I never wrote too much about Walter Reed at the time of the scandal. But this week’s resignation of the VA Secretary, reported by the AP as being connected to Walter Reed, is now being used by some on the right to re-attack the concept of universal health care. It’s bad enough that I have to range the web to combat this misinformation. It’s almost worse that it comes from a fellow columnist at my “lay people’s site, Spot-on. So I’m up over there saying, Don’t Blame The VA.

I like to combat the odd Republican in my columns in Spot-on, but it’s fairly unusual that the object of my humorous chiding is a fellow Spot-on-er. But this week Scott Olin Schmidt reworks the tired argument over Walter Reed Army Medical Center saying that since the hospital was revealed as a disaster some months back the government has no hope of competently running health care facilities, and by extension no hope of successfully running any type of health care organization including health insurance.

The evidence that Scott introduces – based on a somewhat misleading Associated Press story – is that Jim Nicholson Secretary of the Department of Veterans Affairs (VA) has resigned, apparently because of the Walter Reed scandal. Scott then makes the huge leap to say that if you don’t want to see the kind of problems Walter Reed represents, then you should be opposed to the very notion of universal health-care. And for good measure, he suggests that it is all Hillary Clinton’s fault as she "would apply the VA model for healthcare to everyone with one single-payer."

The problems at Walter Reed were indeed severe, but they were mostly concerned with the incredibly disorganized treatment of outpatients, and their being housed in shameful conditions, while the system essentially ignored them. No one is denying that these were terrible problems, or that whoever was in charge should have fixed them. But blaming this on the VA as a knee-jerk reaction reveals a teeny tiny error.

Walter Reed is not a VA-run hospital. More

Come back here to comment.  UPDATE: Other THCB posts on Walter Reed and the VA worth noting:             "In Defense of the VA" by Maggie Mahar

            "The VA and Health IT. A model that works" by Maggie Mahar

            "A National Disgrace" by John Irvine

            "Army pledges fixes at Walter Reed" by John Irvine             "Debating the Quality of VA care" by Eric Novack

Even in their point by point defense of Sanjay Gupta’s shoot from the hip attack on Sicko, CNN looks pretty dreadful. They should have asked me for a much more sensible reply to Moore.

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.

Susan Blumenthal, M.D. has created a side-By-side Comparison of all the Presidential candidates’ health care proposals. What does it tell you? None of the Republicans have a real proposal–Rudy Guliani has made some big statements about turning the system over to consumers but no one else — including Romney — has dared say much. While Edwards has a convoluted plan (courtesy of Jonathan Gruber) and Obama has been standing far too close to David Cutler, Hillary Clinton has only announced half of hers.

Of course none of it matters too much. The journey between here and real health care reform is a long, long one. But good job by Susan and her team to put it all together.

Michael Moore’s “Sicko” does two things very well.

First, the film makes it clear that in the U.S., even if you have health insurance, this does not mean that you are “covered.”  Everyone knows that many Americans are uninsured. But now, millions of middle-class Americans are beginning to realize that they are UNDERinsured, and Moore drives that point home.

For-profit-insurers spend a great deal of time designing policies that will limit their “losses”—i.e. limit the amount that they have to pay out.  These “Swiss cheese” policies are filled with holes: for example, a policy may pay for surgery, but not rehabilitation after surgery. And this omission is deliberate. As a former claims adjuster tells Moore, when an insurer denies payment, “You’re not slipping through the cracks. They made the crack and are sweeping you toward it.”

Secondly, “Sicko” underlines the signal difference between healthcare in the U.S. and healthcare in other countries: the citizens of other countries take a collective view of the problem.  Or as Moore puts it, they realize that when it comes to sickness and dying, all of us are vulnerable. “In the end, we truly are all in the same boat . . . they live in a world of ‘we’ not ‘me.’”

Of course people in the U.K. Canada and France know that healthcare is not free. (And contrary to what some of Moore’s critics say, he does not pretend that it is.) But since they think of healthcare as a right—something we all deserve simply because we are human—it seems to them fair that, “You pay according to your means [through taxes] and receive according to your needs.”  In this, national health programs that are funded by taxes resemble Medicare: the higher your salary, the more you pay into Medicare. The sicker you are, the more you will take out in benefits.  If you’re lucky, you put in more than you take out.

What “Sicko” doesn’t do is focus on the waste in our system. As Jonathan Weiner observes below, we can’t afford to pay for everything that someone might possibly want. We need to be sure that we are getting value for our healthcare dollars.  In one case, Moore tells the story of a man dying of kidney cancer. Desperate to save him, his wife valiantly tries to persuade insurers to pay for new treatments –including a bone-marrow transplant that the insurance company calls “experimental.”  But the insurer refuses, and a few weeks later her husband dies. This is one of the saddest moments in the film—both husband and wife are very appealing.

Yet it is not clear that the insurer was wrong to refuse the cover the bone-marrow transplant. It is very difficult to tell from the few details given in the film whether it might have helped—but advanced kidney cancer is not curable. Even the newest drugs give the patient, at most, a few more weeks of life. At the same time, it is understandable that both the husband and the wife (and apparently Moore) assume that the insurer was merely trying to save money.

After all, when it comes to making coverage decisions based on medical evidence, for-profit insurers have a pretty spotty record. In the 1990s, when insurers said they were trying to “manage care,” many were simply “managing costs.” For example, some decided which drugs to  include in their formularies  based simply on whether the manufacturer would give them a deep discount. In return for the discount, the insurance company would assure the drug-maker that it would not cover a competing product.. This had nothing to do with which drug was more effective.

As I suggest below (see my most recent post on MedPac ) the public will always be suspicious of decisions made by for-profit insurers—even when their decisions are based on sound medical evidence. For-profit insurers just don’t have the political or moral standing to make these judgments. (By contrast, most patients are much more comfortable with Medicare’s coverage decisions—which is why we need a federal agency testing and comparing the effectiveness of new treatments. )

But if Moore skips over the problems of overt treatment it may be because he knows that this at this point more Americans are worried about undertreatment. And to be fair, no one could examine all of the problems in our dysfunctional healthcare system in a single film. What is important is that Moore says what he says loudly and clearly. He tells a vivid, memorable story—and in the process, he has managed to spur the national conversation about healthcare reform.

This is what scares people like Peter Chowka. If people begin talking about health care, they may begin to think about it. It may even occur to them that perhaps it wouldn’t be so terrible to borrow a few ideas from other countries. As Moore points out, “If another country builds a better car, we buy it. If they make a better wine, we drink it. If they have better healthcare . . . what’s our problem? “

"It’s conceivable, Moore suggests, that we might even learn something from Cuba, a country that spends 1/27 of what we do on care. Of course the film’s Cuban adventure is controversial—and purposefully so. I’ve written about it here  on TPM café where I recount a very funny story Moore tells about his experience with Standards & Practices at NBC– a tale which shows that he knew exactly what he was doing when he took part of “Sicko’s” cast to  Cuba.)
Looking back on “Sicko” Moore says, “I could have played it safe, I know. I could have gone to Ireland. . . . Everyone loves the Irish ….  But you know you have to get people’s attention.”

And, as usual, Michael Moore  has succeeded in doing just that.

UPDATE: A couple Moore on Sicko. A balanced enough review in the NY Times from Philip Boffey, and an interesting one (sadly firewalled) by Timothy Egan about whether Americans live better than Italians (My take has always been that rich Americans live better than rich Italians) — Matthew

The best political cartoonist in America is at it again–This Modern World