I have mixed feelings about Michael Moore. Though I envy his creativity and his capacity to publicize progressive causes, I am often disturbed by a tendency in his films to vilify individuals and to view societies in black and white terms. The deindustrialization of Flint owes much less to the avarice of Roger Smith than to a multinational capitalist economy and even to the limits of traditional liberal reforms. Perhaps villainy mobilizes one's base, but it seldom convinces the skeptical. SiCKO represents a positive step for Moore, though it still leaves gaps that reformers must address.
SiCKO questions the logic of profit- driven healthcare. Markets do work for many ordinary consumer goods, but the foundations of civilized life are not best left to market competition. Barbara Ehrenreich puts the case well: "if there is one area of human endeavor where private enterprise doesn't work, it's health care. What "innovations" has it produced? The deductible, the co-pay, and the pre-existing condition are the only ones that leap to mind. The great accomplishment of the private health insurance industry has been to overturn the very meaning of "insurance," which is risk-sharing: We all put in some money, though only some of us will need to draw on the common pool by using expensive health care. And the insurance companies have overturned it by refusing to insure the people who need care the most -- those who are already, or are likely to become, sick."
When the health insurance industry competes, there are immense personal and social costs. Just as if multiple electric utilities put up their own polls and wires, the costs to everyone increase. And the consequences are worse. Many cannot afford coverage. Lacking coverage they are more likely both to contract and to spread diseases.
SiCKO correctly portrays the cruelties it documents not as the result of callous individuals but of a system where corporate survival depends on insuring those less likely to need medical care or denying coverage to those who do end up in need. Callous behavior is a product rather than a cause of the fundamental imperatives. Not surprisingly, every major industrial democracy -- except for the US -- has public, universal healthcare. In addition, however, it should hardly come as a surprise that Moore faces intense US criticism.
In my home state of Maine we constantly hear that our Canadian neighbors face long waiting lists for important elective services. Though waiting lists are an undesirable feature of Canadian life, a recent study of six health systems by the Commonwealth Fund points out that four of the six health systems do better than the US even in wait times. All systems promote better outcomes while spending less than half of what the US does.
Moore should, however, devote more attention to the issue of wait time. Just as capitalism is now global, the attack on public healthcare by pharmaceutical and insurance firms is also global. Defenders of public systems need to draw on cross border experiences.
Increasing privatization within Canada, though often promoted as a way to ease waiting lists, has aggravated the problem. A study of cataract surgery in Alberta finds that patients whose eye doctors practice in both private clinics and public hospitals have the longest waiting times. Comparable examples from Australia, Britain, and the US, carefully summarized by the Canadian Center for Policy Alternatives, abound.
In addition, when those with money can cut ahead of others, support for the public system erodes. Waiting lists then grow, thereby further undermining commitment to the public system. By the same token, because healthcare in Canada still is predominantly provided by public funds to all on an equal basis, there is often successful pressure both to expand system resources and to find more efficient ways to manage waiting lists and deliver timely service. Whether the privatizers or the defenders of public health win has immense consequences not only for Canadians but also for US citizens.
Attacks on universal health care in Canada and Europe are part of broader assaults on social democracy. French conservatives seek to make France more competitive by slashing healthcare spending and lowering taxes. In Canada, the Chretien government's obsession with budgetary surpluses set the stage for diminished funding of Canadian health care and the exacerbation of shortages. The task for progressives becomes one both of showing that equitable and efficient health care is a long term competitive advantage and negotiating transnational health and welfare standards as conditions of entry to international trade agreements.
Comparable efforts have been made to undermine US Medicare. The Medicare Modernization Act of 2004 authorizes and even subsidizes private Medicare Advantage programs. These programs provide traditional benefits, often with other sweeteners, but also include various complicated co-payment options. They target healthy seniors and leave the traditional public system with the most costs, thereby fueling critiques of Medicare as inefficient and unsustainable. And a prescription drug program, also run by and for the benefit of private corporations, drives costs up even further.
The last fallback of the insurance industry, amply illustrated in a confidential industry memo on SiCKO, suggests that industry executives blame Americans' lifestyles for raising healthcare costs. No one denies that lifestyle matters. Yet patients receiving good and timely primary care are more likely to make lifestyle changes. Other nations do have better longevity not just because of universal healthcare but also because the gap between rich and poor is less wide. Yet even here, healthcare in the US is an un-indicted co-conspirator. The leading cause of bankruptcy in the US is healthcare expenses, and health insurance CEO salaries are obscene.
John Buell lives in Southwest Harbor, Maine, and writes regularly on labor and environmental issues. Email jbuell@prexar.com.
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