POLICY: Debating SICKO’s Impact by John Irvine

Since opening a week ago, Michael Moore’s latest documentary has focused unprecedented attention on the U.S. healthcare system. The film has brought angry protests outside movie theaters. Standing ovations from audiences. And provoked angry debate in the nation’s editorial pages. It has also done fairly well at the box office, drawing far more viewers to theaters than many experts had predicted.  According to the Hollywood Reporter, the film finished second in per-theater gross last weekend, bringing in $11.3 million at 700 screens across the country — rather a respectable showing for a movie that specializes in disturbing subjects that Americans would generally rather not talk about. So far, Sicko has generated exactly the kind of controversy that the critics predicted it would.  Moore has  already had to deny that he is planning a trip to Iran next month to view the film at an Islamic film festival. (The story turned out to be a rumor spread by conservative opponents.  The filmmaker says he received an invitation from the Iranians but declined to accept.) This week he was on CNN, lambasting the network for its healthcare coverage and getting into a near shouting match on The Larry King Show with medical correspondent Dr. Sanjay Gupta over some of the stats used in the film.

Moore went on to accuse the network of colluding with the film’s
opponents, pointing out that one of Gupta’s researchers, Paul Keckley,
the former head of Vanderbilt’s Center for Evidence Based Medicine and
a current Deloitte consultant, has done a lot of work for big health
insurers and pharma companies
. (Something that could be said of a fair number of people working in the field, as THCB readers know all too well.) Could Keckley be censoring the network’s coverage?  Moore wondered out loud to himself and not-very-subtly. 

The theatrics aren’t a surprise to anyone who has followed Moore throughout his
career. Not surprisingly, the attack drew a rather hurt denial from Gupta on his
CNN blog

Meanwhile, Moore is living up to his reputation for drawing attention to himself. Earlier this week, the filmmaker published a leaked internal memo on his web site allegedly authored by
the Blue Cross communications department.  The document reviewed the film – acknowledging that the documentary is a slickly done piece of work. [Follow the link and scroll down to read the whole thing.] The review begins as follows:

"You would have to be dead to be unaffected by Moore’s movie, he is an effective
storyteller. In Sicko Moore presents a collage of injustices by selecting
stories, no matter how exceptional to the norm, that present the health
insurance industry as a set of organizations and people dedicated to denying
claims in the name of profit. Denial for treatments that are considered
"experimental" is a common story, along with denial for previous conditions, and
denial for application errors or omissions. Individual employees from Humana and
other insurers are interviewed who claim to have actively pursued claim denial
as an institutionalized goal in the name of profit. While Humana and Kaiser
Permanente are demonized, the BlueCross and BlueShield brands appear, separately
and together, visually and verbally, with such frequency that there should be no
doubt that whatever visceral reaction his movie stirs will spill over onto the
Blues brands in every market."

Will the public hold health care providers and insurers accountable for the lapses Moore documents in his film? That remains to be seen. For many Americans who haven’t been paying attention, the documentary is undoubtedly a wake up call. There seems little doubt that people will start to ask more questions when they walk into their doctor’s office or when they sit down to pick an insurer, which is certainly enough to make some people uncomfortable. There is also little doubt that the film has added to the already fiercely burning debate between supporters of a free market based system and a government run universal healthcare system.

PODCAST REVIEW: Here’s THCB contributor Dr. Eric Novack’s take on the film from his radio show last Sunday. Two thumbs up? Er, No. Here’s Part 1 and Part 2. Eric and I will get into this a little later on, we hope!RELATED: "Sicko and Healthcare Reform", Maggie Mahar’s piece on THCB drew thousands of readers  and led to excellent discussion.

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23 replies »

  1. SiCKO is a 2007 documentary film by American filmmaker Michael Moore that investigates the American health care system, focusing on its for-profit health insurance and pharmaceutical industry. The film compares the non-universal and for-profit U.S. system with the universal and non-profit systems of Canada, the United Kingdom, France and Cuba. SiCKO cites the United States as the only industrialized nation that does not provide universal health care to its citizens, highlights cases in which insured individuals were denied care, and condemns for-profit health care for maximizing profit at the expense of patient care.
    SiCKO opened to positive reviews, but also generated criticism and controversy. Policy specialists, especially those on the political right, criticized the film for its overwhelmingly negative view of health care in the United States and what they charge to be an unbalanced positive portrayal of publicly funded health care in nations such as the United Kingdom and Canada.
    SiCKO debuted in the U.S. on June 22, 2007, earning $4.6 million in 441 theatres and achieving the second highest opening weekend for a documentary, after Fahrenheit 9/11. A pirated copy of the film was leaked onto the Internet just prior to its release.
    If you haven’t seen SiCKO yet, you can check out a free video preview at:
    Posted by William Hill on July 14, 2008

  2. Health Insurance Site:
    “People I know, even while following the film, have said that they’ve been bothered by the feeling of “Is Michael Moore trying to pull one over on me?”
    Now from the Health Insurance Site:
    “The average 65-year-old couple retiring this year will need about $215,000 to cover medical costs, according to Fidelity Investments.
    People should not expect Medicare to meet all their needs.”
    I think as baby-boomers move through the system and affect costs on all fronts, cost control in healthcare will be a major issue. We will not get cost control from the insurance/drug/healthcare industries, not at least until the’ve wrung every last dollar from our pockets.
    Who wins the prize for “trying to pull one over on me”, politicians taking “bribes” (AKA campaign donations, lobbying jobs, “fact-finding junkets”, etc.) from the insurance and healthcare industries, or little ole Michael Moore.

  3. I watched the movie online. Wow. I was less surprised at how inhumane our system is than how terrific the systems in Canada, England, France, and Cuba are.
    It was wonderful how our citizens got great healthcare in Cuba. I think the awareness of the propaganda machine that vilifies Cuba and France will make a huge impact on the unaware.
    For me, the contract between the foreign systems to ours is so humiliating. This country really should be very ashamed. This may Moore’s most important movie to date. I hope everyone in the country sees it.
    And yet it’s true. Other governments are afraid of the people, whereas in this country, the people are afraid of the government. It may because as a culture we are so brutal — the police are brutal, people like Cheney and Rumsfeld are brutal. Where is the humanity.
    Keeping the people down is a great strategy. Does it all go back to Nixon and the advent of the HMO? No. He wasn’t that farsighted. The propaganda machine that vilifies “socialism” has been going on for years, and I think that boogie man has given our government a lot of ammunition.
    And how is it that they’ve been successful with that? Because the underlying problem is that the majority of American people are not a bunch of thinkers or readers or at all studious or curious. When a teacher teaches them not to question authority, they buy it.
    In other cultures, they teach kids to question authority. If more Americans were more skeptical and felt more powerful, this would be a different society. As long as this culture remains uneducated and undereducated, there is no hope.
    And as long as Americans feel powerless and therefore don’t vote, nothing will change. Michael Moore was absolutely right about that.

  4. I haven’t seen the film yet, so I can’t weigh in on its validity or politics. My problem is that Michael Moore is his own worst enemy. Even the people more passionate about health care reform are being very careful about this film. Moore’s abrasiveness and his carefree use of facts vs. opinion overshadow the issues at hand. People I know, even while following the film, have said that they’ve been bothered by the feeling of “Is Michael Moore trying to pull one over on me?” It’s a shame, but ultimately the exposure is good for future reform.

  5. Matt G said, “Just too many other important issues in Washington right now besides health care.”
    And that is the point the movie was trying to make over and over and over again. Health care needs to be the priority issue in Washington.
    I tend to be a single issue voter and this next election cycle health care will be that issue.

  6. “but having health insurance contracts be understandable, with adequate disclosures that recipients fully understand is not unreasonable.”
    That would give the insured too much information. Why don’t the insurance companies start with understandable EOB’s. They use the “E” in explanation very loosely.
    Barry, BCBS does pay for out-of-country healthcare and even has an office to handle it. The fight was never about them not having a contractual obligation to pay, it was the extreme run around, repeated lost paperwork, requests for endless and stupid technical follow-ups, failure to process, obfuscation of the facts, etc, etc, etc.

  7. Barry,
    To your question of regarding Medicare paying for services outside the US.
    “In most situations, Medicare won’t pay for health care or supplies that you get outside the United States(U.S.)”
    What does “outside the U.S.” mean ? “Outside the U.S.” means anywhere other than these places: the 50 states of the U.S., the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.
    John Rarey

  8. > I continue to presume you are
    > somewhat ‘tongue in cheek’ here
    Yes, somewhat. But only somewhat. One essential purpose of government state or federal is to provide for third-party enforcement of contracts by credible threat of violence. Of course.
    > Making sure that both parties are standing
    > on somewhat equal ground prior to signing
    > a contract is not big government either.
    Nonsense — this precisely is interference by government (read this as by force) in the process of contracting, and by Libertarian standards is the very definition of Big Government. They say it is not up to the government to see that contracting parties stand on somewhat equal ground, only that the agreements reached are honored by both sides. And so it is interesting to me that you propose at all to regulate permissible contracts.
    I wonder: do you favor the any willing provider laws? Isn’t that just another example of Big Government interfering in Free Markets? I say it is. (Note to non-economists: a Free Market is not necessarily competitive.) The medical industry, including doctors, has lobbied for these laws in order to preserve its monopoly pricing power and information asymmetries (and all that implies). It is one mechanism by which Managed Care in the old-fashioned sense has been made illegal.
    Even if medical insurance contracts were reasonably clear, the trouble is that it takes years to get a lawsuit settled, and almost nobody can afford to pay their medical bills and then sue for a refund, so-to-speak. Find me a bank that’ll loan me the funds with a lawsuit as the collateral.
    In a market-oriented system, there has to be a mechanism to get patients taken care of, docs paid, and lawsuits settled all within the context of contracts that are loose enough to permit the practice of medicine but tight enough that actuaries can set rates. We have tried two styles of clear contracts, and they were rejected by the market (which includes legislatures and courts, IMNSHO). If you think a clear contract is possible, let’s see it and price it out, and then see whether it can be sold alongside the contracts that exist.

  9. Eric, whether “making sure that both parties are standing on somewhat equal ground prior to signing a contract” is big government depends entirely on what counts as making sure the parties are on equal ground. You would agree that government does not need to ensure that parties have comparable economic power, right? Because that would be very big government, indeed. Socialism, even.
    I thought that libertarianism wasn’t concerned with (re)distributive justice, but only with procedural justice. From a libertarian point of view, so long as there is no coercion involved and contracts are enforced consistently, government’s role is fulfilled. Ambiguous language in contracts is to be handled by the courts, not the executive or legislative branch making sure that parties are roughly equal.
    And in government’s role of preventing coercion, you cannot include economic inequalities and pressures. If a libertarian will accept that a poor person can sell a kidney in order to eat, then it’s not clear at all what business they can allow the government to have in making the ground more equal between insurers and physicians (who represent 9 out of the the top 10 professions in terms of income according to Forbes).

  10. Tom– I continue to presume you are somewhat ‘tongue in cheek’ here, but having health insurance contracts be understandable, with adequate disclosures that recipients fully understand is not unreasonable.
    This, of course, should not just apply to healthcare contracts. In the subprime mortgage (and regular as well) world, disclosure and understanding has clearly been a problem, as hundreds of thousands have found out.
    I refer you to this post (http://volokh.com/archives/archive_2007_07_08-2007_07_14.shtml#1184331779) about mortgage disclosures— I am fairly certain the results would be similar (or worse) for healthcare contracts.
    Government enforcing contracts is not big government. Making sure that both parties are standing on somewhat equal ground prior to signing a contract is not big government either.
    If you oppose these concepts, I imagine you will find yourself with little company- left, right or otherwise.

  11. Peter,
    While I’m not certain of this, I don’t think Medicare pays for services incurred outside of the U.S. either. Does anyone know for sure?

  12. I think the American Bourgeoisie could not care less whether every American has access to healthcare. But maybe, just maybe, in order to provide for their own security they can be persuaded to include everyone. Moore got it right — it had to happen eventually.

  13. “that present the health insurance industry as a set of organizations and people dedicated to denying claims in the name of profit.”
    Well if my experience and the experience of other people I have talked is any indication, Blue Cross IS in the business of denying claims, or at least of frustrating the claimer to a point of giving up. Just before I cancelled my insurance with BCBS it took six months of fighting and letters to the (Useless) Department of Insurance to get them to pay a simple cataract surgery claim. I still believe the reason they frustrated my attempts at reimbursement was because I went out of network (to that communist nation of Canada) to have the surgery done for about 1/2 the cost. Apparently not even saving BCBS money is enough for them to protect their contrated providers.

  14. I can’t believe all the attention that Sicko is getting. Yeah it tells some heart-breaking stories but it is similiar in nature to many of the articles demonizing HMOs that appeared in the late 1990s.
    If Michael Moore haven’t done this documentary, it wouldn’t be getting nearly the attention. In fact, I would go as far as to say that it would barely make a blip outside some arthouse theatres in some of the larger urban cities.
    Regardless, I still think the impact of Sicko is going to be muted in the long term. Just too many other important issues in Washington right now besides health care. Washington is going to leave the states to tackle this issue and I bet it remains this way if a Democrat or Republican is elected President in ’08.
    Plus, the real important issue is $$$. It will take a ton of it to cover all of the uninsured and it just isn’t going to be there in the Congressional budget especially if the Democratic Congress continues to abide by the “Pay-As-Go” budget principles.
    I pose this conondrum for you in 2009 or 2010: “Would middle-class Americans rather increasingly pay much higher taxes due to the AMT or ensure that every American has access to healthcare?” I wouldn’t make a bet on the second one.

  15. Dear Dr. Novack,
    I find it interesting that someone who quotes Hayek wants to eliminate the ability for other people to have a contract to their liking. Very interesting.
    Once upon a time we had simple, understandable contracts that said “For $N per year, we will pay for anything a doctor is willing to do to you and you’ll lie still for, up to a lifetime maximum of $M. What happens after that is your problem.”
    As medicine became simultaneously less and less likely to cause harm and more and more likely to do at least a little good, more and more people were willing to lie still, and the whole medical industry wanted to milk those contracts dry. Which of course made the contracts more and more expensive to buy. Eventually the people paying for those contracts balked. A different sort of contract was wanted.
    So we got contracts that said something like “For 80% of $N per year, you will see our doctors and be treated in our hospitals, and we will pay for any treatments our experts deem sufficiently useful to you.” This is simple and understandable, but people (especially doctors and hospital executives, pharmas and device manufacturers) did not like this contract, and now it’s more or less an illegal contract.
    We’re left with complicated, ambiguous contracts, which creates lots of lawsuits. I am actually looking for a way to reduce the number of lawsuits by creating a market for them. It’s the Libertarian thing to do. Instead of everybody filing his own lawsuit, they can be combined and litigated by experts. My approach permits you to be a doctor free of worry about financing or interference in your relationship with your patient. It works because the complicated, ambiguous contract is always construed against the person who wrote it. Everyone good and pure wins: doctors, patients, pharmas, lawyers, and us: the insurance-insurers who take on the risk that an insurer won’t pay. We avoid the Road More Travelled By: The Road to Serfdom. What could be better?
    Of course, we’re told over and over again by doctors and hospital executives, pharmas and device manufacturers that the only contract that ought to be written is the first type (above) because medicine is so very complex that a cookie-cutter approach can’t possibly work, doctors must have the freedom to change their methodologies from time to time, that the very essence of medicine is the doctor-patient relationship, and that the least interference in this reduces doctors to the status of veterinarians. The implication for patients is obvious.
    It’ll take at least ten years to bring back the old fashioned clear and understandable contracts of either style, and meantime I bet we can make a billion or so. Each. And nobody will cry for the nasty old insurance executuves we take it from either. I guess there are losers after all. But just a few, and nobody cares about them anyway. Orthopods are known to be entrepreneurial — you up for it?
    I was not trying to explain your reaction, I was trying to explain the reaction I think Moore was trying to elicit among the mainstream of the Right Wing, so called. This wouldn’t include anybody smart enough to get through medical school.

  16. Tom- I must admit I do not totally understand your post, but I find it interesting that you imply I am promoting mass lawsuits… Quite the contrary, I am saying that clear, understandable, defined contracts can be expected by consumers of health insurance contracts– and that goes for ‘patients’ and well as ‘providers’ (who are all clients of the insurance companies as well).
    If the playing field is leveled– by elminating the ability to have ‘hold harmless’ clauses, by the elminating the clauses that allow insurers to change their methodology “from time to time”– you could use government to enforce the contracts because the failure to uphold one end or the other is fraud.
    As for the French doctor’s Marx quote– apoplectic, though a great word even in print, would not explain my reaction. That I have had to defend this so much– ” the lady doth protest too much, methnks”. (from Shakespeare’s Hamlet (III, ii, 239)— please note this as a point of education, not apoplexy).

  17. OK, I have listened to both parts of the show.
    I think Dr. Novack’s major thesis is false. He says that Moore’s film SiCKO advocates specifically a Canada/UK style system. It doesn’t, and as Dr. Novack points out, actually made several good arguments against one. Novack says this was inadvertent on Moore’s part but I cannot see how he could possibly have drawn this conclusion without his major thesis, which I find entirely unsupported by the film. Therefore, the great majority of the hour-long show was spent arguing not with Moore but with someone else. Peter, maybe.
    If Dr. Novack is serious about suing insurance companies for fraud when they don’t pay, I have a business idea for him. We should securitize the lawsuits. Any time a patient presents and he agrees to operate, Dr. Novack should guarantee the patient that he will pay any and all charges to the hospital, rehab group, whomever! in the event the insurance company does not pay as contracted. The patient will be held completely harmless. In return, the patient agrees to make Dr. Novack his attorney in fact for any fraud lawsuit, and assign the entire proceeds of the suit to him (i.e. a 100% contingency fee). If the insurance company fails to pay, Dr. Novack can sell this contract to a law firm that specializes in suing insurance companies, and use the proceeds to pay the patient’s bills. Anything extra he can keep.
    If Dr. Novack’s patients experience above-average denials, he’ll get less money for the contract, and the converse would also be true. This could be a proxy for how well Dr. Novack determines the medical appropriateness of the procedures he proposes, as well as how crooked the insurance companies in his area really are. Being sued so often, this should be a self-limiting problem though. They’ll either clean up their acts, or withdraw from the local market.
    Having been sold, the contracts are commercial paper and the various law firms can trade it among themselves to maximize their own payouts by combining suits, petitioning for class status, and so-forth, even across state lines. Then the insurance companies can argue in court about who’s defrauding whom. Meantime the patient has his new hip or whatever, is not driven to penury, Dr. Novack and the hospital are paid, and Freedom Rings.
    This way Dr. Novack besides being a doctor is an insurance agent who insures patients against the risk that health insurance companies won’t pay as promised. Occam be damned! Nothing is more libertarian than endlessly multiplying contracts. I shall have to patent this business process forthwith!
    Of course, none of this addresses the patient’s problem obtaining and keeping medical insurance in the first place…

  18. Eric,
    My advice would be to save time by not replying to flat-earthers like Peter. He’s still in denial that private health insurance (for anything covered by the government) is outlawed in most of Canada.

  19. I listened to Eric’s Part 1 Show, the Part 2 Show did not link when clicked.
    Well Eric if the ZERO phone calls you got during the first part of the show is any indication of your, “in touch with the audience” views, then “Sicko” must be far more to the point with its audience. Care to do your own movie?
    Clever Eric how you try to link Canada’s and France’s healthcare system with COMMUNISIM. Of course anyone in the U.S. who wants a similar single-pay system is by linkage, a COMMUNIST. And your use of the quote “Free, Free, Free from the movie was not countered by the, “Pay, Pay, Pay in the present U.S. system. Do you really think the audience is so stupid they believe we can do it all for FREE? How about just for half the cost, like those “communist” nations of Canada, Australia and France.
    Trying to bring out Moore’s so-called, “Hypocracy” by his use of Guantanamo healthcare reference in the movie misses the point completely. Moore was showing the hypocracy of this administration. This administration, along with denying basic human rights and habeas corpus, coupled with torture on Gitmo does give healthcare to our “enemies” while denying healthcare security here to our “patriots” for their inability to pay or at least afford good healthcare. Moore would be the first to cheer the closing of Gitmo, healthcare and all – would you?
    The problem with your attempts to sound unbiased is they are so feeble and transparent. You site Moore’s use of statistics then use HIS statistics to make your point.
    Save the drivel Eric and get on with the real discussion of solutions that will work.

  20. Matthew– I believe it is wholly disingenuous to make the leap that you made about my commentary. Given that few people will listen to my words, but many will read your article– I would ask you to correct the record.
    My point is this: The French physician uses the Marx line— I only ask why Michael Moore would put that line in his movie? I never even remotely suggest that there is any relationship between the french, english, or canadian health care system and a ‘gulag’.
    You know this to be the case.
    If you do not correct the record, please take down my podcast and consider my relationship with THCB terminated.

  21. I saw it on the first night that it came out and actually enjoyed it very much. It’s about time the United States developed a national health system similar to Canada, the UK, France, Germany and the rest of the developed world. It appears that this industry in the US is currently built from the ground up for the margins of pharmaceutical companies and insurance companies. When one looks at the market size for most therapeutic drugs, over 50% of the global market is in the US. Why? Is it that Americans are popping more pills or is it that they are paying an arm and a leg for pharmaceuticals that in other countries cost pennies on the dollar, countries where the one purchaser (the government) has significant negotiating power in comparison to the US where the market appears to be purposely fragmented and against the interests of the consumer.
    Two thumbs up from me to Moore’s latest film that has helped to reignite a debate that pharma and insurance companies have wanted us to forget for a long time.
    On another note: I was quite impressed with how the UK system pays doctors bonuses for preventive care and nutritional advice. For example, based on some recent research at UC Berkeley, UK doctors actually receive bonuses if they get their patients to have a healthier diet resulting in less visits to their office and better over-all health. Wouldn’t it be nice if we could have the same here some day.
    One of the things that personally frustrates me is how little attention is paid to advances in nutrition with significant and far reaching health benefits in the US, whereas in Europe, such advances are usually embrased by physicians (whose continuing medical education isn’t sponsored by pharma companies and who aren’t wined and dined on a regular basis by pharma reps trying to sell their pills over competing pills).
    For example, scientists at UC Berkeley have recently found that a chemical in broccoli is far more potent than some leading drugs for cancer and immune deficiency conditions, and yet the news has not reached most doctors offices in the US nor has it been significantly highlighted in the media. Is our media (primarily privately owned) with pharmaceutical and insurance companies as sponsors and marketing partners also possibly tainted in the way it which portrays things or topics that it selectively focuses on? Would they consider forgoing a story on how a diet rich in brocoli and tomatoes has been shown to be more effective against prostate cancer cells than a leading drug from Merck because Merck is one of their marketing parnters?
    It appears that the average uninsured American has a significant wall to get over before being able to convince people in Washington that now is the time for healthcare reform.
    Mike D.