OutRight: Propaganda, More or Less?

Is American healthcare ‘Sicko’?

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.

Writing from the conservative side, Dale Carpenter began his column for OutSmart in 1994, when he lived in Houston. Now residing in Minneapolis, Carpenter is a University of Minnesota Law School professor.

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