The original idea behind the well-recognized “tragedy of the commons” has been traced to Thucydides and to Aristotle, which philosopher noted that: “that which is common to the greatest number has the least care bestowed upon it.” Its “modern” use can be traced to William Lloyd who described a specific example in his “Lecture on the Notion of Value” in 1833. He observed that when pastureland was held in common (a practice that existed in Boston, where I grew up, and which still has “the Boston Common”, though it is a public park, not pastureland anymore) – cattle owners have a short-term interest in having all their cattle graze on it. Unfortunately, when all do so, the commons are soon overgrazed, and the common pasture becomes worthless for all.

This “tragedy” has been cited as the major reason for there being a healthcare cost crisis. Because the costs of healthcare are paid “in common”, i.e. by having populations insured against their personal need, use, and costs for such care, everyone takes little care to keep the commons in good shape. They permit themselves to get unhealthy and expect others to pay for it, while not prudently purchasing sickness care, but “splurging” on the best that insurance will pay for, since they share so little in the costs of doing so.

There is no question that people who have little personal reason to manage their health well, or their sickness care prudently, are likely to be more careless about both than those who have to pay all costs out of their own pocket. Of course, it is equally true that those who have to pay all costs out of their own pocket are not any healthier than those who do not, and use a lot of health care anyway, particularly ER care where they cannot be turned away for having no money. Moreover, it has generally been shown that except for people with extreme cases of hypochondria or Munchausen’s Syndrome, people seek and use sickness care only when they think they are sick, not for a lark.

The tragedy also has been described as applying to providers of sickness care. Most patients are protected against personal costs by the “commons” of health insurance, once even more “common” when it was based on community vs. the current experience rating. Because more aggressive, or just more sickness care will not add significantly to patients’ personal financial burden, providers feel comfortable about offering and delivering “the best”, even when it does not add to patients’ likelihood of benefiting from it.

Physicians get paid for “procedures”, so when they benefit personally, while patients don’t suffer personally from a few more, critics argue, they tend to prescribe and deliver a few extra. Hospitals create facilities that are comparable to luxury hotels and resorts in their hell-bent efforts to capture a larger share of well-insured patients. Why should patients complain if it doesn’t add to their costs? In fact, they seem to prefer the best possible surroundings and amenities, whether or not these add to the quality of their care and outcomes.

Regardless of how much the tragedy of the commons as applied to healthcare consumers is a cause of the cost crisis, there is another tragedy of the commons that applies to healthcare payers, as well. Governments, commercial insurers, and most employers still pay for people’s healthcare costs, collectively, while often fighting with each other over who is liable in particular cases. Ultimately, they suffer such costs in common, though at different times, and for different populations of people.

Why isn’t and hasn’t it been for a long time the most logical and financially prudent thing for them to do to invest heavily in health promotion, risk behavior and condition prevention, and chronic disease management? Why is so little done to promote healthy childhood for the youngest among us, so that children do not bring to school or later to work the kinds of chronic diseases that account for roughly 75% of all sickness care expenditures. Why do employers not invest in school health programs so that the entering workforce will be healthier? Why did not employers invest more heavily in workers’ health knowing (as Adam Smith did 250 years ago) that healthier workers produce and perform better?

Why has it taken the past decades of worsening health, and the looming crises of Medicare, employer-paid health insurance, Medicaid, labor shortages, and Social Security to finally prompt the growing movement toward prevention and health promotion rather than spending over 95% of our mislabeled healthcare system resources on dealing with sickness? Is it not precisely the same kind of individual myopia that causes overgrazing on common pastureland, and overuse of commonly paid healthcare by consumers?

It can only be assumed that employers hope that schools and parents or local governments do a good enough job at protecting the health of children as they grow up to keep them from being in too bad a shape when they join the workforce. Commercial insurers must hope that employers do a good job or at least that whoever covered their new enrollees did so before their new members join. State and federal governments rely on the “good offices” of local governments, employers, or commercial insurers to see to it that Medicaid and Medicare beneficiaries are not too sick by the time they become eligible.

Of course, no such “commons”-focused behavior has been evident among payers. Each seems to hope that one of the others will take care of the problem, since investing in a solution themselves costs money. When employers, insurers, and governments are focused on this quarter’s income statement or this year’s budget and voter unrest, or making political hay out of reducing taxes, none seem able to look past their immediate, individual interests and problems to recognize that there is a common problem, or that common coordinated action might help solve, or even better prevent it.

The combination of the two tragedies, not that applying to consumers alone has brought us to the looming disaster we all face now. It can only be hoped that payers, as well as consumers will recognize how their myopic thinking and actions with respect to this common problem have contributed to it, and how their more far/wide-seeing, if late recognition of the potential for addressing the crisis jointly might be the right way to go……finally. The recent emergence of the UAW as a major payer for healthcare services adds yet another source of potential collaboration, thanks to the voluntary employees beneficiary association (VEBA) that figures to increase in popularity as employers opt out. But it is employers who gain productivity and performance improvement from healthier employees, so they should not abstain from being part of a common effort.