"Sicko," Michael Moore's indictment of America's healthcare
system, proposes healthcare for all. Free treatment. Free drugs.
All provided by the government. What's not to like? Before gay
Americans rush to embrace state-run healthcare, we ought to think
very hard about it.
Start with the basic proposition that healthcare is something
gay Americans need more than most other Americans. For gay men, the
need is obvious and the stakes are very high. The Centers for
Disease Control and Prevention estimates that 232,000 gay men in
the U.S. are living with HIV/AIDS. In 2005, male-to-male sexual
transmission accounted for about 70 percent of new cases among
males.
HIV disease is chronic and potentially fatal. Keeping it under
control requires frequent visits with doctors, monitoring of blood,
and a very expensive regimen of prescription drugs. All of this
places disproportionately large demands on the healthcare system,
including on patients, nurses, doctors, drug manufacturers,
insurance companies, and taxpayers.
Over time, the life-saving drugs that have been available for a
decade now often stop working effectively. HIV develops resistance
to them. That means new drugs must replace the old ones.
Somebody has to provide, and to pay for, all of this expensive
care. How do we do it? America's answer so far has been a
hodgepodge of private insurance and public subsidy. In countries
Moore would like us to emulate, the answer has been
government-controlled healthcare.
I don't have answers about how to reform America's system, if at
all. And it's difficult to talk about the issue in the abstract,
since the devil will be in the details. But here are a couple of
things that gay Americans, especially, ought to think about.
First, as a general matter, we should be wary of any proposal
calling for greater government control. Historically, government
has been an enemy of gay people. While that has begun to change,
there is no reason to believe that government at the federal level
and in most states will not continue to be an adversary for some
time.
What might this adversary do to our healthcare? Any state-run
system will mean government funding of hospitals, doctors, and
drugs. With funding comes control.
Efforts will be made to control costs and decisions will be made
about how to allocate limited budgets. Politics will govern those
decisions, yet gays' political clout is small. Questions will be
asked: How much of the public fisc should be devoted to paying for
new drugs for people who continue to get themselves infected with
an avoidable disease? How many HIV specialists do we really need
and how much should we pay for their services? If we have to pay to
treat their disease, shouldn't we be monitoring their lives more
closely to prevent it?
There are rational ways of discussing these sorts of questions,
but given our history with government, there is little reason to
believe reason will dominate the political discussion. The
questions will be answered by the people who gave us bans on
immigration by HIV-positive people and the military exclusion.
Other countries with government-run healthcare - notably Moore's
favorite countries, like Canada, Britain, and France - have much
more enlightened attitudes toward homosexuality. There is
comparatively less reason to fear turning such an important matter
over to public authorities in these countries. The U.S. is
different.
The private sector, by contrast, has led the way for equality.
Unlike the federal government and most state governments, most
large private companies now ban discrimination against gays and
many offer health benefits to same-sex couples. That's not because
they're nice; it's because they compete with each other for the
best employees.
But if the government were the only game in town, as it would be
under some proposals for healthcare reform, there would be no
competitive pressure to ensure gay Americans are treated fairly.
It's hard even to know how sweeping the consequences might be in a
political environment still quite hostile to homosexuals.
Second, America is now the leader in medical advances of all
kinds: education, treatment, and most importantly for our purposes,
the development of new drugs. One of the reasons America spends so
much more on healthcare than other nations is that it is a leader
in these areas. Other countries free-ride on American research and
development.
Tens of thousands of gay men in this country are alive today
because profit-seeking private companies, with the help of public
investment, researched and developed life-saving anti-HIV
drugs.
But drug development is risky. Most new drugs are scrapped
because they don't work or are dangerous. Creating and testing them
costs a lot of money. Unless private investors can be tempted with
the possibility of large profits, they won't take chances and drugs
won't get developed.
Government-controlled healthcare doesn't mean drug development
will stop. But there will be strong efforts to limit drug costs,
which will limit profits, which will have some stifling effect on
development. There will be some risk that not as many expensive new
AIDS drugs will enter, or get through, the development pipeline.
That could mean lives lost as resistance to existing drugs sets
in.
None of this is decisive, even from a gay perspective, against
all reform of healthcare. But nobody should pretend the choices are
risk-free. And we should not indulge the fantasy that healthcare
will ever be "free."