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AAOS Now

Published 8/1/2007
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Howard R. Epps, MD

Moore’s message deserves a hearing

“SiCKO” may not be balanced, but will stimulate debate

“SiCKO,” the latest production from controversial filmmaker Michael Moore, depicts the healthcare system in America as hopelessly flawed. The solution, Moore believes, is a single payor system. Through anecdotes, interviews, and occasional gimmicks, “SiCKO” is an insightful portrayal of the many paths to health care taken by both the uninsured and insured in America.

Moore’s polarizing history may suppress the potential widespread audience. That would be unfortunate, because “SiCKO” does much to stimulate the ongoing national debate over healthcare systems.

Balance has never been Moore’s forté, and “SiCKO” is no different. As in his previous films, Moore identifies a target he paints as a villain. He then conducts interviews on camera with a false naiveté to make his points. His style has made him widely vilified by conservatives.

With “SiCKO”, however, the audience may not segregate as readily into the typical liberal and conservative factions. The liberal slant persists, but the power of the personal stories and glimpses into the lives of healthcare consumers in other countries ultimately raise questions not easily answered by either political camp.

A failed system
Moore abhors the failures of the U.S. healthcare system and argues that insurance companies, health maintenance organizations, and pharmaceutical companies fatally corrupt the system. He reminds the audience of the grim statistics: the more than 40 million Americans who lack healthcare insurance, the shockingly high infant mortality rate for a western nation, and the abysmal ranking of the United States by the World Health Organization. Do not expect to see any heroic successes of U.S. health care; this isn’t the Discovery Health Channel.

The film effectively uses the unfortunate and often riveting stories of real people to illustrate the problems. After Moore announced he was looking for examples of the healthcare system’s failures, more than 25,000 people contacted him within a week. He documents some of the most egregious cases––a woman denied treatment for cervical cancer because she was “too young,” the working-class family bankrupted by healthcare expenses, the cancer patient who died after his insurance company refused to pay for a bone marrow transplant it deemed “experimental,” a senior citizen forced out of retirement so he could afford his medications, a man without insurance who opted to have only the “cheaper” of his two severed fingers replanted.

Not surprisingly, many of the scenarios hit close to home for physicians who fight on a daily basis with insurance companies for authorizations and reimbursement. Moore doesn’t have to include physicians’ woes to make his point. He highlights how absurd and arbitrary the decisions can be. One insurance carrier refused to pay for the cost of an ambulance trip to the hospital for a woman unconscious from a motor vehicle accident because she did not have prior authorization. This strikes a chord with those of us who have cared for patients emergently on trauma call, only to have the claims denied because there was no prior authorization.

Guilt makes the case
The film is most effective and compelling when we hear from current and former employees of insurance companies who are racked with guilt about their routine, daily decisions to deny authorization for tests and procedures—decisions that earned them raises, bonuses, and promotions.

This argument is based on the companies’ need to increase profits by minimizing expenditures. Thus they have tremendous incentives to provide as little care as possible. Cameos from insurance industry executives whose compensation packages ranged from $200 million to $1.6 billion hammer this point home.

Next, the film analyzes the role of insurance company and pharmaceutical industry money in the political process. It reviews the demise of healthcare reform in the early 90s, as well as organized medicine’s role in the process. For more current events, Moore chose former Representative Billy Tauzin as his poster child. After shepherding the Medicare drug benefit program through Congress, Tauzin promptly left public service to join a pharmaceutical industry-lobbying firm for a $2 million annual salary. Contributions from healthcare industries have enriched politicians and continue to influence legislators on both sides of the aisle.

Is it better elsewhere?
With the situation in America so bleak, Moore follows some of the patients to look elsewhere. Here he returns to the filmmaking style demonstrated in his other films. He travels to Canada, the United Kingdom, France, and Cuba to illustrate the charms of a single-payor system. The remainder of the film is a series of interviews with patients and healthcare providers in other countries, interspersed with humor, stunts, and an occasional cheap shot.

Do not expect a balanced perspective. Elsewhere, health care is flawless and everyone—doctors, patients, and taxpayers—is thoroughly satisfied with available healthcare options. Wait times in the emergency department are brief, medications are affordable, everybody who needs surgery gets it in a timely fashion, and no one pays anything upfront. He debunks the myths about universal health care, some more convincingly than others.

To demonstrate that physicians in other countries are well compensated, Moore profiles a London physician who has a $1 million home and a French couple who live in an elegant apartment on a monthly income of $8,000. In his most provocative stunt, he takes a group of chronically ill 9/11 rescue workers to Guantanamo (since enemy combatants enjoy free universal health care), but eventually ends up in Cuba. The patients are treated like royalty and get all the needed tests and medicines for a nominal charge. Clearly, the Cuban government relished an opportunity to make the U.S. system look inferior.

With such a rosy picture elsewhere, one can imagine how a similar system here could have avoided the earlier problems. Unfortunately, Moore does not present any information on what such a system might cost, or how we would pay for it. Taxes are higher in these other countries, but trying to extrapolate these systems to American society seems daunting. Nevertheless, the film succeeds in raising the question of whether the citizens of one of the wealthiest nations in the world deserve better health care than they currently receive.

Although it sometimes loses focus, “SiCKO” makes two persuasive arguments. First, as in any other industry, health insurance companies’ primary objective is to maximize profits for the shareholders. To meet this goal, which they do quite handsomely, expenses must be kept down—usually at the expense of the subscriber’s health and financial well-being. Second, health care in countries with a single payor system is not as onerous as some would have us believe. As the presidential election cycle continues, “SiCKO” has the potential to alter the debate and thrust health care to the forefront once again. The issues affect Americans across the political spectrum. Hopefully, the reputation of the messenger will not limit the breadth of the audience.

Howard R. Epps, MD, is a member of the AAOS Now editorial board. He can be reached at epps@fondren.com.