WHERE'S THE CARE IN HEALTH CARE?

January 27, 2011

Having delayed it a week in deference towards Representative Gabrielle Giffords, shot through the head in Tucson, the Republicans of the House brought up and voted en bloc to repeal the health-care bill signed into law just ten months ago. The measure is entitled "Repealing the Job-Killing Health Care Law Act." Job-killing? Killing, period? Now that's a lovely choice of words, considering the topic and the circumstances. But even something kinder and gentler — "job-eliminating" or "employment- effacing," for instance — wouldn't soften the Republican message that health-care legislation is about jobs, or about the deficit, or about taxation, or about states' rights — about anything but health.
As usual, the anything-but arguments are hardly compelling. Republicans contend that the law will "kill" jobs because businesses will let employees go rather than be burdened by either insuring them or paying an additional tax; Democrats say the effect will be minimal.
The ambiguity in the deficit argument is even greater. The Congressional Budget Office predicts that repealing the law will add $230 billion to the federal deficit over ten years, while the Republicans insist that keeping the existing law will add $701 billion. The fact made obvious by this divergence is that nobody really knows for sure. This isn't policy, it's politics.
But consider the case of Rep. Giffords. What will be the total cost of repairing her wounded brain and leading her to recovery — the hospitalization, the teams of medical specialists, the surgeries, the medications, and all the rehabilitation therapies — speech, occupational, physical - that will last for months or quite possibly years? The figure will be astronomical, and it will be paid for almost entirely by her federal insurance plan.
What of the 12 others wounded in the shooting? Five of them are over 65 and covered by Medicare. As for the rest, are there maybe some who have little or no health insurance? What will they and their families do?
Last month, Virginia federal judge Henry Hudson ruled that federally-mandated insurance coverage for almost all Americans, a key provision in the law intended to distribute the costs more equitably, violates the Commerce Clause of the U.S. Constitution. "Neither the Supreme Court nor any federal circuit court of appeals has extended Commerce Clause powers to compel an individual to involuntarily enter the stream of commerce by purchasing a commodity in the private market," he wrote. Virginia state attorney general Ken Cuccinelli, who brought the suit, remarked that "if the government can order you to buy health insurance, they can order you to buy a car, to buy asparagus, even cauliflower ... or join a gym. The power is expandable almost without limit if this is allowable and constitutional."
Two other federal judges have also weighed in on the question thus far, affirming the opposite, that the mandate is constitutional; so the issue is hardly settled. But while Cuccinelli's comment is just typically embarrassing Republican rhetoric (see "job-killing," above) the judge's sober analysis makes sense. Health insurance is no different from life insurance or homeowner's insurance; it's a product. How can the government compel people to buy it?
Health insurance is a commodity, "in the stream of commerce" — but the essential medical services it pays for are not. They are not a matter of choice, like cauliflower; they are a necessity.
Return to Rep. Giffords. When she was shot, the entire nation, and I daresay that includes the most libertarian opponents of health-care reform, focused single-mindedly on her condition and on the measures being taken by the heroic medical staff to save her life and restore her wholeness. In this tragic moment, health care suddenly was not about jobs or deficits or comparison shopping. It was about health.
And it's about us all. Rep. Giffords is exactly like the tens of thousands of people who will be hit with something just as unexpected and devastating this very day — a gunshot wound, a workplace accident, a heart attack, a diagnosis of cancer. Injury and disease are the absolute leveler, the one thing that eventually will afflict every single human being, from the billionaire to the indigent to the immigrant.
Despite its "laudable intentions," as Judge Hudson readily admitted, I believe the present law is flawed in preserving almost intact the role of insurance companies, reinforcing the notion that health care is product involving, in the judge's words, "an individual's right to choose to participate." It is not. Because it is a universal need, medical care should be considered a public responsibility whose burden must be shared by all. Like education, health care should be treated not as a commodity but as a civil right.

HIGH DRAMA IN HEALTH CARE

March 25, 2010

Last Sunday's rush to passage of the health-care reform bill by the House of Representatives was an example of high drama you never thought happened in a place better known for droning diatribes made to an empty chamber. It was a parliamentary flurry of motions and amendments and scrupulously-timed speechlets and nail-biting votes. For those watching it on TV, the experience was positively exhilarating, a seldom-seen live civics lesson on how bills become laws, how your do-nothing Congress actually does something. It may have changed the minds of not a few young voters about the value of entering public service.
Another civics lesson, far beyond the scope of textbooks, was the way in which Speaker Nancy Pelosi and President Barack Obama marshaled their recalcitrant troops for the necessary 216 votes, an outcome quite uncertain just hours before.
To the surprise of almost everybody, they hauled in the two big fighting fish of totally different ideological species, single-payer proponent Dennis Kucinich and abortion opponent Bart Stupak, along with their respective schools.
Exactly how they did it may never be fully known. No smarmy sweeteners like those bestowed on certain Senators are yet evident; it appears to have been the result of fervent appeal to party loyalty, the promise that their respective objections would not go unheeded, and Obama's Voltairian mantra, "We cannot let the perfect be the enemy of the good." Whatever the tactics, it was a masterful display of the power of persuasion, Dale Carnegie on steroids.
Of all the high drama, swaying Stupak and his anti-abortion Democratic colleagues was certainly the highest. Long before Saturday's vote, this new little caucus, whose convictions had been excluded from the Democratic tent and platform for decades, became the makers or breakers of health-care legislation. They were no naïve fools, either, showing serpentine political acumen first in allying themselves with the Republican minority to block passage of last November's House bill unless highly restrictive language on abortion funding were included, and then in pulling the rug out from under them by going with their party at virtually the last minute on Sunday ("Baby killer!").
Stupak himself was the best of all. Last week, when the Network nuns defied their own bishops by coming out in favor of the bill, he enfuriated them by declaring that "on right-to-life issues, we don't call the nuns"; days later, he reversed positions and became their hero. Most interestingly, Stupak and Co. not only exhibited a flexibility seldom seen in the anti- abortion movement but forced flexibility from staunch abortion- rights advocates Pelosi and Obama. Both sides, for the time being at least, eschewed the perfect for the good.
Many more fascinating developments still lie ahead. The first is what enactment of this law will do to the fate of the Democrats in general and Democrat-in-Chief Obama in particular. Over the months, the public has expressed ambivalence at best and hostility at worst both to the legislation and to the legislative process itself. Republicans act convinced that they can still tap into fears of "socialized medicine" and fan a backlash to the majority party's parliamentary ploys; Democrats act convinced that once the law is on the books and people see its immediate effects, they'll come around to support it. We'll get a hard sell from both sides right through the November elections.
The second development is development; reforming the health-care system is a work in progress. Next week, Senate Republicans will try to thwart the House's "fixes" to the new law, then try to repeal it altogether; neither attempt is likely to succeed. Progressive Democrats will do the opposite, proposing gradual changes leading to what they've wanted all along, a sleek and seamless single-payer plan. Having a law in place may allow them to do what they couldn't do in committee; as with Medicare — initially indefensible but now indispensable — they believe that once people see government actually doing some good, they'll ask for even more of it.
As with much high drama, the denouement may be as exciting as the climax.

THE HEALTH CARE VOTE

March 18, 2010

Can it possibly be? After a year of dithering, this week the Democratic leadership in the House of Representatives will actually attempt to ram through a health-care bill that has already passed the Senate and send it to the President's desk.
Forget the niceties. Forget bipartisanship. Even forget it's a bill many Democrats don't particularly like.
Just do it.
Finally, an act of courage from a party, or most of a party, now fabled for its spinelessness and liberal angst. Next thing you know they'll be taking on Big Coal.
Even their Supreme Leader Barack Obama has shed his failed big-tent strategy and is starting to act like Lyndon Johnson, postponing a trip to Indonesia to fan the embers of his dispirited base and to cajole his party's waverers in the House.
It's a do-or-die battle for House Speaker Nancy Pelosi and her minions. Unlike the Republicans, who stand like a stone wall against the legislation, the Democrats are the usual herd of cats. At one end, you've got all those Blue Cats that object because the bill goes too far; at the other you've got those Pink Cats that object because it doesn't go far enough; and then you've got the abortion-rights advocates and opponents, both reluctant to compromise.
Can Pelosi pull it off?
On the PBS NewsHour on Friday, pundits Mark Shield and David Brooks were both uncharacteristically flummoxed. "Right now they're short" of the 216 votes necessary to put the measure over the top, Brooks said. "But Pelosi is very smart and knows what she's doing. I don't see how they'll do it, but I assume they're very close."
If Obama, Pelosi, and Co. can come up with the votes, it will be the biggest legislative coup since Johnson passed Medicare in 1965, or at least since Clinton passed the surplus- generating tax hike by a tie-breaking vote in 1993. It would not only be a step towards reshaping U.S. health care; it would also give Democrats something like faith in themselves, a sense of solidarity that could result in bold initiatives on education, environment, agriculture, lobbying, obstructionists be damned. "Yes we can!" could at last be not a campaign slogan but a party mandate.
There's no doubt that the bill Pelosi wants to pass is flawed. It's your standard sausage, a mishmash of provisions that keep the present dysfunctional "system" virtually intact. Nevertheless, as many advocates of a "Medicare for All" single- payer system agree, it's far better than nothing, a modest reform that moves toward universal coverage and control of insurance- company policies and profits.
Believe it or not, there seems to be a certain sense of moral obligation to this effort. With mid-term elections coming up, many House Democrats in swing districts are rightly worried that a yes vote will give the Tea Party people ammunition enough to shoot them down. Their bet will have to be that Senate Minority Leader Mitch McConnell is wrong, that the American people don't "hate this bill" but are merely skittish about it, and that once it becomes a fact rather than a fantasy, they will eventually wonder how they ever got along without it, much like what happened with Medicare and, more recently, with Massachusetts' compulsory-insurance law.
Access to health care is not so much a matter of dollars as of justice. The Democrats now have the chance to show what they're made of. Amazingly, they just might be made of principle.

HEALTH CARE AS JUSTICE

September 17, 2009

The most moving part of Barack Obama's speech to Congress and the country on health care last week was his tribute to Ted Kennedy. He quoted from a letter the ailing senator had written in May, to be delivered after his death. "What we face," Kennedy wrote, "is above all a moral issue; at stake are not just the details of policy, but fundamental principles of social justice and the character of our country."
Obama went on to say that "part of the American character" is "a recognition that we are all in this together; that when fate turns against one of us, others are there to lend a helping hand," and that "sometimes government has to step in to deliver on that promise."
A major disappointment in Obama's approach to health care is that he has never framed the debate specifically in terms of moral principle and collective responsibility. He has used morality as a rhetorical device, as he did in this speech, but has never made a compelling philosophical argument that medical care is a basic human and civil right that demands a unified national commitment and the sacrifice of individual interest for the common good. Doing so would have changed the very nature of the debate, calling on legislators and the public to account for their various positions in ethical terms.
The fundamental moral question is: Is care for those who are sick part of the Constitution's pledge that "we the people of the United States" will "promote the general welfare," right along with ensuring domestic tranquility, providing for the common defense, and securing the blessings of liberty? Common sense would surely say so. When the country is threatened by swine flu, doesn't the federal government have the obligation to muster all of its resources, financial and technical, to combat and prevent it? Virtually no one would argue otherwise. Are not infant mortality, whose rate in this country is among the highest of all developed nations, and the thousands of needless deaths for lack of care to the uninsured and denial of care by insurance companies just a slower, institution-caused pandemic?
Is making money off the sick morally wrong? Aren't doctors and hospitals care-givers rather than businesses? Shouldn't insurance companies be simply risk-sharers, not profit centers? Denial of coverage for a woman with breast cancer, Obama lamented in his speech, "is heart-breaking, it is wrong, and no one should be treated that way in the United States of America." And yet, he said, "insurance executives don't do this because they are bad people. They do it because it's profitable" — strangely implying that profit is a good in every case. A law compelling all insurance companies to return to their roots as non-profit collectives would be an important step towards health-care justice.
Is health care a privilege reserved only to American citizens? "There are also those who claim that our reform efforts will insure illegal immigrants," Obama stated. "This too is false — the reforms I'm proposing would not apply to those who are here illegally." The "You lie!" blurt by Representative Joe Wilson of South Carolina only called attention to a moral contradiction. Health care is a universal human need. Denying coverage to illegals is not only morally inconsistent, it undermines the nation's collective health. Doesn't the good health of every person living in this country enhance the good health of all? The president himself noted that emergency-room care, mandated as a social obligation to the uninsured and to the illegal, adds "a hidden and growing tax" of $1,000 per insured person per year. Would it not simply be better, both morally and practically, to provide equal care to all human beings living in this country without scrutinizing their papers?
In his 1933 inaugural address on the economic crisis, Franklin Roosevelt saw the solution in "our interdependence on each other; that we can not merely take but we must give as well; that if we are to go forward, we must move as a trained and loyal army willing to sacrifice for the good of a common discipline." The situation is similar with health care today.
"I am not the first president to take up this cause," Obama stated at the beginning of his speech, "but I am determined to be the last."
As long as the fundamental principles of social justice, rather than the details of policy, are not addressed, his solution will only be an interim one.
With audacity, I hope he won't be the last.

HEALTH CARE: VISION, WORD, AND WILL

August 20, 2009

My friend Joanie tells the story of her bout with strep throat while vacationing in London some years back.
"I was getting really sick, so I went over to the medical clinic near where I was staying. A doctor saw me right away, did an examination and prescribed antibiotics, which I got at the dispensary right on the premises. The whole thing took maybe 40 minutes, and my total cost was something like $2.50 for the pills. And I was a foreigner! No questions asked, no identification to show, I just signed in. I was sick, so they treated me."
It's experiences like Joanie's that change Americans' minds about universal health care. What? No preliminary questions about payment? No paperwork? No cost? It makes you want to tip the doctor.
Britain's National Health Service (NHS) has been drawn into our own so-called debate in the most curious ways. Opponents of reform here have made the NHS a frightening caricature, the Ghost of Christmas Future if Congress adopts even modest changes to our non-system. They thought that the Brits' frequent complaints about the NHS for its acknowledged inadequacies was a sure sign they're ready to ditch it. But they got an unexpected reaction from across the Pond: Citizens were outraged at the exploitation and embarrassed for America's callous treatment of its sick. Despite its problems, they are fiercely loyal to their system. Even the leader of the Conservative party, David Cameron, last week declared forcefully that the NHS would be strengthened, never abolished.
What brings about such adamance in a country that's not only not socialist but that has privatized many other government entities over the last three decades? Perhaps it's because, like our Social Security system, the NHS was instituted in a time of crisis, after World War II, a living symbol of the cohesiveness that brought the country through the war. It removed a Dickensian social scourge and affirmed British dignity as a civilized people. After 60 years, universal health care in the United Kingdom is a given; it's part of the national identity.
You'd think that the U.S., so close to the U.K. in attitude and outlook, would come to see it this way too. Aren't we the most generous nation on earth? What is it about health care that has made it the hot-button issue, even more divisive than war?
Given the widespread dissatisfaction with skyrocketing costs and denials of coverage, the time seemed ripe for a real shift. Yet the same sorry arguments that have been used since Harry Truman's time are de-wheeling the reform juggernaut: socialized medicine and higher taxes. "If Barack Obama and the Democrats get their way," runs a Republican National Committee radio ad, "the federal government will make the decisions about your health care. And their plan costs a trillion dollars we don't have." Whether or not these assertions have anything to do with the actual proposed legislation is almost beside the point. The G- word and the T-word still cause inflammation of that little Darwinian lobe in the collective brain that evokes the self- reliant pioneers and the self-made John D. Rockefeller. No matter that it's insurance companies that now make your health-care decisions and that they're the ones that are taxing you; once the fever starts, the nation becomes delirious.
This could have been stopped.
As the history of effective leadership has shown, it takes a clear vision, a forceful word, and an iron will to dampen inflammatory rhetoric and rally the country around a cause.
Many of us thought this was what Obama was about. Remember "CHANGE"? "HOPE"? "YES, WE CAN!"?
Well, ah ... maybe we can.
Obama's problem with health care is that he thought he could apply the principle of dialogue, one of his most attractive and effective features, to achieve reform. Right after inauguration, he got all those health-policy wonks and insurance/drug execs around a table and they all came out smiling. Then he threw the ball to Congress, somehow presuming they'd play as a team to craft bipartisan legislation to his liking, instead of sending down a bill himself. The first hundred days have turned to 200, those executive smiles hover over the Capitol like the Cheshire cat's, the radical right saw the door wide open to bring him down, and now it's a town-hall free-for-all. Couldn't he see this coming?
The extent to which Obama has lost control of the issue was no better illustrated than by his exchange with the college student in Grand Junction, Colo., last Saturday, who asked him how private insurance could ever expect to compete with a government-run "public option." All he could say was, "This is a legitimate debate to have."
College kid wins. FDR turns in grave.
Rather than taking on the insurance/drug establishment (the correct answer to the student question is: "You're exactly right, and that's why we want it."), he's not only let them in the game but let them call the shots. And rather than taking on the ultra- right by identifying their smears as plain old lies, he tells us they're just "differences of opinion."
Remember Chicago on election night? Remember Inauguration Day? Obama once had the momentum to make health care a national imperative, a part of our identity, as it is in Britain.
No vision, no word, no will: No more.

MEDICARE FOR ALL?

August 13, 2009

The September issue of Consumer Reports is out. Cover story: "Ratings of 76 Health Plans."
Seventy-six health plans? And those are only the major ones identified in a survey of 37,500 CR subscribers.
Talk about bureaucracy. Most of those plans — 35 health maintenance organizations (HMO's) and 41 preferred provider organizations (PPO's) — operate in individual states; only a few are multi-state or nationwide. Each has its own policies and protocols, each its own billing and payment system, each its own customer service apparatus. It's no wonder that the average health-insurance premium rose 38% over the last two years, due substantially to administrative costs (lobbying included) that comprise around 30% of their budgets.
The CR article reports that 64% of those surveyed were "completely satisfied" with their insurance plan, wryly noting that such a "lukewarm response" is only slightly higher than the satisfaction level for cable TV companies. And as with cable TV, people can't use CR to comparison-shop for a better deal; they're basically stuck with whatever they've got.
The health-care "system" today isn't a system at all; it's a byzantine collection of individual units from providers to insurers, all out there to profit from the third thing that's sure in life besides death and taxes: sickness.
You'd think that with all the red tape people are tangled in (the CR survey rated the billing procedures of every single PPO as fair to poor), they would be clamoring for a simple, unobtrusive insurance system. Today, almost 30% of the people of America are covered by some form of government-funded insurance: Medicare for the elderly, Medicaid for the poor, S-CHIP for children, Tricare for military personnel and veterans. Medicare and the military programs, which are administered by the federal government, are user-friendly and immensely popular — so popular, in fact, that some people don't even think they're government- run; witness the widely-reported story of the man who told Rep. Robert Inglis of South Carolina, "Keep your government hands off my Medicare."
Why not take something that works admirably for people over 65 and extend it to everyone?
What Congress is now grinding out is the usual sausage — baloney, specifically: a hodgepodge of tinkering that leaves the non-system basically intact and has so confused and frightened the public that they're pulling back from these proposals like turtles into their shells. It's not that they've suddenly become happy with their health plans; it's just that they have utterly no idea about how these various thousand-page pieces of work will affect them.
That's why it was so refreshing to hear that Rep. Anthony Weiner of Brooklyn/Queens is introducing two bills into Congress, one to abolish Medicare and the other to extend Medicare to everyone. The first one is a piece of legislative irony you seldom see in the present climate of Congressional nastiness, daring all those public-payer paranoids to dismantle a program their constituents love. The second one is a straightforward single-payer alternative. Weiner had to wait a long time for this — he had to secure Speaker Nancy Pelosi's reluctant agreement to put single-payer on the docket — but it may in fact be a stroke of good timing. Many people, including some members of Congress, are so frustrated by the mishmash that they may take a good look at a plan that's clear, simple, and efficient (administrative costs for the present Medicare program are 3%).
So many of the objections to single-payer are driven not by evidence and common sense but by ideology, and of course by the insurance industry. As Weiner has noted, almost everybody who's privately insured has a single payer right now: their insurance company. There's very little "freedom of choice" involved; employers give few options other than choosing between an HMO and a PPO. The only difference is that their money is going to a business rather than to a government agency.
It's so strange that people and politicians can get so worked up about paying taxes and be so resigned to paying premiums. According to CR, the median annual premium of the individuals surveyed — that's not counting employer contributions — is now $1,829. Why not eliminate the premiums — and the companies that charge them — and tack that amount, and perhaps substantially less, onto a universal Medicare tax?
Once again, as in so many other legislative proposals both federal and state, there is apparently little in the several health-care bills about paying for them. President Obama himself has created his own "read-my-lips" moment by promising "no new taxes" on the middle class. But new programs should always be directly linked to new taxes. All this "creative financing" — cigarettes here, "the very wealthy" there — just leaves everybody, middle class included, with feelings of unfairness. The best solution is the most "transparent": a graduated health tax on income both individual and corporate. Right now, the Medicare tax is flat — 1.45% on all earnings for employer and employee, and 2.9% for the self-employed. Graduating the tax based on ability to pay (and that would include retirees, who presently pay nothing for Medicare Part A hospital insurance) would equitably raise the funds for universal health care.
The intangible health benefit of the current Medicare program lies in its providing not only insurance but assurance. It's guaranteed, and in most cases, it's hassle-free. People can worry about their health rather than their health insurance.
For those over 65, health care has come to be seen as a universal right. Why not extend that right to the population at large?

HEALTH CARE AT THE BATES MOTEL

July 5, 2007

Sicko. When I first saw the title of Michael Moore’s new movie on the state of health care at home and abroad, I thought: Uh-oh, he’s doing it again, squandering an opportunity to be a real player in a critical national issue by veering to his base of leftist absurdists and letting the right write him off as the Holy Fool. Why not call it something less flippant, more engaging, more Al Gore-like? Well, maybe not.

Moore likes allusions to the classics. His last work, Fahrenheit 9/11, was a faint thematic echo of Ray Bradbury’s dystopic book and film. Sicko may well be a distant accolade to Alfred Hitchcock. Perhaps he wants our subconscious to imagine the American health care "system" as a gargantuan Bates Motel, with the insurance companies as the bloodthirsty proprietors and the federal government as their embalmed mother.

However off-putting the title may be to some, the topic itself is so timely that the movie may draw the curious of all persuasions into the theaters just to see what Moore does with it - or to it.
They won’t be disappointed. Aesthetically, the film is great satire, pitting irony against irony at every turn. Politically, it is provocative in the best sense, challenging the country and its leaders to quit dancing around the question and face it head-on: Why not universal health care?

Moore began his project with a simple little inquiry on his website, michaelmoore.com: If you’ve had any problems with your health insurance, contact me. Within weeks, e-mail responses ran to the tens of thousands. With his characteristic genius for culling through mountains of data to find the perfect illustrations, he selected witnesses with both telling cases and good camera presence, people like you and me with stories like yours and mine. Among them are a middle-aged couple forced into bankruptcy by life-threatening diseases, moving in with one of their children; a wiry, wry retiree working as a supermarket janitor to meet his drug expenses; a bearded, good-natured craftsman who cut off two of his finger-tips at his table saw and left them that way rather than pay the $75,000 his insurance company wouldn’t; a sampling of ailing 9/11 rescue volunteers excluded from the government’s paltry compensation plan; and the wide-spread news story of the deranged indigent woman dropped off at the door of the Union Rescue Mission in L.A. by Kaiser Permanente Hospital.

Unlike his previous films, Moore made no attempt to barge into the offices of the corporate big shots to gather embarrassing off-the-cuff comments, mostly because he didn’t have to: Insurance company employees were coming out of the woodwork by the hundreds with plenty of heart-rending tales of their own: There is, for example, the young customer service rep, tearfully describing her daily agony of knowing that her desperate applicants would be denied coverage because of preexisting conditions; and then the former adjustor burdened with guilt over the thousands of people whose claims he rejected - and received bonuses for.

Also unlike Moore’s other movies, this one actually shows a very bright side to the issue - unfortunately, he has to go across the border to find it, always with a clever segue. First he drops up to Canada, where a single mother from Detroit has established a common-law marriage of convenience with an acquaintance and drives up as needed for checkups and treatment for herself and her daughter. Then he flies off to England, where an American Beatles fan who broke his arm while attempting a somersault across Abbey Road (all documented on a friend’s home video) found to his amazement that the British National Health Service fixed him up immediately, for free. Then down to France, where young American expatriates relax with Moore in a lovely restaurant, telling stories of French health care complete with doctors who make house calls and nannies supplied by the government not only to do child-care but the laundry too - all without a bill.

And finally, across to Cuba, where Moore loads his dispirited 9/11 volunteers onto a motorboat, sails within bullhorn distance of the Guantanamo prison, and pleads for admittance, since Pentagon officials had proudly testified that the enemy combatants there receive top-notch medical care, including dentistry, eyeglasses, and routine annual colonoscopies, at full government expense. Failing that, he takes them to a Havana hospital, where they are welcomed effusively and are given all the MRI’s and dental work and medications denied them in the U.S.A.

The Cuban episode is a reversion to those stretch-the-truth shenanigans of his earlier works, quite obviously contrived and thus the weakest part of the film. It is also the cleverest.

After all this, Moore pops his simple question. He reminds us of all the public things that benefit us throughout our lives and over which there is no controversy: free public education, free public libraries, free public museums, free public fire and police protection. Why not, he asks, free public health care?

Of course, for all of the above, "free" is never really free, and Moore, the polemicist, sidesteps the problems of financing and cost-containment both abroad and at home. What he does do is to brilliantly illustrate the real meaning of "free" in these cases: The complete leveling of society, where rich and poor have equal access to those things essential to human well-being. Yes, taxes are higher in countries with universal health care, but most of their citizens agree that it’s a small price to pay for peace of mind.

As the population ages, there is more and more general sentiment in favor of universal health care. Nevertheless, it will take a popular revolt, led by visionary public officials, to break the back of big insurance and big pharmaceutical. This is not forthcoming - just review the half-hearted positions of the major precedential candidates on the issue, all of whom are beholden to the drug and insurance lobbies.

In the final scene, Michael Moore, that corpulent gadfly with the basset-hound eyes, lumbers up the steps of the U.S. Capitol with his bag of dirty laundry. If the French can do it, why can’t we?