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