Michael Moore and Jane Jacobs

Sicko is a great movie, one of the most emotion-evoking films I have ever seen. In this interview

Moore says something that is at the heart of Sicko:

They [HMOs] are required by law . . . to maximize profits for their shareholders. That’s what the law requires them to do. The way they can maximize profits is to deny care, is to not pay out claims. The more claims they pay, the less profit they make. You should never have the idea of profit enter into a health decision. We wouldn’t allow it for the fire department or the police department. We wouldn’t say, well, you know, we’ve got to be sure the fire department posts a profit. We wouldn’t turn it over to a private company, have investors invest in it, say, well, some people are going to get fire protection and other people aren’t. We wouldn’t allow that, would we? It would be immoral.

This is what Systems of Survival by Jane Jacobs is all about. Jacobs argued that there are two sets of “moral” rules — one appropriate for “guardians” (such as firemen, police and doctors), the other appropriate for “traders” (business people) — and that the two should not be mixed. When guardians follow commercial rules or when traders follow guardian rules, bad things happen. Sicko is about the bad things that happen when doctors follow commercial rules and how these bad things are avoided when (in other countries) doctors follow guardian rules.

20 Replies to “Michael Moore and Jane Jacobs”

  1. Seth,

    While you are clearly intelligent, your take on Sicko and socialized medicine is naive at best.

    Explain to me how socialized medicine, in the absence of visible prices, would ration healthcare.

    In Canada, healthcare is often rationed via someone’s ability to wait for an operation. In the UK and other places, after a certain age, people do not get operated on b/c it is considered a waste of public monies.

  2. Of course we take money into account when deciding who we’ll save from crime and fire. We decide, in advance, how much we will spend on police and firefighters, even though we know we could save more people if we spent more. Moreover, the amount spent on your protection from crime and fire does vary directly with your income because rich towns chose to buy better services than poor ones. Actual policemen and firemen may not follow “trader” rules but society follows trader rules in apportioning money for those services. What’s the difference where we take money into account?

  3. Varangy, that’s a very good question, outside my area of expertise.

    Varangy, you don’t clearly explain why my take on Sicko is naive. It is propaganda, not a think piece. There is a place for films and books that engage emotions. Sicko is a Common Sense for our times.

  4. Seth,

    Paine’s Common Sense was a political pamphlet that was written with the unambiguous intention of convincing people to get rid of their present government (Britain). Michael Moore’s film seeks to persuade people to look for a grand, centrally-planned health-care solution.

    No, Sicko is no the Common Sense of our times. Sicko asks us to return to a barbaric state of affairs where the politically connected and powerful are the most likely to have access to health care, and be well-off. Hence, it is more appropriate to say that Sicko is the Occasional Discourse on the Negro Question of our times.

  5. Scoop, we don’t require that the fire department or the police department post a profit, just as Moore says. It’s true that there is consideration of money but it is of a different sort.

  6. I don’t know seth.

    You criticism of our for-profit health care system seems to center on our top-down model. decisions are made according to wall street’s standards instead of those actually administering care, like doctors.

    yet, a single payer system, like canada, is even more top down structured than the US. a centralized agency chooses everything. there’s less flexibility. In the US doctors are more empowered because insurance companies are not unified.

  7. Seth,

    A few things. First, it seems to me that you carefully examine ideas before accepting them, and so I’m surprised to see you endorse a movie or an issue without carefully examining the counterarguments. “Common Sense” tells me that the Shangri-La diet wouldn’t work, and yet I wouldn’t accept that as truth without giving it a fair shake.

    I have to say that I’m shocked that someone who promotes a “heterodox” way of doing things in his own field would favor such a top-down, one-size-fits-all system when it comes to health care. The beauty of the free market (not that medicine is a free market now) is that experimentation flourishes and the best and most cost-effective methods for treatment and care rise to the top. Such a process is impossible when the government controls health care.

    When health care is “free” (paid for by massive tax increases), then the quantity demanded will be unlimited. Without prices to ration care, there will have to be some other rationing mechanism. It might be waiting lists, and more than a few people die every year in Canada waiting for treatment that takes only a few days in the U.S. (since you enjoy propaganda films, you should watch one from the other side of the fence: http://www.onthefencefilms.com/video/twowomen.html).

    A doctor motivated by money is far more trustworthy that a government bureaucrat. When the government provides services, the customer is a nuisance.

  8. My take on Moore’s movie is that above all it is meant to evoke outrage or disgust or sadness that will lead to action — that is, to change. To spell out what the new system should be is left for a different piece of communication. This is perfectly appropriate. Moore is not a thinker and he doesn’t claim to be one. His movie does so well what we always ask of art — that it evoke emotion. We don’t look to novels for solutions, at least we shouldn’t. Perhaps I should have called it a The Jungle for our times.

    I don’t favor any particular new system — that is beyond my expertise, as I have said. But I do favor some new system. The emotion evoked by Moore’s movie is reasonable and helpful, I believe.

    In a free market, you say, “the best and most cost-effective methods” rise to the top, and that such a process “is impossible when the government controls health care.” That’s an interesting point. I’m not so sure it’s impossible. If individuals and individual doctors can be empowered relative to a Washington bureaucracy, you may be wrong. After all people care about their health and getting the best possible treatment. The internet empowers them and maybe they can be empowered further. The voucher system is not incompatible with government control of education.

  9. The difference between police/fire and healthcare is that there is very little incentive to consume unlimited amounts of police/fire services, just because they are free.

  10. Good point, CD. If doctors were as effective as firemen, we would not argue about whether or not they are effective (see my earlier post about the Twilight of Expertise part 2, about doctors). People consume large amounts of health care, I believe, when their basic problems are not solved. E.g., they remain obese, diabetic, depressed, etc. This is what a doctor I know meant when she said “most of the people we see we can’t really help”. She worked in a community hospital.

  11. t is propaganda, not a think piece. There is a place for films and books that engage emotions. Sicko is a Common Sense for our times.

    It is clearly propaganda. Anti-american propaganda. I should point out that Anti-americanism while very chic as well as a cashbox for people of MM’s ilk is nothing less than a vicious prejudice. And you’re right, it does engage emotions, cruel ones that do not wish the US well.

    My take on Moore’s movie is that above all it is meant to evoke outrage or disgust or sadness that will lead to action — that is, to change. To spell out what the new system should be is left for a different piece of communication. This is perfectly appropriate. Moore is not a thinker and he doesn’t claim to be one.

    At least we almost agree here, MM IS NOT a thinker. But he does claim to be one.

    His movie does so well what we always ask of art — that it evoke emotion. We don’t look to novels for solutions, at least we shouldn’t. Perhaps I should have called it a The Jungle for our times.

    His denigration of the world’s best healthcare system (yes, I say that fully knowing its myriad, serious flaws and warts etc etc) is simply not art.

    I don’t favor any particular new system — that is beyond my expertise, as I have said. But I do favor some new system.

    That is rather weak, no? 🙂 YOU are a thinker – you must have an idea of what an ideal system would look like? Keep in mind, utopia does not count.

    The emotion evoked by Moore’s movie is reasonable and helpful, I believe.

    From having read your blog, I don’t think that you believe that predjudice of any sort is reasonable and helpful. And that is what this movie is about.

  12. I hope we can also agree that it is not the world’s best healthcare system for those without health insurance.

    I don’t think Moore’s movie is about prejudice. It is full of facts and examples. I don’t think it is “anti-American” to make a movie criticizing American health care. Lots of Americans agree with Moore — especially the uninsured.

  13. I agree with Seth that our health care system has serious issues (especially for the uninsured)

    and if Moore’s film provokes serious discussion on the issue without offering the Canadian or English system as a template, then that’s great. But I’m concerned that that most viewers of sickco will believe that those two flawed health care systems are the end all of exceptional health care.

    I believe France offers us a better model to look at. French health care offers breadth of coverage while remaining more decentralized than our health care system.

    Yet, Moore raves about Canadian and even Cuban health care due to their geographic proximity.

  14. I agree that healthcare has a conflict of interest which is inappropriate – profit vs quality care. Not sure that socializing healthcare is not just a tradeoff of other negative aspects though.

    As far as police – I hate to say I think there is frequently a conflict of interest as well since they are responsible for issuing tickets for all sorts of things and almost always those dollars go into their budget as well. For example – police have a motivation to have dangerous controlled intersections with red light cameras as these generate revenues. While it is always good to stop people from running red lights, from a police perspective there is motivation to write tickets as opposed to re-engineer the intersection to reduce that behavior.

    Jason

  15. One of Jacobs’s examples of commercial values being used inappropriately by guardians is about police — being given a quota of tickets to issue, I think.

    I don’t think Jacobs says it explicitly but an underlying idea of her book is that these two sets of values represent accumulated wisdom. That is, they are based on experience and perhaps competition between different ways of doing things.

  16. Seth – I am surprised to hear you speak so favorably of emotional, poorly researched propaganda. If someone inaccurately portrays the problem, or what the solution is, in an emotional manner which moves people, that does not help the debate. It adds noise. It gets people stirred up, without really understanding the subject. I think that’s a bad thing, not a good thing.

    I mean, undirected emotional manipulation is a good way to be popular, to get lots of viewers and sell lots of tickets. But why is it good? There is a reason “demagogue” has negative connotations.

    As an example, would you call Bush’s speeches about the War on Terror a good thing, because they get people stirred up about terrorism? I would call them a bad thing b/c they blindly evoke emotionally moving subjects while having little to do with reality. I’d describe Moore’s work (that which I’ve seen – I haven’t seen Sicko) the same way, just from the other side of the fence.

  17. A lot of these posts are fishy. I just don’t believe there are that many people out there still flogging the “socialized medicine” canard. I just don’t believe there are that many people out there happy with the way things are.

    There is some kind of orchestrated campaign to post on blogs going on.

  18. When Bush talked about us versus them, I was appalled and believed it was a step in the wrong direction. One big difference is that after 9/11, I thought the danger was overreaction. People were already stirred up. Bush rode the wave.

    I don’t think Moore has inaccurately portrayed the problem, nor would I say Sicko says what the solution is, except that it is different than what we have now in the direction of more universal coverage. It is going too far to say that a vague proposal is “inaccurate” or at least I don’t understand why you say that.

    Why is it good to get people “stirred up” in this instance? So that something will happen. In Demosclerosis by Jonathan Rausch he wrote about why so little changes in our federal government. One big reason, Rausch said, is that with any proposed change the people who have something to lose fight much harder than the people who have something to gain. In this case, to get anywhere — to improve health care — you need to energize the people who have something to gain. Namely, the public. Emotion = activation energy.

  19. The above comments tend to fall into an either-or stance: favoring either the current U.S. healthcare system or some sort of universal single-payer system. Actually, I think that both are seriously flawed for the same reason: they remove true market forces by severing the connection between the individual patient and the provider of health care solutions. In the U.S. we don’t have anything even closely approaching a true free market. Rather, we have a cartel of “approved” (and very expensive) solutions and we ban or place barriers on more effective, less expensive solutions.

    The real scandal is the high cost of health care – everywhere. If we removed subsidies (provided through both government and institutional insurance) and let folks spend their money on what really works, we’d quickly drive the market to more cost effective solutions. And in fact, many of today’s health care problems could be greatly diminished, if not reversed, by focusing on nutritional and dietary approaches — yes, including the Shangri-la Diet, the using of omega-3 oils, B vitamins, etc. Removing the subsidy to “Big Medicine” would drive people to more carefully look at how nutritional deficiencies, poor health habits, sedentary lifestyles, etc. underlie a good deal of the health crisis in this country. Research should shift to epidemiology, self-experimentation, nutritional science, and better methods for understanding biochemical individuality. We also need to radically change our liability laws which remove individual responsibility and prevent or discourage cheaper “non-orthodox” solutions. We rely on a methodology of mega-funded establishment medicine driven more by legal and political considerations than by true benefit to the medical consumer.

    The result of pulling the plug on “subsidized health care” would be a far more affordable, individualized, and effective approach to health care than what we have in EITHER the U.S. or in “socialized” Europe and Canada.

  20. Those are good points. By allowing a certain kind of research — focussed on cure rather than prevention — to get most of the research money, you end up with a very expensive system that doesn’t work very well. We have “doctors” who mainly try to cure people — what is the comparable prevention-focussed job? There isn’t one.

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