Sicko and Health Care Reform
The new Michael Moore movie is provocative. It reminds me of Al Gore's "An Inconvenient Truth" and then also Morgan Spurlock's "Super Size Me." These are manipulative movies with single-minded aims and characters. They can be very annoying to watch, especially as the enthusiastic audience, in attendance at the sneak preview of Sicko that I patronized, cheers for the sorry citizens who have bad results under our current health care system and gasps in horror at the evil insurers. The policy argument could be much, much better. Moore makes very little of the enormous cost of our system. He loves showing the audience that there is no billing department in the French and Canadian hospitals he visits, but does not bother to point out that a substantial fraction of our costs goes to administration, including billing. The insurance carriers are made out to be evil when they deny coverage, but it would have been much more interesting to try and see whether the "experimental" treatments denied would indeed have been undertaken in France or Canada. Part of the movie makes us out to be ungenerous, but then then the better part begins to get at the fact that we have poor overall performace for the resources we do spend. The funniest and most provocative part of the movie comes toward the end, when Moore takes some of the sad cases from the U.S. and seeks help in Cuba. For an annoying, anti-intellectual, biased, and manipulative documentary, it is finally entertaining and provocative. It is hardly the best thing that could have been done in favor of universal health care but, like the Al Gore movie, it just might make more Americans care about the subject, and begin to ask the right questions.
So let me ask some questions. Moore tries to show that many Canadians and French are happy with their systems and do not have long queues and so forth, but some real data would be excellent. We tend to think that when prices are fixed (by law or by insurance payouts) queues are a convenient method of rationing scarce resources. Still, we do not like our time spent in hospital waiting rooms. It might be that there is a tradeoff between these queues and simply being told that the system does not provide certain procedures; the latter may be a better form of rationing, especially for people who place a high value on their time. In the U.S. we often wait a month or two or more for an appointment; how should we compare and quantify time spent in the waiting room with the cost of this sort of waiting? What do we know about queues across health care systems?
The movie does draw attention, as it should, to aggregate life expectancy statistics in Canada and Cuba. Defenders of our system (with its high costs/poor mortality) like to say that we need to correct for failures of prevention in the underclass in the U.S. (but why do other systems do better?), for gun violence, drunk driving rates or perhaps automobile usage in general, and for American obesity. On the other hand, we have relatively low smoking rates. I am not aware of studies that really try to correct for these things. And of course some of these may be endogenous. In some countries, doctors are rewarded for reducing smoking and perhaps obesity.
I hope to write more about these topics. Meanwhile, I left the theater with the message that Americans detest the current system and can be stirred up against it - but then also with the knowledge that Americans are horrified at the prospect of giving up choice, as enjoyed by many in the present system. I suspect that universal health care, or just something close to a single payer system, could only come here if people can opt for private market add-ons. Our health care might become like our school system or city transportation systems, with a basic care system that involves significant rationing, but then private suppliers of those things that are most heavily rationed.