Sicko, Soundbites, and Reform v. Revolution
posted by Frank Pasquale
Michael Moore’s film Sicko highlights the basic injustices of the American health care system:
1) tens of millions of people lack insurance
2) you can easily get bankrupted by illness even if you have good insurance
3) you can end up in a game of insurance company “chutes and ladders” if you need expensive treatment
4) France spends less, and gets better results, and has more satisfied patients.
Sadly, Moore goes “over the top” towards the end, viewing Cuba through red-colored glasses. And he ignores how some of the pharmaceutical innovation enjoyed by people of all countries is funded by the U.S. But I am glad someone is getting us to think about comparative health policy.
As David Hyman notes, this is a war of anecdotes. The creators of Harry and Louise should have known that some day someone would be rebutting them with stories of preventable infant deaths, HMO excesses, and patient-dumping. It’s only fair…but leaves me with a few regrets.
Having just attended a conference on the future of Medicaid, I’m saddened by the fact that discourse on health care is probably going to focus on the extremes: Moore vs. the dead-enders at Cato who can’t even get behind the Romneycare initiative Heritage backed. I disagree with Moore’s assumption that nothing less than social revolution can bring health care for all to America. Good people in Massachusetts, California, Maryland, Pennsylvania, and many other states are addressing the problem of the uninsured. Newt Gingrich has some excellent ideas, and even the market-loving doyenne of consumer-directed health care believes Swiss style universal coverage is appropriate for the US.
My only plea to those who would trash the film: before you do, please read Tim Jost’s essay on “Our Broken Health Care System.” He’s thought about these problems for decades, has an encyclopedic knowledge of comparative health systems, and is genuinely fair-minded.
June 28, 2007 at 11:47 am
Posted in: Health Law
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Responses (6)
Patrick S. O'Donnell - June 28, 2007 at 2:30 pm
Frank,
I haven’t seen the movie, but I suspect the following is hyperbole if not unfair: “Sadly, Moore goes ‘over the top’ towards the end, viewing Cuba through red-colored glasses.” See, for example, this: http://www.cubasolidarity.net/inhealth.html
See too the Wikipedia entry on “Healthcare in Cuba,” which notes, for example, “In 2001, members of the UK House of Commons Health Select Committee traveled to Cuba and issued a report that paid tribute to ‘the success of the Cuban healthcare system’, based on its ‘strong emphasis on disease prevention’ and ‘commitment to the practice of medicine in a community’.
The Parliament of the United Kingdom also drew up an analysis of the key features of Cuba’s healthcare system, drawing comparisons with the state funded National Health Service (NHS). The overall conclusion was that many of the features identified would not have occurred had there not been an obvious commitment to health provision demonstrated by the protection and proportion of the budget given the health care. The study concluded the following.
There appeared to be little evidence of a divide between the prevention/proactive response and the disease management/reactive response within Cuban healthcare.
By far the biggest difference was the ratio of doctors per person. In Cuba it was one doctor per 175 people, in the UK the figure was one doctor per 600 people.
There is a commitment in Cuba to the triple diagnosis (physical/psychological/social) at all levels.
Extensive involvement of ‘patient’ and the public in decision making at all levels.
Integration of hospital/community/primary care via polyclinics.
Team-work that works is much more evident both in the community and the hospital sector and the mental-health and care of the elderly sites visited were very well staffed and supported.
The study also pointed to problems within the system, these included;
Low pay of doctors
Poor facilities—buildings in poor state of repair and mostly outdated.
Poor provision of equipment.
Frequent absence of essential drugs.
Concern regarding freedom of choice both for patient and doctor.”
Given our country’s efforts to destroy the Cuban economy, the above problems are not surprising.
Finally, see this 2002 Oxfam study, “Cuba: Social Policy at the Crossroads.” http://www.oxfamamerica.org/newsandpublications/publications/research_reports/art3670.html
All things considered, the history of health care in Cuba is worth studying on several fronts and I think Moore is right to draw our attention to it.
Frank - June 28, 2007 at 2:49 pm
Patrick, that’s very important empirical research and I’ll have to take a look at it.
But regardless of how compelling the Cuban health care system is, its record on treatment of dissidents is horrendous. People are just not going to be persuaded that a good health care system is “worth it” if social solidarity comes at the consequence of that level of loss freedom…or even if it is merely associated with that level of oppression.
Moore should have stopped the movie after talking about France.
Patrick S. O'Donnell - June 28, 2007 at 3:06 pm
Frank,
With all due respect: the treatment of dissidents and the health care system are largely separate topics and the latter is in no way dependent on the former. I’m not suggesting we adopt wholesale the Cuban health care system, but simply that we assess it with an open mind. A simple thought experiment should suffice: imagine the health care system apart from the regime’s record with regard to political dissent. It’s not impossible and may prove enlightening.
Daniel Goldberg - June 28, 2007 at 7:27 pm
I think there may be good reason to believe the treatment of dissidents and the health care system in Cuba are not nearly as separable as Patrick suggests. Many of the public health policies commonly cited as principal reasons for Cuba’s favorable population health indices are unattainable in the U.S. because of the dramatic differences in political culture.
The most well-known example of this dynamic occurs with HIV in Cuba, which as a nation scores favorably on public health measures for having relatively low rates of HIV infection and AIDS. The most obvious reason for these rates is the Cuban government’s policy of forcibly quarantining all individuals known to be infected with HIV to prevent transmission of the disease.
Does this policy work? Clearly, as demonstrated by the low rates of infection and of AIDS itself. Is such a policy plausible in the U.S.? I think most would agree that the answer is “obviously not.”
The argument, then, is that the Cuban health care system’s relatively high health indices are, to some extent, a product of public health policies and practices that are totally untenable in the U.S. IMO, this makes comparison of American health care with Cuban health care somewhat unhelpful, as the differences in political culture are simply too stark to draw meaningful comparisons.
I doubt that Patrick believes that political ethos and culture are really separable from health care, as the overwhelming consensus from health policy wonks and historians of medicine is that the emphasis on individualism and capitalism has largely albeit not completely animated the U.S.’s failure to nationalize health care.
The other instructive point from this analysis, if it has any merit, is Rosenberg’s brilliant argument that efficacy is a function of culture, and that interventions “work” in response to disease if they explain and give meaning to illness experiences. That the Cuban system may “work” for Cubans — assuming it does — is not in and of itself good evidence that it would work for Americans. Of course, this is not to say there might not be some very good reasons why other nations’ health care systems might not work for Americans, but simply that thinking about health policy, public health, and therapeutic medicine is necessarily a local and contextual endeavor. JMO.
Catherine - June 28, 2007 at 7:33 pm
Patrick,
The Cuba segment of the film appeared to have been wholly orchestrated by a Castro PR team. The issues you mention with regard to problems with facilities, equipment, availability of drugs, doctors’ pay and patient choice were nowhere evident.
Frank’s suggestion of ending the film after the France segment would have left us with a more legitimate illustration of a functioning national health care system, rather than a fantasy world version of one that does in fact suffer from the problems you cite.
Ending with the less assailable France segment would have served Moore’s purposes better, as the Cuba segment is so broadly open to attack that it will allow his opponents to dismiss the whole project by pointing out the severe flaws in this small portion of a wide ranging film.
See David Denby:
http://www.newyorker.com/arts/critics/cinema/2007/07/02/070702crci_cinema_denby
It also, of course, prompted the ridiculous / nonsensical / highly popular Thompson response.
http://www.youtube.com/watch?v=DdAm6UY4xOE
David - June 29, 2007 at 12:10 pm
I can see two sides to the question as to whether we should include Cuba in the debate. On the positive side, perhaps some people will be shamed into thinking, “even Cuba” has better healthcare than the US–we can’t lose to Cuba.
Or, maybe it will cause people to not be so scared of the socialist bogeyman, although that’s probably unlikely.
But the concern is that it makes Moore an even bigger target by allowing his critics to lump him in with Castro, as a “pinko”.
Sadly, this last effect is the one that i predict will dominate. Frank’s right in suggesting that the important substantive issues will be drowned out by the noise of outrage from Moore’s rhetorical Cuba showcase.
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