This column was written by Jonathan Cohn.
The warnings went out in a 2004 company newsletter: Watch out for "a scruffy guy in a baseball cap." The scruffy guy was Michael Moore, and the company was pharmaceutical giant GlaxoSmithKline, whose executives had gotten wind of Moore's new project: a documentary about the health care system called "Sicko." The executives figured it was only a matter of time before Moore showed up on their doorstep, camera in hand — if he hadn't already. "We have six business centers nationwide," a Glaxo official confided to the Los Angeles Times, "all of which report sightings."
Earlier this month, when I got my first glimpse of "Sicko," I felt similar trepidation, though for rather different reasons. My bias in watching Moore's film is that, in the broad sense, I agree with him. I've been writing about the flaws of the U.S. health care system, and the need for universal health insurance, for nearly a decade now. (And, yes, I recently wrote a book with almost the exact same title as Moore's movie — "Sick" — although I'm pretty sure I thought of it first.) But Moore has not always been the most intellectually rigorous storyteller — or, for liberals, the most useful ally. "Fahrenheit 9/11," Moore's attack on the Bush administration and the Iraq war, may be wildly popular among Bush-haters and the most financially successful documentary ever. But a lot of people think it also ended up helping Bush win reelection, by trading in unsubstantiated conspiracy theories and firing up the Republican base. As Jon Feltheimer, the CEO of Lion's Gate Films, told Vanity Fair, "I've been told a number of times [by Republicans], 'Isn't it great what you've done for the party?'"
As "Sicko" rolled, it did little to allay my fears. I spotted plenty of intellectual dishonesties and arguments without context — enough, surely, to keep right-wing truth squads (and some left-wing ones) busy for weeks. Moore also couldn't help but stick in unrelated jabs about the Bush administration's efforts to fight terrorism and insisted on hyping Cuba's medical system — an awfully poor way to counter the generations-old slander that universal health care is tantamount to "socialized medicine."
Still, by the time the final credits ran, it was hard to get too worked up about all of that. Because, beyond all the grandstanding and political theater, the movie actually made a compelling argument about what's wrong with U.S. health care and how to fix it. "Sicko" got a lot of the little things wrong. But it got most of the big things right.
When Moore was filming "Sicko," he frequently told people that he was filming a comedy about the 45 million Americans who don't have health insurance — people who represent the most glaring failure of U.S. health care. And, in fact, the opening sequence of his movie portrays two people in precisely that situation — one of whom is Rick, who accidentally sawed off the tops of two fingers while working at home. With no insurance to pay the bill and limited funds at his disposal, he has to choose whether to have the hospital reattach his middle finger for $60,000 or his ring finger for $12,000. (He chooses the ring finger.)
But, as Moore quickly explains, uninsured Americans aren't the primary subject of his film. Instead, he announces to the backdrop of 1950s music and newsreel footage, he's chosen to focus on the rest of America, the people who do have insurance and the hardship many of them go through anyway. He does so primarily by telling the stories of hapless victims, deftly weaving farce and tragedy. We hear both from a woman who gets stuck with an ambulance bill because she didn't clear the charge with her insurer before losing consciousness during a car accident, and from the widow of Tracy Pierce, who died after his insurer denied a potentially life-saving bone-marrow transplant for his kidney cancer.
Moore isn't aiming for balance: Officials defending the health care industry don't get any airtime. Instead, Moore gives us the views of former insiders turned whistleblowers — like Linda Peeno, former medical director at the HMO Humana. Peeno stopped working there in the late '80s after becoming disgusted with pressure to deny coverage — including for a heart transplant for a man who otherwise might have lived. Moore also introduces viewers to Lee Einer, whose job at a major insurance carrier (Moore doesn't say which) was to pore over insurance applications retroactively, focusing on people with large claims in order to find evidence that they had hidden previous conditions. As Einer explains, it was widely understood that intent to mislead was irrelevant; the companies just wanted excuses to avoid paying bills. (To illustrate what this means in practice, Moore also tells the story of a woman whose carrier pulled coverage after an operation, because on her application she didn't mention a past yeast infection.)
Moore wants to weave these tales into an indictment of the idea that for-profit companies can be counted upon to provide Americans with affordable medical care. But that's a complicated argument to make. Even an intellectually rigorous filmmaker would have to cut a few corners; Moore cuts many.
Sometimes, for example, there are good reasons to deny coverage of experimental treatments. In the 1990s, HMOs caught a lot of grief for denying bone-marrow transplants to breast cancer victims. Years later, studies showed the treatments — which are both expensive and painful — worked in only a tiny fraction of special cases. Would the bone-marrow transplant denied to Pierce have made a difference? It seems unlikely. Experts told me that the treatment never made it past the experimental phase because of ineffectiveness and harmful side-effects.
But, while not every HMO treatment denial bears second-guessing, many do: During the '90s, peer-reviewed studies showed that insurance companies were cutting costs in ways that routinely jeopardized patient care. Nor is there any doubt that insurers try desperately to avoid covering people with serious medical conditions: Following exposés by Lisa Girion in the Los Angeles Times, California officials investigated BlueCross for precisely the kind of practices Lee Einer describes, eventually fining the insurer $1 million because it was rescinding coverage without even asking policy-holders about supposed misrepresentations. Although Wellpoint, the parent company of Blue Cross, denied wrongdoing, it also promised to change its cancellation procedures.
Still, while it's easy to beat up on insurance companies that deny coverage — or drug companies that charge a lot of money, or employers that don't offer their workers benefits — the truth is that they're all acting rationally. They're businesses, after all, and businesses are designed to make profits — which, it turns out, isn't always in the best of interests of people who are sick. If you want a different outcome, you need to come up with a different system, one that starts by guaranteeing every single person health insurance and making sure that insurance includes generous benefits.
Moore spends the second half of his film concentrating on systems abroad that do precisely this. Over the years, opponents of universal health care have scared middle-class voters into thinking universal coverage means long lines and substandard care. Moore responds by reprising his familiar man-on-the-street role, taking his cameras for a lively jaunt through some of these countries.
He starts with Great Britain and Canada, focusing on what is undoubtedly their chief virtue: affordability. Inside a British hospital, Moore prowls the halls, looking for a place to pay bills. But, when he finally finds the cashier, he learns that this cashier is there not to take money but to give it away, in case people need money for transport home. (Apparently, that's covered under British national health insurance.)
Nobody in the United States seriously proposes recreating the British or Canadian systems here — in part because, as critics charge and Moore ignores, they really do have waiting lines. A closer model for the United States would be France, which doesn't have that problem and which — thankfully — also merits considerable screen time in Moore's movie. As Paul Dutton explains in a new book called "Differential Diagnoses," the French prize individual liberty, so they created an insurance system that, today, allows free choice of doctor and offers highly advanced medical care to those who need it. One of this system's most appealing features, which Moore showcases, is the availability of 24-hour house-call service via a company called SOS Médecins. (Moore travels along with one of the company's doctors as he rides around Paris one night, taking dispatch calls like a taxi driver and then administering at-home medical care to a young man with some kind of stomach problem.)
All of this does cost money, naturally, and Moore acknowledges what many assume is the French system's big drawback: its high taxes. But Moore also provides the same answer that any good policy wonk (including yours truly) would: They pay more in taxes but less in private insurance. In fact, the French system, like every other one in the rest of the developed world, costs less than ours overall.
The French like their system a lot — more than the citizens of any other country, including the United States, if you believe the opinion polls. The World Health Organization likes it a lot, too: It has ranked France's system tops in the world. But that isn't stopping critics from attacking it. In a pre-buttal of "Sicko" that appeared in the New York Post, the Cato Institute's Michael Tanner warned last week that Moore missed the real problem in France: its shortage of high-tech care.
This was news to me. I spent a lot of time researching France when I wrote my book, and I never heard anything about shortages of high-tech care. I asked Victor Rodwin of New York University, this country's leading expert on the French health care system, if he had ever heard of such shortages. He hadn't, either.
In the interest of fairness, I decided I would ask Tanner himself: What was his evidence? He said the French government was starting to tighten access to specialists. Well, sure — but it's still a far cry from what managed care has done in this country for years. He also said that France has fewer MRIs and CT scanners than the United States, which is very true and very irrelevant. Most experts think we have far more than we need here. If there were real shortages in France, there would be long queues to use them, and there's no evidence of this, either.
Tanner's op-ed was a good reminder of the proper context for considering "Sicko" — the fact that opponents of universal health care have been spewing half-truths and outright falsehoods for decades. If anything, the proponents of universal health care have probably been too honest, getting so caught up in nuance and policy accuracy that they undermine the very real moral power of their own argument. As another great health care debate begins, it's worth remembering that the fundamental challenge isn't technical. We have plenty of good ideas for achieving universal coverage. The challenge is political. Our side needs some passion and, yes, perhaps a little simplicity, too. That's what Moore has supplied. No wonder the health care industry is spooked.
By Jonathan Cohn
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