Sicko: Can Socialism Fold into a Capitalist Society?

By Karoli June 19, 2007 Domestic Policy No Comments

Michael Moore’s new film “Sicko” is a must-see for everyone, regardless of party affiliation, regardless of how you feel about Moore, and regardless of where you stand on the state of health care in the United States. He presents a picture of health care in our country that strikes a chord and resonates in one way or another. For me, his call-out of insurance companies and pharmaceutical companies’ incessant rape of the health care system in the name of higher profits got a high five and then some. He does a great job of choosing out the inequalities in the current system without flinching.

After a stellar job of beating down the current system in the US, viewers are given selective glimpses of health care delivery in four countries: Canada, France, the UK, and Cuba. If we are to believe Moore, these other health care systems are specimens of finely-designed social policy in motion, offering free health care to all at no cost and no limit. This is where the film begins to falter for me.

Let’s start with this: When filming a documentary anywhere with a clearly visible camera and well-known filmmaker, the subjects would be idiots if they didn’t paint themselves in the best possible light. Moore uses that to his advantage, choosing archival footage to prove the brokenness of the American system and live footage of the four other systems. While he uses some live interviews to illustrate the inanity that is American health care, he carefully builds his case for why the system is broken with archival footage, including some eye-opening footage of a meeting between Nixon and Haldeman concerning Kaiser Permanente and the idea of private, for-profit health organizations. There is no question that his point is driven home with the combination of statistics and never-before-seen footage of a private Nixon-Haldeman meeting.

Moore was interviewed by Amy Goodman today.  This excerpt sums up his argument against our current system:

And these health insurance companies are — they’re just — they’re the Halliburtons of the health industry. I mean, they really — they get away with murder. They charge whatever they want. There’s no government control. And frankly, we will not really fix our system until we remove these private insurance companies.

On the candidates’ proposals for reform:

Kucinich is closest to the right idea, and, of course, he keeps, you know, saying “nonprofit,” or whatever. But I kind of don’t want to use that word anymore, and I wish that Dennis wouldn’t use that, because Kaiser Permanente is a nonprofit. Blue Cross is a nonprofit.

That’s why I say that essentially you don’t want any private insurance companies involved and that whether they’re for private or nonprofit, because — but when I say “profit,” you have these huge nonprofits that are under the guise of nonprofit, but they’re all about profit. They’re all about making money for themselves and for their executives, and what they make is obscene. And so, I favor the removal of all private insurance companies.

I agree with everything he says. It’s a sick joke to call these organizations “non-profit”. Of course they’re about profit. It’s just that the profit goes into the pockets of suppliers and managers and executives at the expense of patients and doctors. I argued in an earlier post that the reason the Pharmacy Benefit Managers remain for-profit corporations is to line the pockets of the executives who sit on the boards of the non-profit health insurance corporations. I haven’t seen anything to convince me to change my mind, and the statistics tell the story:

First Quarter Results for the Top 3 PBMs:

So Michael, now that we know it’s broken, how should it be fixed?

Moore takes us on a short, worldwide odyssey to look at four other systems in action. In each case, health care access is universal, unrestricted, does not appear to have the bureaucratic red tape of other systems, and delivers better end results.

As I watched, I kept asking myself the same two questions:

  1. How is it administered?
  2. How is it funded?

You will not have the answers to these questions at the end of the film.  So I went looking for my own, in Moore-esque fashion.  In each case, I tried to go either to the source itself or a respected organization.  Because I do not speak French, for example, I relied on the English-language reports of Civitas.org, which appeared to be an objective analysis of the French health care system. If there are flaws in these reports, please post a comment with suggestions for more objective reports that I can actually read.

Canada
WHO Core Statistics

In a comment to my initial post about this film, Stephen Downes challenged me to ask Canadians whether they’d trade their health care system for the one in the US. So I’m asking — Canadians, would you trade? And if not, why not? And beyond that, it would be great to read about what you like, what you don’t like and what you’d change about your current system, too, assuming you would keep it.

Health care benefits in Canada are paid for through a combination of taxes (public sources), supplemental insurance, out-of-pocket expenditures, and donations (private sources). According to the Canadian Institute for Health Information, the split of public/private expenditure in 2005 was 70% public, 30% private. However, the Canadian healthcare is struggling with rising drug expenditure costs, long wait times for some health services (See Wait times for treatment in Canada), and rising drug expenditures, which are rising at a nearly-exponential rate.

When Michael Moore was asked about these flaws in the Canadian system, he responded with this:

And, you know, you’ll hear the critics of the Canadian system here talk about, “Oh, the Canadians, you have to wait in line, you know, before you can get a knee replacement, or you have to wait x-number of number of weeks, you know, where you don’t have to wait in America.” You know, when I hear that, I think, well, that’s what you do when you have to share the pie. Sometimes you have to wait.

I agree — sometimes you have to wait. The problem is, there are some conditions that don’t wait. They worsen with time. But what Moore misses is this: Canada’s health care system is threatened by the same gremlins that haunt ours. The issues of cost containment and out-of-control pharmaceutical costs are global — they affect the Canadian system, the UK system, and the French system. These problems have not gone away, despite the universal access to health care offered by these other countries.

France
WHO Core Statistics

France has an amazingly complex system. The best illustration of its structure is this page, excerpted from the full Civitas.org report cited below. As close as I can tell, France employs a hybrid payer system which largely funded with public funds and supplemented to a small degree with private funds. France also has one of the top-rated health care systems in the world, yet this country is also grappling with similar questions on how to maintain excellence while containing rapidly rising costs.

From Civitas.org1:

The organizational structure of the French health care system makes this goal [cost containment] difficult to achieve. It is difficult to control expenditure in a system where the freedom of patients and providers is unrestricted, where care is largely publicly funded and retrospectively reimbursed and where health insurance funds have no real financial responsibility. Not surprisingly, therefore, the French health care system is relatively expensive by international standards, and the slowing down of expenditure growth which most countries achieved during the 1980s has only recently occurred in France, in the second half of the 1990s.

Although relatively high levels of expenditure on health care result in patient satisfaction and good health outcomes, cost containment remains a permanent subject of debate, since many of the measures taken to reduce expenditure growth have been ineffective and have always been strongly opposed by professional associations, particularly doctors’ associations.[emphasis mine]

and this, from the conclusions:

Finally, the financial sustainability of the health care system is a perpetual source of concern, particularly due to the fact that actual expenditure consistently exceeds the targets set. Until now, the high cost of the health care system has been accompanied by high levels of access to health care, but the demographic change expected within the health professions may lead to an increase in explicit rationing in future years.

Great Britain/NHS
NHS Core Statistics

Great Britain’s system is completely funded by public funds. It is widely regarded as one of the most accessible and patient-friendly systems in the world, and yet, reforms are being considered for this system as well.
From a 2005 NHS document2, a description of the NHS today:

  • the NHS has achieved a lot
  • there are both public and staff concerns
  • the NHS has been underfunded for decades
  • a 1940s system in a 21st century world

According to the report, decades of underfunding are now coming home to roost. Some of the reforms the NHS are weighing include: empowering patients, decentralizing services, more focus on wellness, preventive care and self-care, increased funding and yes, managing the cost of pharmaceuticals and facilities.

Wait time is also an issue in Great Britain, and the initiative seeks to implement procedures which will ultimately reduce the wait time and improve overall delivery of healthcare services.

Cuba

Cuba’s health care system is completely nationalized and controlled by the government. According to the Journal of the American Board of Family Medicine, Cuba’s health care system is “notable for achieving developed country health outcomes despite a developing country economy.”3  Despite the stark differences in economic models and per capita income, Cuba has health outcomes that rival those in the US for a fraction of the cost.

The central framework of the Cuban health care system rests on the family practice, an emphasis on wellness and disease prevention.  As Moore points out in Sicko, there is a clinic on nearly every block, with doctor or nurse who live in the community they serve.  Cuban physicians practice traditional and complementary medicine, and interface with the specialists serving those in their patient-community. 

Here is a comparison of the Cuban health care system to that of the United States:

Cuba has the highest family physician-to-population ratio in the world,11 and it has a family physician-per-patient ratio of approximately 1:600.8 In the United States, the average family physician-per-population ratio is approximately 1:3200.15 In 2001, only 35% of Cuban residency graduates specialized further (including 8% who graduated in general internal medicine and pediatrics).16 In the United States, only a third of physicians are primary care physicians (ie, family practice, internal medicine, and pediatrics physicians).17 Only 11% are family physicians.18

Other features of the Cuban health care system include holding physicans accountable for health care outcome measures in their community, evaluation of patients within the context of their family and community, and combining traditional pharmaceuticals with the complementary treatment methods by doctors trained in their use and implementation.

The conclusion to this report is one worth noting:

Despite political differences, Cuba and the United States share a passion for baseball and for family medicine as an important component of the health care system. At a structural level, the Cuban and US health systems differ drastically: Cuba provides universal health insurance and every physician completes a family medicine residency. In contrast, the United States has more than 46 million uninsured residents, and only 11% of its physicians practice family medicine.

So What?

Michael Moore gets more right than he does wrong with Sicko. He hasn’t convinced me that universal health care will work in this country without a radical takedown of some long-revered and powerful institutions. To accomplish any meaningful reform, Americans will have to dismantle the insurance and pharma lobbies at a minimum, and begin to tackle the question of how to deliver universal health care without tying it to employment, marital status, or other qualifiers (and figure out how to put all those unemployed pharma and insurance reps to work, too). Once those lobbies have been set aside, the questions of how to implement a healthcare system which avoids the pitfalls faced by Canada, the UK and France, embraces the positives in the Cuban system, and essentially folds a socialist system into a capitalist society will have to be addressed.

One thing is sure: This will not happen overnight. I do believe it can happen, but only if it’s done as part of the largest social, non-partisan debate we’ve ever had in our country about something which is truly universal. Health care may not be a right, but it is a fundamental need and without a method to deliver it effectively, we are dooming ourselves to a stunted economic outlook where the mega-rich become richer at the expense of public health. What cannot happen is the application of a political, band-aid solution that gives the appearance of reform but carries the stench of the profiteers underneath.

1Health Care Systems in Transition, 2004, Simone Sandier,Valérie Paris,Dominique Polton
2The NHS Plan: a plan for investment, a plan for reform
3Family Medicine in Cuba: Community-Oriented Primary Care and Complementary and Alternative Medicine

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