JULY 2, 2007
The warnings went out in a 2004 company newsletter: Watch out for "ascruffy guy in a baseball cap." The scruffy guy was Michael Mooreand the company was pharmaceutical giant GlaxoSmithKline, whoseexecutives had gotten wind of Moore's new project: a documentaryabout the health care system called Sicko. The executives figuredit was only a matter of time before Moore showed up on theirdoorstep, camera in hand--if he hadn't already. "We have sixbusiness centers nationwide," a Glaxo official confided to the LosAngeles Times, "all of which report sightings."
Earlier this month, when I got my first glimpse of Sicko, I feltsimilar trepidation, though for rather different reasons. My biasin watching Moore's film is that, in the broad sense, I agree withhim. I've been writing about the flaws of the U.S. health caresystem, and the need for universal health insurance, for nearly adecade now. (And, yes, I recently wrote a book with almost theexact same title as Moore's movie--Sick--although I'm pretty sure Ithought of it first.) But Moore has not always been the mostintellectually rigorous storyteller--or, for liberals, the mostuseful ally. Fahrenheit 9/11, Moore's attack on the Bushadministration and the Iraq war, may be wildly popular amongBush-haters and the most financially successful documentary ever.But a lot of people think it also ended up helping Bush winreelection, by trading in unsubstantiated conspiracy theories andfiring up the Republican base. As Jon Feltheimer, the CEO of Lion'sGate Films, told Vanity Fair, "I've been told a number of times [byRepublicans], 'Isn't it great what you've done for the party?'"
As Sicko rolled, it did little to allay my fears. I spotted plentyof intellectual dishonesties and arguments without context--enough,surely, to keep right-wing truth squads (and some left-wing ones)busy for weeks. Moore also couldn't help but stick in unrelatedjabs about the Bush administration's efforts to fight terrorism andinsisted on hyping Cuba's medical system--an awfully poor way tocounter the generations-old slander that universal health care istantamount to "socialized medicine."
Still, by the time the final credits ran, it was hard to get tooworked up about all of that. Because, beyond all the grandstandingand political theater, the movie actually made a compellingargument about what's wrong with U.S. health care and how to fixit. Sicko got a lot of the little things wrong. But it got most ofthe big things right.
When Moore was filming Sicko, he frequently told people that he wasfilming a comedy about the 45 million Americans who don't havehealth insurance--people who represent the most glaring failure ofU.S. health care. And, in fact, the opening sequence of his movieportrays two people in precisely that situation-- one of whom isRick, who accidentally sawed off the tops of two fingers whileworking at home. With no insurance to pay the bill and limited fundsat his disposal, he has to choose whether to have the hospitalreattach his middle finger for $60,000 or his ring finger for$12,000. (He chooses the ring finger.)
But, as Moore quickly explains, uninsured Americans aren't theprimary subject of his film. Instead, he announces to the backdropof 1950s music and newsreel footage, he's chosen to focus on therest of America, the people who do have insurance and the hardshipmany of them go through anyway. He does so primarily by telling thestories of hapless victims, deftly weaving farce and tragedy. Wehear both from a woman who gets stuck with an ambulance billbecause she didn't clear the charge with her insurer before losingconsciousness during a car accident and from the widow of TracyPierce, who died after his insurer denied a potentially life-savingbone-marrow transplant for his kidney cancer.
Moore isn't aiming for balance: Officials defending the health careindustry don't get any airtime. Instead, Moore gives us the viewsof former insiders turned whistleblowers--like Linda Peeno, formermedical director at the HMO Humana. Peeno stopped working there inthe late '80s after becoming disgusted with pressure to denycoverage-- including for a heart transplant for a man who otherwisemight have lived. Moore also introduces viewers to Lee Einer, whosejob at a major insurance carrier (Moore doesn't say which) was topore over insurance applications retroactively, focusing on peoplewith large claims in order to find evidence that they had hiddenprevious conditions. As Einer explains, it was widely understoodthat intent to mislead was irrelevant; the companies just wantedexcuses to avoid paying bills. (To illustrate what this means inpractice, Moore also tells the story of a woman whose carrierpulled coverage after an operation, because on her application shedidn't mention a past yeast infection.)
Moore wants to weave these tales into an indictment of the idea thatfor- profit companies can be counted upon to provide Americans withaffordable medical care. But that's a complicated argument to make.Even an intellectually rigorous filmmaker would have to cut a fewcorners; Moore cuts many.
Sometimes, for example, there are good reasons to deny coverage ofexperimental treatments. In the 1990s, HMOs caught a lot of grieffor denying bone-marrow transplants to breast cancer victims. Yearslater, studies showed the treatments--which are both expensive andpainful--worked in only a tiny fraction of special cases. Would thebone-marrow transplant denied to Pierce have made a difference? Itseems unlikely. Experts told me that the treatment never made itpast the experimental phase because of ineffectiveness and harmfulside-effects.
But, while not every HMO treatment denial bears second-guessing,many do: During the '90s, peer-reviewed studies showed thatinsurance companies were cutting costs in ways that routinelyjeopardized patient care. Nor is there any doubt that insurers trydesperately to avoid covering people with serious medicalconditions: Following exposes by Lisa Girion in the Los AngelesTimes, California officials investigated BlueCross for preciselythe kind of practices Lee Einer describes, eventually fining theinsurer $1 million because it was rescinding coverage without evenasking policy-holders about supposed misrepresentations. AlthoughWellpoint, the parent company of Blue Cross, denied wrongdoing, italso promised to change its cancellation procedures.
Still, while it's easy to beat up on insurance companies that denycoverage-- or drug companies that charge a lot of money, oremployers that don't offer their workers benefits--the truth isthat they're all acting rationally. They're businesses, after all,and businesses are designed to make profits-- which, it turns out,isn't always in the best of interests of people who are sick. Ifyou want a different outcome, you need to come up with a differentsystem, one that starts by guaranteeing every single person healthinsurance and making sure that insurance includes generousbenefits.
Moore spends the second half of his film concentrating on systemsabroad that do precisely this. Over the years, opponents ofuniversal health care have scared middle-class voters into thinkinguniversal coverage means long lines and substandard care. Mooreresponds by reprising his familiar man-on-the- street role, takinghis cameras for a lively jaunt through some of these countries.
He starts with Great Britain and Canada, focusing on what isundoubtedly their chief virtue: affordability. Inside a Britishhospital, Moore prowls the halls, looking for a place to pay bills.But, when he finally finds the cashier, he learns that this cashieris there not to take money but to give it away, in case people needmoney for transport home. (Apparently, that's covered under Britishnational health insurance.)
Nobody in the United States seriously proposes recreating theBritish or Canadian systems here--in part because, as criticscharge and Moore ignores, they really do have waiting lines. Acloser model for the United States would be France, which doesn'thave that problem and which--thankfully--also merits considerablescreen time in Moore's movie. As Paul Dutton explains in a new bookcalled Differential Diagnoses, the French prize individual liberty,so they created an insurance system that, today, allows free choiceof doctor and offers highly advanced medical care to those who needit. One of this system's most appealing features, which Mooreshowcases, is the availability of 24-hour house-call service via acompany called SOS Medecins. (Moore travels along with one of thecompany's doctors as he rides around Paris one night, takingdispatch calls like a taxi driver and then administering at-homemedical care to a young man with some kind of stomach problem.)
All of this does cost money, naturally, and Moore acknowledges whatmany assume is the French system's big drawback: its high taxes.But Moore also provides the same answer that any good policy wonk(including yours truly) would: They pay more in taxes but less inprivate insurance. In fact, the French system, like every other onein the rest of the developed world, costs less than ours overall.
The French like their system a lot--more than the citizens of anyother country, including the United States, if you believe theopinion polls. The World Health Organization likes it a lot, too:It has ranked France's system tops in the world. But that isn'tstopping critics from attacking it. In a pre- buttal of Sicko thatappeared in the New York Post, the Cato Institute's Michael Tannerwarned last week that Moore missed the real problem in France: itsshortage of high-tech care.
This was news to me. I spent a lot of time researching France when Iwrote my book, and I never heard anything about shortages ofhigh-tech care. I asked Victor Rodwin of New York University, thiscountry's leading expert on the French health care system, if hehad ever heard of such shortages. He hadn't, either.
In the interest of fairness, I decided I would ask Tanner himself:What was his evidence? He said the French government was startingto tighten access to specialists. Well, sure--but it's still a farcry from what managed care has done in this country for years. Healso said that France has fewer MRIs and CT scanners than theUnited States, which is very true and very irrelevant. Most expertsthink we have far more than we need here. If there were realshortages in France, there would be long queues to use them, andthere's no evidence of this, either.
Tanner's op-ed was a good reminder of the proper context forconsidering Sicko--the fact that opponents of universal health carehave been spewing half- truths and outright falsehoods for decades.If anything, the proponents of universal health care have probablybeen too honest, getting so caught up in nuance and policy accuracythat they undermine the very real moral power of their ownargument. As another great health care debate begins, it's worthremembering that the fundamental challenge isn't technical. We haveplenty of good ideas for achieving universal coverage. Thechallenge is political. Our side needs some passion and, yes,perhaps a little simplicity, too. That's what Moore has supplied.No wonder the health care industry is spooked.