everyone is willing to pay $300 for their healthcare every year. Almost nobody can pay over $100,000 when they randomly get cancer. What people are inclined to do is take advantage of the fact that other folks are paying into a system to support cancer care and then, when they get cancer, show up and  assume “it’ll get paid for.” The problem of the commons. The mandate was put in place to make us all pay for it to be there. Also, to make us all aware that the way we have it set up is very expensive and inefficient.

What we have made explicit through the Obamacare mandate is that the admission to the healthcare commons costs working families about $17,000 a year. On top of that about a third of our tax dollars are going into paying for the healthcare commons. Given the small amount Americans see themselves taking in a given year, it is no wonder they resented the mandate. On top of that, the value we receive is much less than what citizens of other countries get. On average they live longer, are healthier, and report fewer problems than Americans. They pay about half (or less) of what we do as well.

In the analogy of healthcare as a commons, who is getting rich?  Unlike sheep, sick Americans are not left to graze alone. Although there are now “free riders” because the mandate has been removed, this is only a small part of the problem. Turns out that our “grazing” is directed by doctors and hospitals motivated by the profit motive (with no price transparency), pharmaceutical companies advertising high cost medications directly to the consumer (with no price transparency) and people with limited health literacy who are making decisions based on fear, misinformation, and who are given guidance by folks who profit from the consumers ignorance. Other aspects of Obamacare, designed to fix these problem, are either not being implemented or being held in check by powerful interests (doctors, hospitals, pharmaceutical companies).

Which brings us to the the tragedy of the healthcare commons. We as a country are about to enter into a time where we spend more on healthcare than the average person makes. In England, to this day, there are all sorts of rules about who can use the common land and how many ducks, sheep, and the like he or she may put on the land. In America, we declare where our cows are to be a “sovereign state” and shoot at those who try to enforce the rules of the commons. One Republican Senator said of the  folks engaged in rule-breaking, “These people are patriots.”

We thought the individual mandate addressed free-riders. The reality is that the person with no health insurance who gets in a car crash or gets bad cancer is only part of the problem. The real “free riders” are those who profit but have no responsibility for the upkeep of the commons. The controls needed are not to keep people from consuming healthcare. The real need is for controls on those who would profit from folks who are scared, hurt, and confused about how to use a broken system. There are many ways for these controls to be put into place. The question is do we have the strength as a country to enforce such controls or do we declare those folks who profit at the expense of all of us patriots?