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

Jonathan Weiner, Professor of Health Policy and Management at Johns Hopkins, tells it like it is in a great interview at Managed Care magazine. It’s so good I’ve extracted several real zingers. I particularly love the last one about “getting the government out of the way of the market.” Here’s a selection:

“Other developed countries have come to two realizations that we have not come to. One is that it is immoral — or at best, amoral — not to provide health care to everybody if we believe that basic health care is a sign of a developed country.”

“The second realization is that other countries acknowledge that the collective — social insurance programs like the sickness funds of Germany, government agencies, or third parties that look very much like our insurance or managed care companies — cannot provide everything for everybody.”

“When managed care plans, working mainly as agents for employers and government, tried to make some necessary changes and do the right thing, nobody would let them. We shot the messenger. We’re lousy at doing what’s necessary in our health care system. Tightly controlled managed care as envisioned in the ’90’s in the Clinton reform plan is not managed care today. I’m a big supporter of good forward-thinking managed care on the part of executives and clinicians, and I definitely support the appropriate role of the market and consumerism. But we can’t lose sight of population-based care and public policy issues that don’t come naturally to managed care organizations facing pressure every quarter to make a profit and keep investors happy.”

“Within a generation or two, we’ll see the positive side of health information technology. Health care will actually get more humane, with more human interaction and more communication, because the technical side of what doctors do now will be handled by the electronic box. Things like figuring out what tests should be ordered, what drugs should be used, looking at an EKG and comparing it to the evidence will all be done better by electronic systems, using algorithms developed by doctors at places like Cleveland Clinic and Johns Hopkins. Doctors will need to be communicators, facilitators, coordinators, and coaches. I believe that model will favor women doctors, because they happen to be better at those skills.”

“Every advanced HIT system I’ve studied — the British, Hong Kong, Kaiser Permanente, and Geisinger Health System in the U.S. — has a centralized rational entity that looks at the big picture and sees itself as being in this for the long haul.”

“Our health care system is the most expensive in the world by a factor of two, and the most inefficient probably by a factor of three. Yes, we pay our doctors and administrators more and patients who get care get a lot more, but a lot of the cost difference is due to waste. We need clinical research of the type funded by NIH, and we need more operational population-based research. The Agency for Health Care Research and Quality is terribly underfunded now, and once genomics come more fully on line, research into cost effectiveness will become even more important”

“I serve on the Medicare Coverage Advisory Committee, an academic group, and I can tell you that Medicare has nowhere close to the authority it needs. There’s a lot of good people at CMS trying to do a good job, but their hands are tied by legislation. In most cases, they are not allowed to look at cost-benefit issues.”

“Q: Who’s persuading Congress to maintain the status quo? WEINER: Device manufacturers, pharmaceutical companies, everybody and their mother. God bless Big Pharma for keeping the new technology coming out. We may all need it one day, but it doesn’t all work equally well, and it certainly isn’t all cost effective. We cannot as a society pay for everything for everybody. That is absolutely impossible and totally unethical as long as we have 18,000 people a year dying — the equivalent of fifty 747’s going down — because they lack health insurance. My tone and tune will change once we have basic health care for all. We are a rich country and we absolutely can afford it, as long as we operate within a budget.”

“When a young doctor or medical school dean tells me that in this country the market does what the market should do, and government should keep out of it, I tell them that’s fine, as long as they’re willing to return the million and a half dollars in federal and state subsidies for each doctor trained. A plastic surgeon practicing in the fanciest suburb in any city gets more of a subsidy than the family doctor practicing in an inner city or rural area, and that’s not right. Moreover, the plastic surgeon can make a half million dollars a year, while the inner city doctor is making a hundred thousand.”

So there’s a movie called Sicko out and it has the right really riled up. Why? Because Michael Moore has adopted their tactics of using somewhat out of date anecdotes without any real data. At the least he’s made a teeny TV celebrity of Stuart Browning who’s now been on shouting matches on cable twice according to emails he’s sent me. And then into my email box the other day plopped this review at the American Thinker from someone called Peter Chowka, who apparently doesn’t like socialism and the bunch of know nothing, greedy Americans who are apparently ready to abandon the paragon of market efficiency that is our health system, because they think that some other approach might just cover a few more people at a lower cost—I mean just because all those foreigners do it how dare anyone think that we Americans might? Here’s some of Chowka’s rant:

From start to end, SiCKO, the latest "documentary" from notorious writer and filmmaker Michael Moore, is a stunning example of the Big Lie. Almost shockingly devoid of fact and context, it’s instead based on highly selective, emotionally-driven, and deeply flawed anecdotes, strung together by writer-director-producer Moore’s trademark folksy, soft-spoken, whimsical personal narrative. SiCKO (the unusual capitalization is Moore’s conceit) is not a documentary at all, but a naked propaganda exercise on behalf of full-bore socialism. A better title for it would be Pinko.

Continue reading…

Somehow last week in the midst of one of the busiest working months of my life I managed to squeeze in a little time with Peter Orszag who’s the new-ish Director of the Congressional Budget Office. Or as he called it the “soon to be Congressional Health Care Budget Office.” Peter is  a true convert to the cult of Wennberg, and so we had a real meeting of the minds. He has started telling his story to all who’ll listen, and given the power of the CBO in Washington, plenty of important people are listening.

Go read his testimony on health care and the budget (PDF) (similar html here) from earlier this week. Pay particular attention to the figures which you can click on directly in the PDF navigation menu—especially the charts on the variance in costs for Medicare recipients by region (#3) and the impact of the current trends on future Medicare costs (#4). If enough politicians pay attention, then the second biggest problem in health care (practice variation) might get addressed at the same time as the first (lack of universal coverage).

He’ll also be having the CBO in future produce some slightly more synopsized and bite-sized reports, but for now there’s more data on their web site and you can subscribe to RSS feeds of their latest reports. I feel a blog coming on….

Meanwhile it won’t surprise you to know that the first hearing on any comprehensive health care reform legislation since 22 June 1994 is happening tomorrow, when the Wyden bill gets a hearing before the Senate Budget committee. If you want a clue as to how it’ll go, the line up on the panel is Len Nichols, Ph.D., Director, Health Policy Program, New America Foundation; Sara R. Collins, Ph.D., Assistant Vice President, Program on the Future of Health Insurance, The Commonwealth Fund and Arnold Milstein, MD,Medical Director, Pacific Business Health Group.

Luckily there were no problems in the health care system between the end of 1994 and the middle of 2007, so it didn’t matter that Congress ignored the issue.

Thank God the lunatics have at least had their charge of that part of the asylum taken away…

John Cohn on Michael Moore–Fan-fucking-tastic. It’s called “Will Michael Moore’s Sicko help or hurt the universal health care movement?” Go read it.

Ezra Klein takes the wider view on Moore’s attack on American exceptionalism, equally worth it.

As for me, well over at Spot-on I manage to link Sicko with the other big release this week…

Strange things are afoot in the normally rarefied world of health care
punditry. It’s going primetime. And I’m blaming Steve Jobs.

Come back here to comment.

It looks like it might be the end for King Drew, or as it’s known now, King–Harbor. Some of the LA board of supervisors are in favor of closing the hospital immediately, and yesterday the State of California initiated proceedings to revoke its license. No one can pretend that this hasn’t been coming for quite some time.  A couple of years back, a long series in the LA Times found incredible graft, mismanagement, and corruption and appallingly poor care quality at King Drew. Given the hospital’s origins after the Watts riots of the 1960s, and its special place in the African-American downtown community, doing anything to King-Drew has always been politically charged issue. But after the recent incidents, particularly the one where the woman was left to die on the floor of the emergency department waiting room while nurses ignored her, and cleaning staff swept up around her, the hospital seems to have finally run out of defenders.

On the other hand, this is emblematic of a wider problem in American health care—how do you provide care to the poor in a system where there is no universal coverage or systemic primary care?  Bob Sillen, who now runs California’s prison health care system, but used to run Santa Clara Valley Medical Center used to remark that if there wasn’t a County Hospital in which to showcase how the poor were treated it would be impossible to get any attention on to the issue.

So it is my hope that as we enter a period of concern about the future of universal insurance coverage, we don’t abandon the extremely limited safety net that is in place for the poor while we all focus on fixing the wider systemic problems.

This kid (young man’s name is John Heineman) is swimming the English channel to raise money for a free clinic in Iowa. His aunt wrote to me pointing it out, and he certainly sounds like a very interesting and incredibly determined guy. He’s combining an interest in health policy with charity work and incredible sporting fortitude/insanity. Even thought he went to Oxford, I wish him lots of luck.

Of course the picture is for enjoyment of the female/gay readers of THCB!