I'd been holding off on seeing Michael Moore's new film, Sicko, because I am really more interested in the right-wing reaction to it than I am in the film itself. As the author of a book that harshly criticized Moore -- from a left-liberal point of view -- for his habit of loading up his films with deceptions delivered through half-truths, misleading edits, and broad conspiracy theories, I wasn't expecting that much from his latest.
I also wrote in that book that Moore is a liability to the left precisely because he is so useful to the right. Right-wingers like nothing better than presenting Moore's bitter lunacy as typical of the left, his manipulative paranoia as a showcase of what liberals and Democrats secretly believe and would love to implement, given half a chance. This disingenuous, and highly calculated, response tends to drown out any real discussion of the legitimate issues that Moore raises. That's a shame, because these issues are important and deserve a better hearing than either Moore or the reactionary right is willing to give them.
So here we go again. Moore didn't play it straight in Sicko, and the right-wingers are piling on with hysterical defenses of for-profit medicine. According to them, the choices are between a free-enterprise system of health care, or slavelike submission to a state-controlled system that will drag down the quality of care and eliminate all personal decisions and human dignity.
Moore should have known better than to give them this opportunity, but he can't seem to help himself. His criticism of the disgraceful state of American medicine is mostly on target. However, he somewhat misrepresents the Canadian health care system, grievously misrepresents the British, and while he gets some aspects of the French system right, he completely fails to understand the context of the socially dysfunctional French welfare state.
Far more damaging than these errors, however, is his propagandistic presentation of the Cuban health care system, in which Moore shows 9/11 rescue workers with lingering work-related health problems getting state-of-the-art treatment in Cuban hospitals -- and explicitly says that this is the treatment that all Cubans get. This isn't true, and even if it were, any discussion of Cuban medicine that completely omits the totalitarian system in which it is offered would be disgustingly false. Moore isn't concerned with human rights, though. He even shows us the daughter of sadistic psychopath Che Guevara, gushing about the glories of the revolution. Now the predictable responses from the right-wing noise machine: Moore has handed Kyle Smith at the New York Post the opportunity to say that his solution is that "our health-care system ought to be run by Fidel Castro," and Jay Nordlinger at National Review -- who has a bit of a sub-speciality in disingenuously pretending that most leftists and liberals love Fidel -- once again tells us what all thoughtful people, left, right, and center, know: that the Cuban system viciously exploits its doctors and brutalizes its patients (very good for government elites and medical tourists who are rich or have high propaganda value, though. Soon after Moore's movie opened, the Cuban government began using it to advertise cut-rate services for medical tourists to the island.)
Before going on, I have to point out that the truth about Cuba indeed has not been missed by many on the left. Here's Christopher Hayes, writing in the very leftist The Nation, about the problems of presenting Cuba as a health care paradise. Hayes addresses simultaneously the reality of Cuba and the reality of American politics: "The film's final half-hour, in which Moore takes 9/11 rescue workers to Cuba, serves only to reinforce the decades-old slander that equates social democracy with repressive socialism. It's a major miscalculation and nearly squanders the first hour and a half of the film in which Moore so deftly guts arguments that socialized medicine represents the vanguard of Marxism." I'd like to think that Hayes is typical of the thoughtful left. With a few exceptions, leftists and liberals do get it about Cuba and Fidel.
But the larger issue here is whether socialized medicine really can deliver decent health care to everyone in a democracy, and whether it should do this in the name -- as a French doctor interviewed in Sicko puts it -- of social solidarity. On that score I think there is lots of evidence that it can and it should, despite Moore's manifold deceptions. Certainly it can do a much better job than the for-profit system that we presently have in the United States, in which doctors and insurance companies are given incentives not to treat patients. But we should look at the question carefully and dispassionately, and here some of Moore's propaganda -- and the responses to it -- can be instructive.
Moore gets the British health care system very wrong. Anyone who has seen Sicko and thought that it represented reality on that score should read this piece by Theodore Dalrymple, a doctor who worked for 20 years in the British National Health Service. Dalrymple's piece has been trumpeted by the far-right National Review as a devastating blow to the idea of socialized medicine (NR ran it as its cover story for the August 13th edition, under the ominous title "The Doctor Won't See You Now: The Truth About Socialized Medicine.") But any careful reading of Dalrymple's piece will reveal that, far from being a blanket condemnation, it is a blueprint for how socialized medicine can be done right:
In its most successful period, the state-run NHS was possibly the least bureaucratic health-care system in the world: far, far less bureaucratic than the American free-enterprise, or increasingly corporatist, system. This was because the doctors were still the most powerful group within it. The few managers in the system were their handmaidens, not their masters. In return for their salary, the doctors had effective control of most things, including who got what. They neither knew nor were interested in what anything cost: Rationing was informal and implicit rather than formal and explicit as it is now, and quite without bureaucratic control or costs.
The NHS also had the cultural capital of the hospital system that existed before it. It took over hundreds of voluntary hospitals that had been funded by local benefactors and charitable collections, and that were the pride of their area. It takes a long time to vitiate institutional pride, especially when the government is intelligent enough (as were successive governments, both Labour and Conservative) not to attack it directly.
But there were problems from the first. Chief among them was that capital expenditure came to an immediate halt after the NHS was begun...
Which begs the obvious question: Why not have a fully-funded national health care system that continues to make investments as necessary, and in which doctors and patients make decisions free from meddling by bureaucrats? Dalrymple blames Margaret Thatcher for dramatically expanding the role of the bureaucracy, and notes that increased government involvement has greatly increased inefficiency, inhumanity, and cost. He continues:
Managers in the NHS now often decide on the priority of patients' operations, not on clinical grounds, but according to government targets; they scour the wards for patients they believe can be discharged; they set priorities in the emergency rooms, again not according to clinical criteria, but according to the need to meet government targets. Managers now screen all referrals to psychiatrists, and decide which patients the psychiatrists should see, which is a fundamental breach of medical ethics. A central organization, the National Institute for Clinical Excellence, lays down what drugs may be prescribed by doctors in the NHS.
Both Dalrymple and Nordlinger refer with approval to one of the most ridiculous moments in Moore's film, an excerpt from a speech in which the corporate shill Ronald Reagan (a man who showed throughout his career that he had no core beliefs, an opportunist always on the lookout for the main chance, although, as an actor, he was able to convince himself of his sincerity, and therefore to convince others) parrots a Randian line about how government control of medicine is the high road to totalitarianism. Dalrymple remarks that the situation above proves that Reagan was right; but Dalrymple's description of restrictions on health-care access applies to American free-enterprise, for-profit HMOs equally as well as it does to the British NHS. The fault, dear Brutus, lies not in the general framework of our systems, but in the practical decisions we make about how to administer those systems, and the social values that underlie these decisions.
With this in mind, let's take a look at Moore's interviews with American expats in France, and the high standard of health care they receive, even though they are not French citizens, just because they are resident in France (full disclosure: one of these Americans happens to be a friend of mine) It's not that there's anything wrong here, per se; most of the French do get an excellent standard of care, and they do pay a lot for it in taxes, which Moore -- very briefly -- does acknowledge. But what does "most" mean? Although coverage and benefits are universal on paper, I don't think there are too many French doctors making midnight calls to the infamous banlieues, where France's large population of disaffected citizens of North African origin live, resentful, unemployed, unassimilated, and prone to outbursts of spectacular violence. This is not just a simple case of social injustice. It relates to a massive misunderstanding on Moore's part.
For Moore believes that the French have their health care system because they have intimidated their government: they will go on strike, march and besiege the streets of Paris whenever the government wants to cut any part of France's bloated welfare state, all on that principle of solidarity. But in fact it is anything but solidarity. Because France has very powerful unions that have made it almost impossible to fire anyone with a job, to demand productivity, or to make economic reforms that encourage economic growth, it's a great place to live if one has a job. And who is most likely to have a good shot at a job? The educated children of the large French middle classes. Those marchers in Paris, the ones protesting against any interference with job security, any meddling with the 35-hour work week, are in fact parochial guardians of class privilege, a most un-socialistic phenomenon. This situation has led to very high unemployment, very low economic growth, and massive social problems. Left out of the rent-seeking club are French citizens of non-French ethnicities, immigrants, those who are trapped in the exurban ghettos, all of whom may technically have access to great health care but who, due to the circumstances of their lives, may have a hard time getting into the system. Socialized medicine can and should operate in a social context that expects it to be both efficient and inclusive. The French, in recently electing Nicolas Sarkozy president on promises to make them work harder and to open up the job market, in preference to a featherweight Socialist who tried to bribe them with more and more free stuff, seem to have understood that their society was in cultural and economic decline.
Finally, let's look at Moore's treatment of the Canadian system. As usual, he gushes with love for all things Canadian, and sees their society as a model of solidarity in which everyone looks after everyone else, there is no wait in Canadian emergency rooms, and all Canadians are delighted with their health care. This isn't true, although it is more true than his Cuban fantasy. But neither is it true that Canadian health care is a shambles in which people wait months for life-saving operations, and often die while they are waiting, contrary to the anecdotal claims of filmmaker Stuart Browning. In general, as supporters of the Canadian system claim, urgent needs are met with urgent priority, while less-than-urgent needs may be met only after significant waits. But to the extent that the Canadian system has serious problems -- and it does have serious problems -- these are largely the result of cutbacks in health care by successive conservative provincial governments over the last 20 years (the Canadian "national" health care system is actually funded and administered at the provincial level, and the various provincial programs differ somewhat from each other). I speak with some experience here; I grew up in Canada, and I know the system well. It works fine for my mother and for many close friends, who still live there. When I was a teenager I had a friend with a life-threatening condition that required urgent and very expensive treatment. The treatment began on the day of diagnosis. My friend made a full recovery; there was no direct cost to his family. And he was not even a Canadian citizen.
So it irritates me when the right-wingers start bad-mouthing the Canadian system, or suggesting that the solution to its problems lies in more for-profit incentives rather than more funding. Yes, Canadians do pay high taxes, but most of them find it worthwhile, both because they can rely on the system and, yes, out of that principle of solidarity. In Moore's film the first president Bush is seen dismissing the idea of socialized medicine, remarking that if you think it could work, "Ask a Canadian." The fact is that while many Canadians have criticisms of their health care system, almost none would choose a U.S.-style, for-profit system. They would laugh at the idea that it would work better for them.
What the right-wingers really don't want you to know is that despite all the problems with the various flavors of socialized medicine throughout the democratic developed world, by many measures we in the U.S. do not have the best health care system in the world. We have the best medical research. We have the most advanced technology. We have the best doctors. But in terms of access and overall results, as measured by the World Health Organization using standards developed by an international team of health care professionals, the U.S. comes in seventeenth, behind all the major European countries and Canada (France is first.) Don't worry, the U.S. is Number One in health care spending per capita.
Now I know that this ranking and the methods used to obtain it can be questioned on many grounds, including political ones. So let's use the measure of actual patient satisfaction with health care received, perhaps a more acceptable (if more subjective and culturally determined) measure of health care quality. By this measure, 40 percent of American health care consumers were satisfied with the care they got in the years 1997-2000; behind, well, most of the major European states and Canada (Italy, Portugal and Greece did worse; Denmark was first, with 91 percent.)
These results closely track other measures of international health care quality, such as infant mortality, where the U.S. comes in 180 out of 221 countries assessed (highest infant mortality is ranked number one, so higher numbers are better). Singapore has the lowest infant mortality in the world; once again, the U.S. comes in behind all the major European countries, (including Greece, Portugal and Italy), some not so major ones, Canada, and many Asian countries. Malta beats us. Guernsey beats us.
Shall I go on? How about life expectancy at birth? Here we're number 45 out of 222 (highest life expectancy is ranked number one, so lower numbers are better.) Here, again, we come in behind all the major European countries, some Asian ones, and Canada. Guam beats us. Macau beats us. You think Israel's a dangerous place to live? Israel beats us. And no, my source for infant mortality and life expectancy stats is not the One World Government Ministry of Propaganda; it's that other famous communist front organization, the CIA.
These statistics and their interpretations can be disputed, but the trends that emerge show that the American free enterprise system of health care is doing worse than the folks at the Cato Institute would like you to believe, and that socialized medicine systems are doing better. It is worthwhile to ask what the socialized systems are doing right, as well as what they are doing wrong.
The surprising fact is that a true single-payer system (and I'm not talking about the rightly-derided HillaryCare plan of the early 1990s, which attempted to keep private insurance and employer-mandates) is more efficient than a for-profit one. Our HMOs eat up about 13 percent of their cost in profit and administrative overhead; Medicare's fee-for-service costs are about two percent overhead, and Canada's only one percent, which is why Canada can spend about half what we do per capita and still have better stats. There's also the question of efficiency. In a system in which many people are not covered, the emergency room becomes the health care clinic of first and last resort. Despite George W. Bush's belief that "People have health care in America -- after all, you just go to an emergency room," this is not a good thing and it's not coverage. Do emergency rooms provide treatment for cancer? Emergency rooms are the most expensive way to provide primary care. Enormous amounts of money could be saved by a well-funded system that included good primary care and preventive medicine.
How would this save money? The free enterprise people at Cato and the Heritage Foundation are always moaning about the enormous cost of preventive medicine. But what's the cost of not having it? Not only in emergency room care, but in unnecessary illness and procedures. Think of all the man-hours of work time lost to illnesses that didn't have to happen, but did because people had no access to preventive medicine.
Then there's economy of scale. The Medicare Reform Act of 2003, with its prescription drug benefit, was a disgrace because it was an enormous gift to the pharmaceutical industry: not socialized medicine, and not good capitalism either. It explicitly prohibited the federal government from using its enormous buying power to negotiate prices with drug suppliers. This is just stupid - or sinister. Canada doesn't have this problem.
But wouldn't having government control our health care result in rationing and collectivist dehumanization? Well, it could, if it were done by putting the government in direct administrative control of the system. But we've already got rationing now with gatekeeper HMOs, and only someone as privileged and vacant as George W. Bush could fail to see that. And a national health care system doesn't have to be run by the government. It could be handled as social insurance, with private providers and personal choice, and with plenty of room for merit pay for doctors and researchers.
I am not an enemy of the free market system. I believe that in most cases, the market is the best and most efficient way to distribute goods and services, and that it fosters political liberty and a free society. But it should not be a religion, and I recognize that there are certain areas in which the market does not serve society. One of them is health care. There are a few simple reasons for this.
1. Society as a whole has an interest in the health of its constituent individuals (if the moral arguments for social solidarity don't move you, think of those lost man-hours.)
2. Health care can be beyond the means of an individual.
3. Traditional insurance won't work for universal coverage as long as insurers are free to choose not to cover at-risk individuals.
4. In a profit-driven system, there will always be an incentive to provide less service at higher cost.
5. Competition won't necessarily pull in the direction of lower costs and better service, since medical information is so opaque to non-experts. Ordinary patients are not able to make judgments about the efficacy of treatment techniques; instead, these judgments, in our free-market system, are made not by consumers nor by their doctors, but by doctors who work for the providers.
This is why we need social insurance, to distribute the risks and costs of health care among all members of society, young and old, healthy and sick, low risk and high risk. We'd have to throw out the actuarial tables as a basis for coverage, and with them the profit motive. We'd have to take responsibility for each other. We could still have private doctors, who would be paid from this single-payer insurance fund. Choice, dignity, and quality of care can be preserved under such a system, although it would not be cheap.
And yes, we'd have to pay more taxes, which would be largely offset by not having to buy private insurance or to directly pay for service.
Such a plan would kill the private insurance industry and its enormous profits, which is the right-wingers are so strident in screaming that we'll all become prisoners of Castro. They are adept at invoking a national ideology that the individual is everything and society is nothing. Of course, this has never actually been the case, since no human society can function in this way. But the ideology has its uses. Here's a particularly cunning and invidious example, from Rich Lowry at National Review. Lowry probably believes this nonsense with the all sincere fervor of his very naïve and idealistic young heart, but then delivering quality health care for all is not a concern of the Lowrys or Bushes of this world. If it were, they'd pay more attention to the cogent arguments of people like Paul Krugman, here and here.
Maybe someday the American people will see themselves as part of a society in which they have both rights and obligations, and stop being terrified by the phrase "socialized medicine." Michael Moore's film, a clumsy piece of propaganda, doesn't advance the serious debate that will get us there eventually, and it provides many openings to the cruel ideologues who see nothing wrong in profiting from illness. It might, however, spark a populist trend toward education and a comparative perspective on health care issues. That would be a start.