Michael Moore and the Beige Bomber
He's got the indictment of health care right, but not the fix.
But that's a big question mark. The U.S. system differs for a lot of reasons, and the insurance industry is only one of them.
Our doctors are paid substantially more than British docs, for example. To get costs down to a comparable level, a single-payer system in the United States would have to seriously cut doctors' pay. Moore seems to anticipate this critique and thus interviews a doctor in the U.K. who makes $200,000 a year and drives an Audi. But this time the anecdote is at odds with the data.
Nor do these countries have the same costs associated with malpractice lawsuits that we do. A single-payer system here would have to also include some truly major rearrangment of the tort system to bring those costs down.
You would also need to dramatically slash drug prices. Moore takes some neglected 9/11 workers to Cuba, and an inhaler that cost them $100 in the U.S. costs 5 cents there. The price differences are also present, to a less extreme degree, in Canada and the United Kingdom. The problem is that these places get cheap drugs only because they are free-riding off the massive profits made in the American market. If our government required medicine here to be sold at no more than the lowest price charged abroad, the drug companies would drive the costs up in the other markets rather than reduce them here.
Each of these caveats is important. But the main problem with Moore's policy solution is that a national health system wouldn't fix one of our health care system's main flaws—one that people really hate—the denial of service. It just changes who decides, so that the government makes the call.
In one heart-wrenching case in the movie, a woman whose husband has kidney cancer is told by the insurance people that they won't allow an experimental treatment that might save his life. But that scene would likely play out just the same way in a nationalized health system. In those systems, cost-effectiveness decisions get made all the time. Care is rationed. That's what happens if you offer something for free—you have to make rules about who is allowed to get it. So, you forbid smokers from having heart bypasses, or, in a more recent debate in the U.K. about a new hay fever medicine, you just say the medicine is too expensive to be used.
In Sicko, Moore tries to skirt the issue of rationing by going to a Canadian emergency room and finding that people have only had to wait there for 20 minutes. But that's not the relevant comparison, of course. The emergency room is less crowded in places where everyone has health care. The question is what happens for the vast majority of expensive procedures that you don't go to the emergency room for. And for those, patients in single-payer countries tend to wait much longer than in the U.S. and can easily be told that they can't have a particular treatment at all.
So, to do as Moore wants in the United States, you would need to do more than just overcome the insurance industry. You would need to cut the salaries of doctors, reform the legal system, enrage our allies by causing their prescription drug costs to escalate, and accustom patients to a central decision-maker authorized to determine what procedures they are and are not allowed to get. Unless every one of these changes comes together, Moore's new system would end up costing an enormous amount of money.
You can see, then, why many reformers (like Edwards and Obama; Hillary Clinton hasn't gotten as comprehensive yet) argue that we should start by fixing the most glaring problems of our system without junking it and starting over. We could use pooling to move away from the dump-and-deny insurance we have now. We could reward doctors for doing a good job, the way they do in the United Kingdom. We could focus more on preventing sickness, the way they do in Cuba, to reduce the number of illnesses. These step-by-step changes would go a long way to alleviating the most damning problems with the U.S. system.
I used to have an old, old car that my friends called The Beige Bomber. It constantly had problems. Every time something went wrong, I had to decide whether to pay the $300 to fix it or shell out many thousands to get a new car. Eventually, yes, it completely died and I had to buy a new car. But I held out as long as I could.
Austan Goolsbee is an economics professor at the University of Chicago Graduate School of Business and a senior research fellow at the American Bar Foundation.