The Tragedy of the Commons

            The Tragedy of the Commons is a situation where a shared resource is overused.  Typically this happens when members of a group fail to communicate about their mutual needs, or self-interest overshadows the common good.

            The most visible examples of a shared resource being misused involve natural resources like water, air, or forest.  Far less often will you hear health insurance mentioned as a Tragedy of the Commons.  Of course, health insurance is usually designed to discourage near term overuse (deductibles, copays, and coinsurance.)  Unfortunately, these short term incentives have had little effect on behaviors that create delayed demands (heart disease, cancer, etc.) for high-cost services.

            If not familiar with the Tragedy of the Commons, the classic example of a shared pasture for grazing makes the point.  In the beginning, each farmer is allowed to graze his cattle in a shared pasture as much as desired (to his own benefit). Eventually, the cattle exceed the carrying capacity of the land and can no longer support the herds.  To the detriment of all parties involved, soon not enough grass grows anywhere resulting in a “tragedy to the commons.” In this tragedy, there are no villains.  Rather, each farmer did what made the most sense for himself given a free range that encouraged self-interest without accountability for the greater need.

            Within healthcare, the Tragedy of the Commons appears in the form of insurance that all pay into and withdraw from without regard to the limits of affordability for the group.  Within this system, providers, patients, and payers each compete for resources and often seek to do what is in their best interests, regardless of cost or effectiveness.  While there may be an occasional villain in this system, most are doing what a system designed for acute medical care requires.  By way of analogy, imagine a system where insurance covered all car repairs regardless of the cause.  Some would drive till the wheels fell off and then turn to a specialist trained to put wheels back on cars with mangled axels.  Personal choices that affect long term healthcare needs are not so different.  The annoying dilemma is that a harmful lifestyle may feel pretty good in the beginning.  Unfortunately, the ultimate cost to the common pool of insurance resources can be very high.

Although I belong to several medical organizations, I credit The American College of Lifestyle Medicine (ACLM) for providing the guidance needed to help avoid the Tragedy of the Commons in our healthcare system.  Because of their guidance to policymakers, I see hope that we can create a healthcare system that is affordable and of high quality in the years to come.

As counterproductive as it may seem, most of the initiatives coming from policymakers today focus on how to make the existing system of care more efficient at serving sick people rather than how to reduce the demand by keeping people healthy.  While the efficiency of the existing healthcare system could certainly be improved, the possible gains are not as great as might be expected.  The dilemma is that for all of the efficiency that’s possible in producing automobiles or cell phones on a production line, human beings don’t fit the production line concept.  No two people are the same, and when acute health events happen, they happen at random times.  Think of it as the difference between building custom cars one at a time vs. a Detroit factory producing a hundred thousand of the same model. The custom car may cost several hundred thousand dollars compared with the production line car that cost a few tens of thousands of dollars.

Ken Beckman, a healthcare actuary and member of ACLM, summed up the situation in a Washington Post Op-ed.  “Lifestyle Medicine is the missing link in the ongoing health care reform debate. The research evidence is clear that conditions such as heart disease, Type 2 diabetes, high blood pressure, arthritis, and erectile dysfunction do not have to be permanent or treated with prescription drugs, but in many cases, can be reversed simply by using whole food plant-based nutrition. Rather than trying to figure out who is going to pay for the ever-increasing care costs, the focus needs to be on reducing demand for healthcare by reversing chronic disease. A Lifestyle Medicine-first approach to health care will stop the present protocol of managing chronic conditions using prescription drugs and preventative measures that fail to address the underlying cause of disease, which is draining the pocketbooks of Americans.”

Indeed, until the underlying root causes of chronic disease are addressed, more disease will be diagnosed, costs will continue to increase and no amount of preventative screening or care coordination will change that.

            The solution involves unwinding decades of entrenched corporate and Government policy.  More importantly, it will require a public that understands that more insurance options are not the answer.  Rather, the availability of lower-cost insurance will be the hallmark of a healthcare system that offers longer lives with a better quality of life.

            Points to Ponder in ACLM’s Recommendations

  • The US currently spends 18% of its gross national product ($3.35 trillion) on health expenditures.   The Federal Congressional Budget office estimates Medicaid and Medicare alone will account for 20% of the GDP by the year 2050, placing the US at risk of financial insolvency.
  • 80% of non-communicable diseases such as type-2 diabetes, heart disease, stroke, hypertension, cancer, and osteoporosis are preventable primarily through lifestyle. 
  • Lifestyle intervention for type-2 diabetic patients can be almost six times more effective than traditional diabetes support and education.
  • Of all healthcare dollars spent, 86% are attributable to chronic conditions that are mostly attributable to lifestyle causes.
  • The ability of US companies to compete in international trade is negatively affected by the high healthcare cost.

            The full details are in a report titled, “ACLM’s recommendations to the Senate Committee on Health, Education, Labor, and Pensions (HELP).”  While the details in the report are more than you may care to read right now, I hope that when you cast your vote, you will compare your candidate’s platform with the ACLM recommendations.  Better yet, mail a copy of the ACLM’s recommendations to your representatives along with the question, “Where do you stand on these important issues?”  When elected official know you care, they care.  In healthcare, The Tragedy of the Commons can be avoided if enough take action.

It is important to appreciate that in healthcare, the Tragedy of the Commons is inevitable unless doctors, patients, insurance companies, and governing bodies all recognize the peril of inaction.  Doctors must educate patients about the consequences of lifestyle choices and potential harm from risky procedures.  Patients must learn to choose wisely from the available medical alternatives.  Governing bodies will need to invest in research to identify the most effective recommendations and where possible incentivize wise individual choices. Hopefully, we can find a way to have these conversations in a way that leads to a sustainable and affordable “healthcare commons.”

Nancy Neighbors, MD

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The Tragedy of the Commons in Healthcare

Spinach and Mushroom Lasagna

            Love lasagna? This favorite Italian dish has been transformed into a heart-healthy classic, with whole-grain noodles layered with a vitamin-rich filling of spinach, mushrooms, and roasted garlic. This recipe makes enough to feed a crowd, so it’s perfect for a big get-together or potluck–or just plenty of delicious leftovers!  It’s easy to make the oil-free Roasted Garlic puree called for in this recipe. Besides adding appetizing flavor, garlic is packed with phytochemicals and antioxidants that promote heart health.  Click here to view the recipe.

Published by Nancy Neighbors, MD

... Dr. Neighbors provides a blend of traditional family medicine and evidence-based lifestyle medicine in Huntsville, Alabama. When indicated, lifestyle change is recommended as the first line of therapy.

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