'Sicko' For Smarties

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BOOKS AND ARTS APRIL 15, 2008

'Sicko' For Smarties

It was a little less than a year ago that filmmaker Michael Moore got the nation’s attention with Sicko. But it’s hard to know how many people watching the film came away convinced, particularly when it came to Moore’s portrayal of health care systems abroad.

Critics of universal coverage have long claimed that such systems inevitably lead to long waits, substandard care, and generally unsatisfied patients; to counter these arguments, Moore showcased happy patients in Britain, Canada, and France. But while Moore presented these stories with great style--a sequence about the house calls available to Parisians was superb--he didn’t always tell the completely story. He failed to mention that in some (though not all) of these countries, waiting for non-emergency medical services has been a chronic problem. Nor did he point out that, even in universal health care systems, sometimes officials end up rejecting treatments because they are unproven or simply not cost-effective. And if viewers weren’t clued into these nuances, Moore’s reputation for intellectual rigor (or lack thereof) probably left many more than a little skeptical.

That’s why I wish I could make all of these people watch a documentary airing tonight on “Frontline.” It’s called “Sick Around the World” (PBS, Tuesday night at 9 p.m.). And, like Moore’s Sicko, it takes viewers on a tour of some notable health care systems from different countries. But the tour guide this time isn’t a self-described provocateur. It’s a veteran and well-respected journalist, Washington Post correspondent T.R. Reid. Running things from behind the camera is an equally acclaimed filmmaker named Jon Palfreman.

Here I have to confess a bias: I’ve known Jon since 2002, when we both had fellowships with the Kaiser Family Foundation. (More disclosures: The Kaiser Foundation also helped underwrite this documentary. Another sponsor is the Commonwealth Fund, where I have also sought funding for research.) But I think the film stands up just fine on its own terms. Unlike Sicko, “Sick Around the World” isn’t afraid to talk about the problems in other countries. In England, the film notes, patients frequently wait for elective services; in Germany, physicians are unhappy that they don’t get paid more; in Japan, the government’s hyper-aggressive price controls have led to chronic underfunding. And yet the new film also puts these drawbacks in their rightful context. Every system the film portrays has its problems, but overall each one seems to deliver a better total package than the one in the U.S.

The most interesting case study is probably Taiwan. A few years ago, when Taiwan decided to revamp its health care system, it studied other countries to determine which system might work best. Its conclusion? A single-payer system--one in which the government insures everybody directly--made the most sense.

Virtually alone among health care commentators in the U.S.--a category that includes me--Paul Krugman has been touting Taiwan for a while. The film makes it easy to see why. Today, the people of Taiwan have guaranteed access to health care--and, according to the film, it’s very good health care. There are no chronic waiting lists, like you find in Britain, and the care is very advanced. Among other things, Taiwan is among the world leaders in establishing electronic medical records--an innovation that should significantly improve care by keeping doctors and nurses better informed about patient histories and, no less important, avoiding potentially dangerous drug interactions.

Reid and Palfreman note, rightly, that the Taiwanese system isn’t as foreign as it seems: We actually have a similar program here in the U.S.--for the elderly. It’s called Medicare.

Single-payer is still a tough sell politically, at least in this country. Fortunately, “Sick Around the World” makes it clear that alternatives to single-payer work pretty well, too. The reports from Germany, Japan, and Switzerland make it clear that it’s possible to have everything Americans like about their health care system--quick access, choice of doctor and provider, high quality care--while covering everybody and spending less. The film also does an admirable job of pointing out the virtues of a system like England’s, which may be too spartan for American tastes but nevertheless has been a true innovator when it comes to encouraging quality and cost-effective spending.

I did have two quibbles--one stylistic and one substantive. The stylistic one is about the film’s scope, which inevitably limits its depth. A documentary can never capture the nuances the way an article or policy brief could, nor should it. (That’s not the point of making a film!) But if Palfreman and Reid had been willing to sacrifice even one of their countries, they could have addressed some of the questions they leave out presently. If nothing else, I would have loved a rejoinder to the claim, made famous by Rudy Giuliani last year, that universal coverage systems inevitably stymie the development and diffusion of advanced cancer treatments. (Here’s mine.)

My other, more important criticism is about the final sequence--which turns to the politics of health care here in America. One by one, the three remaining presidential candidates outline their positions on reform. Then Reid offers his take: “If you listen carefully none of the candidates talks much about the lessons we could learn from other rich democracies like the ones I visited.” This is literally true: The presidential candidates don’t talk about other countries, except (for opponents of universal coverage, like McCain) to bash them.

But both of the Democrats call for covering everybody--and for overhauling the system so that it can achieve the sorts efficiencies the best systems abroad have realized. Their plans, if implemented as they’ve been drawn up, would make American health care look a lot like the Swiss version.

Neither plan would accomplish that transition overnight. (Clinton’s would come closer, because she would literally require that everybody be part of the system; Senator Ron Wyden’s promising bill would probably come closer still.) Still, that’s a far cry from what McCain and much of his party advocates, which is essentially to fix the existing patchwork with even more patches. And that’s a crucial difference of which viewers (and voters) should be aware.

But those are minor quibbles. This is an important, most welcomed contribution to the debate over health care--definitely worth a look tonight.

Jonathan Cohn is a senior editor at The New Republic and the author of Sick: The untold story of America's health care crisis--and the people who pay the price (HarperCollins).

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