Michael Moore closes his movie SiCKO with a quotation from Alexis de Tocqueville. His paean to French social welfare benefits perhaps has to end with a Frenchman’s unique view of America, but a more appropriate lament for the state of America’s vision of ourselves should come from an earlier source, from the pen of one of America’s English founders and settlers, John Winthrop.

As the Puritans were sailing on board the Arbella in 1630, bound for Massachusetts Bay, Winthrop, their leader, wrote a famous sermon, a text that has been used for the basis of American “exceptionalism” ever since:

“We shall find that the God of Israel is among us, when ten of us shall be able to resist a thousand of our enemies; when He shall make us a praise and glory that men shall say of succeeding plantations, ‘may the Lord make it like of New England.’ For we must consider that we shall be as a city upon a hill. The eyes of all people are upon us.”

What is often forgotten in discussing Winthrop’s uniquely distinctive vision is that it was also communitarian [see Amitai Etzioni’s free-access article on communitarian principles]. In numerous places in Winthrop’s sermon he reminds his followers that they bear responsibility for one another’s condition:

“We must delight in each other, make others’ conditions our own, rejoice together, mourn together, labor and suffer together, always having before our eyes our community as members of the same body.” And “we must bear one another’s burdens. We must not look only on our own things, but also on the things of our brethren.”

More than 375 years later we are still struggling with how to be both uniquely and individually American and yet knit together as a caring community. Princeton economist Uwe Reinhardt spoke of this American community ethos recently on NPR, and also 20 years ago in Health Affairs [free access]:

“Americans must ask themselves this fundamental question: Should an American citizen in, say, New England be at all concerned with what health care is or is not being given to a suffering American infant or adult in, say, Texas or Florida, and vice versa? If the answer to this question is ‘no,’ then, with all respect, one must judge this country to be less of a nation than is ritually professed on the Fourth of July. An affirmative answer, on the other hand, would seem to imply direct federal involvement in defining and financing the floor below which no American is permitted to sink in health care.”

The current looming political divide over universal health care exemplifies this struggle over the American social contract. While Moore’s movie and its right-wing critics paint this divide as a huge chasm between those who believe in the profit motive versus socialism, the reality is that soon nearly half of U.S. health care will be provided by the government. Almost half of all Americans with insurance have the government paying for part or all of their care and the salaries of their providers through Medicaid, SCHIP, Medicare, Tricare, and the Department of Veterans Affairs. None of these are particularly socialist.

The great political battle of the summer is where we draw the lines in the increasingly murky divide between private and public. Private insurance has been both declining and growing more costly. How do we as a country address the decline and the costs? The SCHIP reauthorization is but a battle in this debate, but hopefully not one portending a war. SCHIP has combined aspects of federal, state, and private support in extending the safety net to poor but not impoverished children and at times their parents. The question before Congress for the summer is, Do we pull back from where SCHIP has taken many states, providing health insurance to kids and sometimes parents whose family incomes are over 200 percent of the federal poverty level? Or do we continue as a country to provide for our neediest citizens, even if they are not our poorest, making health insurance available in a uniquely American mix of federal, state, and private sources?

Moore argues that we betray the promise of America if we do not provide for our sick. Other countries can do it, why don’t we? The question for Americans and Congress as we come up to the July 4th holiday, SCHIP reauthorization, and the 2008 elections is, How do we do this in an American system?

Additional reading: See Maggie Mahar’s review of SiCKO on The Health Care Blog. Also, starting July 26, Health Affairs will be publishing a series of articles on SCHIP reauthorization.