Requiring people to purchase health insurance is a central feature of the Affordable Care Act; it is also a red flag to the extreme conservatives in the Republican Party, popularly known as the Tea Party. Constitutional issues have been raised about this requirement, but there is little discussion of why it is necessary for all Americans to be insured and why it is necessary for us all to do our fair share. What follows is a way to show why free riding is not appropriate when it comes to health insurance.

Everything old is new again, at least according to the satirical songwriter Randy Newman. As C. Wright Mills put it in the 60’s, there are problems associated with overdevelopment, which was a nice twist on the conventional concerns of the era about newly emerging nations, their underdeveloped state, and how far behind they were economically and politically compared to North America and Western Europe. I co-edited, with Edward Sagarin, an anthology of articles devoted to that premise that was published in 1972. With acknowledgment to Mills in the introduction, this collection was subtitled: “Private Troubles and Public Issues”.

Writers of the time other than Mills provided inspiration for the book. John Kenneth Galbraith talked about problems associated with generalized affluence, the failure to create appropriate public facilities, and the conditions related to the punishing economic impact on the environment. Being slightly ahead of our time, Ed and I also had contributions from writers about the impending ecosystem degrading we were to face as a result of the population explosion, air pollution, and the unbalanced environment. This was an age where it was believed that big things could be done in our rich society for the good of all. There was a feeling of empathy and mutuality in the air; and, of course, a need to raise public issues to the national agenda. Ed and I didn’t address how, as a nation, we might become concerned about particular social problems, although I did write about how the contemporary “self” had something to do with being aware that something had to be done to put this nation on the right path.

There was one article in that collection on social problems that stands out as sensitive to the need to change how we think politically and continues an arc from the early history of capital formation and the subsequent fallout to our current situation. In drawing attention to overpopulation, Garrett Hardin, a distinguished biologist, introduced the concept that holds true today—that there is a “Tragedy of the Commons.” There is not quite a one-to-one correlation between population increases and threats to our well being, mainly because population growth is not as out-of-control as it was in the early 1970s, but there are new problems related to a world of increasing expectations regarding what constitutes appropriate life styles in affluent societies, continued dependence on older forms of energy, and the shifting health-care needs of aging populations. Today we call sustainability of our well-being the problem, whether it is continued increases in global temperatures or the unending rises in health care costs. Hardin was right that the solution to these threats depend on political agreement that these conditions can be reversed, and that it is necessary to alter these conditions. The American “can-do spirit” has to be called upon to create a better alignment between people and the ecosystem.

To get to political agreement requires changes in how we think about continued threats to the Commons.  There is some concern expressed through some small-bore efforts to reduce the presence of waste through changes in legal codes. In contemporary city and suburban life, the idea of the Commons has taken hold sufficiently in a minor, but not completely trivial way, so that dog owners are required to scoop up the turd their dogs produce. Still, there are dog owners who defy the law because it is very unenforceable, even when it smacks of civic virtue.

Some urban Americans rise to the occasion and use the failure to scoop as a teachable moment. Brave citizens, such as my friend Jane, may confront a scofflaw and request that they pick up after their dogs and some clever people will carry a plastic bag with them and say, with a gleam in their eyes, “Oh, you must have forgotten your baggie. Here’s one you can use.” This is a smart way of showing empathy not to the benefit of the abuser of the law but for the common good. So far, Jane’s effort to reform delinquent dog owners has not led to her physical harm.

Dealing with dog droppings is not a planet-threatening issue, no matter how excited some of us get about it. The concept of the Commons goes beyond public spaces. It is a metaphoric expression that invokes the harsh changes that had taken place in the English countryside. Hardin knew his history and saw the requirement to protect the Commons as applying to all, even those who were too rich to need to use it directly but who were powerful enough to end the existence of ground held in common by the people. If we don’t find democratic ways of coming to political agreement about the sustainability of the current environment, we may be repeating, writ large, the narrative of Tudor England, 1485-1603. Way back then, the idea of the Commons did not arise out of the fertile imagination of Garrett Hardin, or some functional equivalent, but was intrinsic to the transformation of the English countryside, when the Commons all but disappeared through enclosures--to the benefit of the keepers of flocks of sheep to support the emerging wool industry.

As E. P. Thompson reports in The Making of the English Working Class, not only did men of property create the natural ingredients for the newly established mills but also made it impossible for small cottagers to survive. Common people used the Commons for wood, hunting, growing crops, and collecting berries and other wild fruits and vegetables. Commoners were forced to sell their small plots and to seek work in the factories that turned sheep wool into cloth. Using sheepskins in the British House of Commons as seating for its leaders was a symbolic way to remind the lawmakers about the foundation of the nation’s power. Over the centuries, the idea of the Commons remained an equally powerful key to our understanding of democracy in capitalist society. The end of the Commons was, graphically, the end of a way of life in England, remembered today in poetry and prose. Still, while physically gone, the idea of the Commons remains embedded in our thinking about how we live.

If we fast forward to our time, the idea of the Commons can still help us create the good society but we need to deploy it more nimbly and more abstractly. Whatever is held in common, the atmosphere or the health-care system, can be overused or abused, and that can eliminate the way that commonly held property provides a safety net. Mandatory health insurance means everyone pays for using the Commons, which in this case is our health care system, in much the same way that pollution permits for energy companies is a way to make them pay for what they use. Uninsured people who receive uncompensated health care still use up the work time of professionals, require admissions to hospitals or emergency department, which when giving free services, are driving up premiums for everyone else. They get a free ride and help to distort the health care systems financing.

As George Lakoff argues in The Political Brain, the coal, gas, and oil companies have no incentive to create clean energy because they are not charged for the pollution they create. Yes, one can claim that energy companies only sell to individuals and firms that really do the polluting; but the energy producers don’t give them a choice since alternative energy sources remain either undeveloped or, when available today, extremely expensive. Climate change, as most of the scientific community believes, continues to mount challenges to our health, safety and food supply and the source of these challenges via burning carbon and producing greenhouse gases imposes a cost that remains uncompensated.

Paying for the care of the uninsured out of private insurers, public insurers or from the co-pays and deductibles of the insured, also drives up costs of coverage while making sure that any intervention for the uninsured becomes expensive since they, as people of modest means, often seek care later than others. The truth is that those receiving uncompensated care in hospitals often get less done for them than either those patients with public or private coverage. Not everything that is done for the insured patient is necessary but we also don’t know if stinting on services for the uninsured patient is completely without harm. We do know that receiving uncompensated care is not free. Someone is furnishing sometimes costly service without charge. They are expecting to be paid something.

I am afraid that we are all in this health care muddle together; hence, the idea of the Commons is useful to keep in mind so that we can see how much weight we bear for the uninsured in a health care system that is out of alignment. We can see something out of balance more easily when there is a monumental kind of disaster looming on our high definition screens or computers. Take, for example, an oil spill or a drilling operation that cannot shut off the gushing black gold of the Gulf of Mexico. An energy company, e.g., BP, leaves a large footprint directly traceable to the source, while the weight of the uninsured individual on the costs of coverage is only of concern when it adds up to millions of people who use the health care system without paying their way. This incremental process among millions of free riders contributes to a frame of understanding that fails to capture the necessity of insuring everybody.

In the absence of universal coverage (a democratic take on health care) via a single payer publicly-financed system, requiring members of the American population to buy coverage is a necessary step to allow insurance, a form of interstate commerce, to supply coverage for those with serious chronic illnesses, protect against the unexpected accident or life-threatening acute illness, and receive enough revenues from all beneficiaries so that the bills associated with these events will be paid. Mandatory coverage lubricates the system so there are reserves available and there are no “gamers” of the system who sign up when they are sick or after having been involved in a nasty automobile accident, where they require emergency care, followed by admission to a hospital and serious rehabilitation work. Buying good coverage, which includes rehabilitation services (occupational, physically and speech therapies) is hard to do when you are in a coma.

Health insurance is the functional equivalent of being required by a municipality to pick up after your dog. The Affordable Care Act requirement of mandatory coverage is an effort to create a smarter way of financing health care, at least so that free riding can end and no companies or citizens will be disadvantaged by having to subsidize care for those who can’t pay their charges at health facilities, at least as that becomes based on income and the use of a sliding scale. That innovation will make for a fairer and more democratic way of using the more abstract kind of Commons that we find in twenty-first century America.     

                                                                                --Arnold Birenbaum