The market of exceptions and Michael Moore's Sicko

I saw Michael Moore’s Sicko on the last day that it was showing in Northampton. Sitting by myself in the basement of Pleasant Street Theater, I had nothing better to do before movie began than to listen to the two elderly couples ahead of me discussing what they had heard about the film, their own medical woes, and how easy it was for them to see a doctor. Neither couple needed to use Medicare because in each case they had continuous coverage through their former employers. I could tell they thought of themselves as the fortunate ones. It turns out that they are not only the intended audience of the film but the subject of the film as well. For that matter, so am I.

Insurance as assurance

As he states from the outset, the focus of Moore’s film is not 45 to 60 million people who are excluded from access to care, rather it is a critique of the accessibility of care for those who think they are “covered.” His diagnosis seems to be that the private managers of care access consistently manage costs (and maximize profits) by ensuring that it is difficult to access care in the event that you actually need it. The more serious the ailment or injury the harder they try to impose constraints. Why are we surprised by this? Isn’t this the same sort of behavior (minimizing liabilities and maximizing gains) that we celebrate elsewhere in society? What would ever have led us to believe that things would be, or should be different in the domain of health care? I realize these questions bespeak a kind of naiveté, but I think these expectationsnot only have to do with caring labor itself but actually with the expectations/entailments that surround insurance. It is here what we expect and what we actually obtain diverge most widely.

Insurance, Uwe Reinhardt observed, is a socialization of risk whether it is delivered to us by the state or purchased from a private firm in the market. This socialization of risk, on a fundamental level, is simultaneously the creation of a fund that mitigates risk by entrusting the eventuality of illness or injury to an imagined community. The very nature of the service that “insurance” provides invites us to have faith that our needs will be met, that we will be taken care of, should the need arise. What Moore reveals is the chimerical nature of this social contract in the United States—this feeling of being “covered” lasts only so long as we do not need to actually access the health care system. Insurance is understood as the assurance that things will be okay. For many people, when the need actually arises, these assurances often reveal themselves as a cruel joke.

From “profit” to “surplus”

Part of Moore’s agenda is to challenge the idea that “profit” should have anything to do with health care or its allocation. I will return to this point at the end and argue that those of us who would like to see “profit” eliminated from health care must be equally insistent upon our support of an allocation of “surplus” for care. This is not a point that we can approach directly. The distance that separates “profit” from “surplus” is vast and must be traversed in precisely the way that Moore suggests—through a sort of “cultural” shift in perspective. By digressing into how the film (and Moore himself) has been received by critics I think we can brush in broad strokes the kind of cultural transformation Moore is attempting to produce in his films before addressing what might be missing from our perspective (as anti-essentialist Marxists).

In reading reviews of the film, two remarks seem to appear over and over again (though not necessarily in the same review). First, some argue that Sicko marks a point of departure in Moore’s cinematic career, that it was a sort of strategic move to the center. Unlike the preceding films—Bowling for Columbine and Fahrenheit 911—Moore seems to make a film here that had the potential to speak to the “insured” majority, even to those who would dismiss his documentary efforts out of hand as so much spin. The second common remark was that Moore continues to indulge in a sort of smarmy sentimentality—that he takes over the screen through his abundant corporeality and his willingness to stage an encounter between victims of the 911 rescue efforts and Cuban health care system and rescue workers.

In response to these observations, I would like to make the following claims. First, Sicko should be read as the third part in a trilogy and that its main argument entirely consistent with the themes that he explored in his previous two films. Second, Moore’s ‘sentimentality’, which seems to draw such a negative reaction—from “liberals” as well as “conservatives”—, stems from his effort to tell a particular story that makes both “sides” uncomfortable. In each of these films, he produces a complicated representation of the U.S. culture—particularly its tendency towards fear, aggression, and mistrust. This fear/aggression is inwardly directed in Bowling for Columbine and xenophobic Fahrenheit 9/11. In some ways, Sicko brushes up against this culture of mistrust in its most abstract form. The “fear” that this film seems to circle around is the fear that a national health insurance system would result in out-of-control demand—manifesting itself in long lines, higher taxes, and diminished personal opportunity. Moore does his best to allay these fears by interviewing a successful French couple, pointing out that physicians live quite well in the U.K, and that the wait for treatment in other countries in most cases is not too much longer than in the United States.

Ultimately though I think Moore realizes that these anecdotal examples and arguments are not going to be sufficient to produce the cultural shift in perspective that he is hoping for. This fear of the other(’s demand) is not so easily dispelled. It reflects a deep seated economistic belief in America’s “individualist” psyche. The telling moment in the film was when Moore casually asked the French physician if something similar to the French health care system could be created in the United States to which the Frenchmanautomatically responded with an emphatic “NO”. Moore’s hope is to somehow produce a counter-narrative U.S. history and culture, an alternative identity founded in a sense of hospitality and generosity. I think this effort, and its sometimes latent sometimes explicit patriotism, is regarded as hypocritical by his critics on the right and with hostility on the left because it breaks from the usual left-critical agenda. The usual charge that follows this is that Moore is a muddled populist who raises some good points but fails to deliver a comprehensive analysis (a.k.a., to make a documentary film that no one would actually watch).

At the risk of boring everyone in a different way [No Bigbadbull, you are not boring us. Editor.] I would like to take a different critical approach to Moore’s work. Rather than suggest that Moore is a smarmy opportunist, a hypocrite (and he may well be both of those things, I do not know the man) or that he is theoretically muddled, I think there is a way of reading his film in relation to contemporary theory which reveals a depth in the film. My approach here is to argue that Moore’s film reflects some of the decisive issues in contemporary social theory and that there is an attendant theoretical sophistication to the film that he may or may not have been aware.

Moore with Agamben

Moore’s trip to Guantanamo Bay was to demonstrate that the enemies of the United States get better care than the people who heroically attended to the 9/11 disaster (a dramatic move based on the false premise that the people confined there are actually receiving the care the government says they are). If it is not correct to say that enemy combatants receive better care than American heroes (though both parties would fare better under the Cuban system), than what is the correct relationship between the enemy combatants and Americans who are nominally insured but find themselves outside of the care system? This question got me thinking about Giorgio Agamben’s Homo Sacer and The State of Exception and their analyses of governance. What I would like to argue here is that beneath Moore’s false premise—that Guantanamo inmates have universal health care and we don’t—is a more startling truth that also comes through in the film when the film is read in a particular way.

Michael’s false start—his brief consideration of the man who needed to choose between his middle finger and his ring finger (I would have picked the middle, of course) and other examples of the excluded were truly unsettling. Moore lets know that these people—who also look like the average American to his audience—are not the focus of his film. This, of course, begs the question: Why not!?! I think Moore’s strategic decision to focus on the “insured” rather than the uninsured partially confirms a fear that I have about what the usual call for universal access logically implies to skeptics. Namely, if the system is already inadequate, how much will it be helped by extending coverage to 45 to 60 million more people? Of course, the easy way in which the current rhetoric around access has shifted to identify immigrant demand for health care as part of the problem reveals the extent to which the broader public is unconsciously invested in a logic of scarcity.

Here I am reminded of Agamben’s reflections on the role of both an excluded other (the terrorist) and the state that defines itself as the exception endowed with the ability and entrusted with the duty to suppress this disruptive power of the excluded. The logic of the constitutive exception and its counter part, homo sacer, work to define the parameters of citizenship—who is under the law’s protection and who is beneath it--but they function as a conceptual topology. The example Agamben gives us is that of the ban—in which a person is simultaneously outside of the law of one state while also being clearly defined by it—that what emerges here is a zone of indetermination where the banned is simultaneously inside and outside of the law.

[It's not just the identity of the citizen that is defined within this topological space but their rights as well. In some sense we can see already that a citizen’s right to care, is only secure so long as the rights of non-citizens are denied—though really we should not accept this at face value (most Europeans would insist on carrying travelers insurance within the United States but in other countries, the need for treating foreigners is more or less just seen as a cost that can be socially borne.)]

Zizek’s chilling observation is that the meaning of this zone of indetermination establishes the exception and the excluded other is precisely to be found in this conceptual indetermination, its expandability. We are all, potentially, homo sacer: A subject that can be killed without being sacrificed.

Linda Peno, in her testimony before congress, spoke precisely on this point. Working for a private insurance company she condemned people to death without it being deemed a murder but is instead a justifiable denial of treatment. I think Peno’s testimony brings something about insurance secured through a private company into relief. The “buyer” of insurance is not in a position to understand all the contingencies that might emerge in relation to choosing one particular insurance plan as opposed to another. It's true, access to medical care in countries with socialized medicine can be restricted to medicines and treatments with proven (as opposed to experimental) efficacy but the fact that this is done through the state means, in theory, there is political redress.

Consider for instance the following scenario. If I were to have Blue Cross medical and discover that I had a condition that required a treatment that they refused to pay for, it would, at that point, be too late to switch to another plan and would most probably be too large an expense to bear myself. Faced with such a predicament, it is usually understandable for the afflicted individual to exclaim—“Why did I bother with insurance when they are not, in fact good for anything?” There are two possible explanations for this. When we secure insurance (whether we purchase it ourselves or obtain it through an employer) we are not paying into a bank that will payout in our time of need, we are in fact paying for the insurer to act as a broker of sorts, effectively securing a rate of discount for us with a physician or hospital—paying these providers a certain amount and leaving the remainder for us. While insurance is, as Reinhardt says, a collectivization of risk, which risks are deemed “acceptable” and “worth taking” are not specified beforehand because they are at the discretion of the private insurer. The decision as to whether or not to pay for an experimental treatment for stage IV breast cancer is something an insurer decides—it is not, in a straightforward way, up for negotiation. Is it not the case then that the insurer acts as Agamben’s sovereign—as the entity that administers bare life?

Totalitarianism Insured

“Politics in our age had been entirely transformed into biopolitics was it possible for politics to for politics to be constituted as totalitarian politics to a degree hitherto unknown.” (Agamben, Homo Sacer, 120)

As the film underscored with several examples, this privately administered zone of indetermination that separates inside from outside, the insured from the excluded, is administered retroactively—the example of the woman who was denied treatment for a serious illness because she had failed to disclose an aspect of her past history (a yeast infection). It is easy enough to recognize the “totalitarian”/undemocratic way in which health care access is allocated. I am not sure however that this is the real scandal. My diagnosis is that, on a certain level, most people in the U.S. would prefer to have a bio-politics of administration than to wrestle with the difficult issues—ethical and economic—as it pertains to the allocation of care.

This freedom from worry and ethical responsibility has a price.

As much as I think Moore might be right that the U.S. culture is currently dominated by fear as well as a calculating mistrust of the other’s demand (for care, for work, etc.), I am not sure that the correct solution is necessarily to just remind Americans of their generous and charitable past. At the same time, I think what needs to be confronted more directly is our passivity. Just to speculate for a moment, what if the ideological comfort that insurance as it currently exists offers is that the anonymous bureaucrat does the wet work of sacrifice without our having to know about it?

There is another, larger question, that Moore raises without really pursuing it too far. Social security is a collectivized response to the problem of old age and the need to reproduce oneself after one has stopped working. As Hayakawa pointed out in the early 1940s, there is an important difference between how we understand social security and the way we think about various “social entitlements”—welfare payments, food stamps, and Medicaid. Social security is understood as a universal system that is not administered on the basis of need—rather it is a social guarantee that we can enforce because everyone is perceived as having “paid into” the system. In contrast, programs like Medicaid are a type of entitlement that accrues to some because of their indigence, but not to others. The recent declaration by President Bush that he would veto the measure to extend SCHIP (the program that insures children in families that earn up to three times above poverty) is a case in point as to how decisions get made in relation to needs-based entitlements—who gets it, how big is the entitlement, and how long should it last, lest we encourage the dreaded “dependence” are all relevant questions because of the basic way that we perceive these types of social reproduction.

In principle, of course, I do not have a problem with the ethical standard—“from each according to their ability, to each according to his need”. The allocation of care, social support, and welfare is always going to be conducted in relation to this ethic because the need for care is not evenly distributed and capacities—no matter how blessed we are—are highly contingent. Perhaps our resistance to thinking of health insurance as a type of social security—as something that all are entitled to regardless of need—could be overcome if we came to see ourselves as having already earned it.

I think there might be a number of ways of doing this that carry us beyond what gets represented and discussed in Moore’s films—though he comes closest in his interview with Tony Benn—and back to some of the very issues that Saint ymM represented in his post on the subject some weeks ago.