Michael Moore's documentary, "Sicko", has started a new round of
thinking about reforming America's healthcare system. For gay
Americans, especially gay men, the stakes in this debate are
unusually high and the answers are not obvious.
"Sicko" has two basic messages. The first is that America's
system of privately run healthcare is broken, leaving millions
without insurance and many of the rest frustrated by inadequate and
expensive coverage. The result is a country that, according to the
World Health Organization (WHO), ranks 37th in healthcare.
The second message of "Sicko" is that other countries - like
Canada, Britain, and France - do a much better job of giving all
citizens quality healthcare through government-run programs.
Along the way, Moore tells us horror stories about Americans
whose insurance companies would not cover some life-saving
treatment they need, about elderly and sick people dumped by the
side of the road, and about 9/11 rescue workers who have to go to
Cuba to get medical care.
These anecdotes are compared to happy tales from countries like
France, where doctors make house-calls (!) free of charge, new
mothers are given a state-paid assistant to do the laundry, and
life expectancy soars.
All of it is punctuated by Moore's trademark humor, sarcastic
and sardonic, which alone makes the film worth seeing. He is the
funniest propagandist in the country.
Funny, but not terribly effective. A really good propagandist
would give one the sense that the other side has been given a
hearing, been considered, and been found wanting. With Moore, you
get beaten over the head by clear good and evil. While Moore just
wants cancer patients to get the treatment they need, the other
side is all rapacious plutocrats putting profits ahead of
lives.
If you're thinking at all during a Moore documentary, you're
constantly wondering, what is he not telling me? I'm no healthcare
expert, but I know enough to be wary of the direction Moore
suggests.
His comparison of the U.S. to other countries is misleading, to
say the least. The WHO report that ranks the U.S. just above Cuba
looks at five factors: overall population health, including life
expectancy; responsiveness of the system to patient needs;
"inequality" of health within the population; "distribution" of
responsiveness within the population (how people of varying
economic status are served); and the "fairness" of the system's
financial burden (who pays).
The first two factors can be measured objectively, and on these
the U.S. does very well. Americans live longer on average than
almost all other people. We're just a half year behind the British
and 1.5 years behind the French in life expectancy. It's hard to
say how much of even this modest gap is attributable to the
countries' healthcare systems, as opposed to diet and exercise
habits.
The U.S. ranks first - first - according to the WHO in
healthcare responsiveness. Responsiveness means things like
"respect for the dignity, confidentiality and autonomy of
individuals and families to decide about their own health," and
"prompt attention, access to social support networks during care,
quality of basic amenities and choice of provider." Even with all
the problems in their healthcare system, Americans report higher
levels of patient satisfaction than citizens of any other
country.
Of course, the U.S. loses out on the remaining three egalitarian
and more subjective factors weighed by the WHO's international
staff. Nations with government-run healthcare systems like France -
and oil-rich Oman and socialist Cuba - do much better providing
everyone healthcare and spreading the costs to those who can afford
it. That's why the overall U.S. score is comparatively low.
It's a point Moore stresses. Everybody in those countries gets
"free" healthcare, regardless of ability to pay, while some 47
million Americans have no health insurance and many receive needed
care only when they go to the emergency room.
But this indictment by itself suggests no obvious reform. There
is no such thing as free healthcare. Consider the example of
Moore's favorite country.
France, which ranks first in healthcare according to the WHO,
pays for its generous system with very high tax rates that absorb
large portions of household income. That limits the freedom to
spend on other things - like education or housing or travel - that
some people value more highly.
High taxes and heavy regulation of business and labor markets,
requiring extended paid leave for things like convalescence,
produce anemic growth rates and chronically high unemployment.
France is now having one of its periodic existential crises about
falling behind more market-oriented countries.
The WHO report does not even consider a country's contribution
to advanced medical education, new technology, innovative
treatments, and drug research - all areas in which the U.S.
unquestionably leads the world. The 36 countries ranked ahead of
the U.S. enjoy such good health in part because of American
creativity and profit-seeking American companies.
The tradeoff - more evenly distributed healthcare in exchange
for some sacrifice of individual liberty and economic dynamism -
might be worth it. But we at least must recognize the tradeoff
exists.
Given the heavy need for healthcare among those with HIV
infection, an expensive, chronic and potentially fatal illness, a
question for gay readers is this: are there any special reasons to
be concerned about reform? And given that the gay experience with
government has not been happy, should we worry about state-run
healthcare? That's the subject of the next column.