Right, Privilege—or Tragedy of the Commons?
Matthew M. Davis, MD, MAPP, is associate professor of pediatrics, of internal medicine, and of public policy at the University of Michigan in Ann Arbor and co-director of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program. In February, he coauthored a commentary in the Journal of the American Medical Association that asked, to paraphrase: Why does the United States ensure universal access to basic, life-saving treatment in emergency rooms but not to more cost-effective, comprehensive, and preventive treatment, and how can it achieve the latter? The RWJF Human Capital Blog asked Davis and his coauthors, both RWJF Clinical Scholars, as well as others from RWJF programs, to respond to the question. Davis’ response follows. Read all the blog posts in this series.
The debate about whether health care is a right or a privilege is familiar and polarized. A quick online search in this topic area yields strong statements, deeply held convictions, and stern admonishments for those who hold opposite views.
As RWJF Clinical Scholars Kate Vickery, MD, and Kori Sauser, MD, (2012-14) point out in their recent blog posts, primary care physicians and emergency physicians can agree that the Emergency Medical Treatment and Active Labor Act (EMTALA)—by focusing exclusively on assuring access to emergency care—fails to ensure that health care is a right for all individuals in the United States across all health care settings.
As the three of us wrote in a Journal of the American Medical Association commentary earlier this year, the Patient Protection and Affordable Care Act (PPACA) will likely fall short of ensuring health-care-as-a-right-for-all as well. That’s largely because one-to-two dozen Americans (or more) will likely remain uninsured even with implementation of all of the coverage provisions of the PPACA. Congress did not have the appetite for even broader coverage initiatives that were considered in PPACA discussions but ultimately left out of the legislation.
If federal legislation falls short of ensuring health care as a right, does that mean that the American public is more comfortable with the idea of health care as a privilege? This is an answerable question. But to respond with data and carry on the debate is to perpetuate the idea that answering the right-vs-privilege question will somehow unshackle the argument from polemics and transport the U.S. to a more functional health care system. I’m not sure that it will.
In fact, I believe that the right-vs-privilege argument actually distracts politicians, health care professionals, and the public from a more fundamental, pressing concern.
From my perspective as a policy researcher and the chief medical executive for the state of Michigan in the Department of Community Health, whether health care is a right or a privilege does not alter the fundamental challenge of allocating scarce resources in the U.S. health care system. Either way, as a country the United States must deal with the fact that the health care workforce, facilities, and funds are available only in finite quantities. By failing to coordinate, systematize, or otherwise organize individuals’ pursuit of their rational goals in the world of health care, the U.S. population is mis-using its common resources related to health.
In this context, misuse occurs by many people and organizations with many different interests, with respect to many resources—for example: prescribing brand-name medications when generic substitutes would be equivalently effective at lower costs; opting for subspecialty care when primary care management would be more efficient; accessing emergency care and hospitalization for ambulatory-care-sensitive conditions when timely access to primary care would be of greater value; health systems’ investment in new therapeutic modalities for limited groups of patients instead of enhancing availability of existing, evidence-based approaches for large groups of individuals in the population; spending on intensive end-of-life care when advanced directive conversations earlier in patients’ lives would have indicated some individuals’ preferences for comfort care only.
Consequently, individuals in the U.S. cannot uniformly maximize their health and therefore the aggregate population health is less than optimal. Instead, some individuals get to optimize their health while others are denied such opportunities; inefficiencies, inequities, and persistent disparities result. In other words, it seems that the U.S. health care system has many aspects of a tragedy of the commons.
Influential economist Adam Smith famously argued (hundreds of years ago) that individuals’ rational pursuit of their own individual goals would lead to maximization of the benefits of a free market for the entire population. Biologist Garrett Hardin countered (in 1968) that, in cases where resources are scarce (his example: cattlemen taking advantage of their herds grazing on common property), unfettered individual actions—even while rational on an individual basis—will collectively degrade and diminish collective resources. Hardin called this situation the ‘tragedy of the commons,’ and anticipated ‘ruin to all’ if appropriate regulation were not imposed to shepherd common resources and thereby control individuals’ behavior that would be harmful to others (and ultimately to themselves) through depletion of resources.
The general response to a tragedy of the commons is to regulate access to the common resources. Regulation can take many forms, not all of which involve larger government. For example, one response is to keep a common resource (e.g., forest preserve) as public property and allocate the right to access (based on strategies such as proportional use, uniform use, or even an auction system), but another is to privatize the property and place the incentive to protect the property and control access in owners’ hands. Another response is to hold property communally (i.e., as an organized group of private owners) and allocate rights to access through that community of owners.
In health care, many peer nations of the U.S. appear to employ the public property strategy to manage the tragedy of the health care commons. For example, in the United Kingdom, government ownership of most health care facilities and payment of health care providers allows the government to control access to those key resources for the population. Even in countries that have greater presence of private medical facilities (e.g., Germany), there is still a robust government-financed system designed to ensure timely and appropriate access to care through management of a set of core organizational and personnel resources.
It is not surprising that the U.S. has not pursued a similar strategy for marshaling and managing its health care resources to optimize population health. After all, the free market ideals of Adam Smith and other economists strongly influenced the enshrinement of capitalist principles at the core of American political and economic thought and practice. Individuals, and their rights to pursue their self-interested goals, are prized in the American mind.
Whether the core debate in U.S. health care can be shifted from the individual (right vs. privilege) to the community (tragedy of the commons vs. managing common resources) remains a key question. While the PPACA certainly includes provisions designed to shift the sense of coverage from a privilege to a right, it is not clear that the U.S. health care system will achieve transformational change until the policy plane shifts from the individual to the collective.
Before there can be agreement about how to address a tragedy of the commons in health care, there must be a perception that there is a commons in health care—and that the commons is being depleted in its resources that key, politically active individuals and communities want and need to optimize their health.
 Vickery KD, Sauser K, Davis MM. Policy responses to demand for health care access: from the individual to the population. JAMA. 2013;309:665-666.
 Smith A. An inquiry into the nature & causes of the wealth of nations. First published in 1776; Bantam Classics, 2003.
 Hardin G. Tragedy of the commons. Science. 1968;162:1243-1248.