I had expectations. Although I tried to ignore preview stories and ads, I suspected Michael Moore would strum some clichéd chords in his film on the U.S. health care system, SiCKO. As I settled in for a media screening, I expected to see attacks on insurance companies. I thought Moore would lay blame on various greedy executives and venal politicians. I doubted he would grapple with powerful cost-drivers, such as drug and device discovery or patient expectations for rescue, regardless of circumstances.
My expectations were fulfilled, and yet SiCKO also surprised me. It is not entirely a rant. Parts of it are really funny. But what was totally unexpected was how clearly Moore identifies the values, beliefs, and assumptions that underlie debate about the health care system.
No single movie is going to instantly change the national discussion, but Moore may influence some of the popular themes by going beyond the clutter of co-pays, deductibles, underwriting, and insurance contract clauses to get to the real points: What do we want from our health care system, and what do we expect of each other to get it?
Many debates about health care reform fizzle into irrelevance because they never connect with the emotional guts of the citizenry. Journals like Health Affairs are chock full of dazzling and insightful analyses of the health care system's characteristics, shortcomings, and potential remedies, but those sorts of airy analyses will never incite crowds. Moore tells stories of individual people, and drops in facts that suit his interpretation of what was happening to them. Sure, he gets a lot of details wrong, but his storytelling will resonate with audiences.
In part, that's because he made a smart decision: He avoids the usual recitation of bad things that happen to people without insurance. He undoubtedly knows that most of the ticket buyers for his movies have jobs and insurance, so he profiles people who generally thought they were covered, up until the moment they really needed their benefits. People sitting in darkened theaters will see characters on the screen that remind them of themselves or family or friends. The tales are not about “them,” they are about “us.” That's good storytelling.
Fair warning, if you haven't seen SiCKO, that the following paragraphs reveal plot details.
Moore makes the U.S. system look pitiful compared with those of other countries. He's no pioneer on this topic; just take a look at the “Mirror, Mirror on the Wall” report from the Commonwealth Fund for a recent example of the many academic analyses of our poor showing on international health scales. (www.commonwealthfund.org/publications/publications_show.htm?doc_id=482678)
But it's likely that many more people will pay attention to Moore's depiction; they need to know that despite our unrivaled spending on health care, the health of Americans lags far behind that of most other developed nations.
Still, he presses the point with unfair comparisons. While going on about the many ways that the French system of social welfare is more comprehensive than ours, he points on one hand to Americans bankrupted by medical expenses and forced to move in with their adult children, and then on the other to professional Parisians apparently living idyllic lives in tony neighborhoods. But he never visits the Paris suburbs that erupted in fiery riots two years ago, where one of three young adults is unemployed and incomes are only a quarter of the French average.
The movie also leaves out essential information. One vignette is set near where the Watts riots scarred neighborhoods in Los Angeles a generation ago. The mother of a child with an intense fever rushes her daughter to King-Drew Medical Center. But she's a member of the Kaiser Permanente health plan, and Moore says she was told to transfer the girl to a Kaiser Permanente facility. The mother resists, then relents. The child's condition nosedives. The girl dies. The clear implication is that she would have been better off receiving care at King-Drew and that heartless health plan calculations contributed to her death.
But Moore never tells filmgoers at least two key facts: febrile convulsions in children may be really scary, but they rarely have serious consequences (and it's not clear the health plan had any reason to suspect that this case was potentially life-threatening) and King-Drew Medical Center is a terribly troubled institution. The hospital lost its Joint Commission accreditation, and has been under intense scrutiny for years. Things are so bad there that the hospital was reorganized as King-Harbor to bring in UCLA management. As the Los Angeles Times recently reported, “The public hospital has flunked more than a dozen inspections, and four times has been cited for problems so severe that regulators deemed patients in ‘immediate jeopardy.’”
While Moore likes to portray himself as a mythbuster, SiCKO feeds the myth that more medical care is always better. He also neglects to say whether this sort of aggressive medical intervention would be provided in the other nations he praises. I'd bet it isn't because being more conservative about treatment in extreme cases is one way most nations conserve resources for the mainstream care of the majority of patients. And, by the way, being more conservative also generally means less treatment-related harm. Moore never seems to consider that aggressive treatment might be futile or even damaging.
The film also makes the common mistake of commingling the concepts of universal coverage and single-payer financing systems. Even as he ridicules those who equate criticizing Iraq War policies with supporting terrorists, he asserts that opposition to single-payer financing is the same as being unconcerned about the millions of Americans without health care coverage. And he implies that the Canadian, British, and French health care systems are virtually unblemished by domestic criticism. Yeah, right.
The Facts vs. the Story
I could go on with a list of inaccuracies and half-truths, and I'm certain many of Moore's critics will, but this article is about the media's portrayals of health and medical issues, and I'm not taking sides in the health care reform debate. What's more, Moore scores many direct hits on a reimbursement system that often rewards health plans for putting roadblocks in the way of treatment or for shutting out applicants who might actually use their insurance benefits.
It's important not to let the gaps in his logic or the flaws in his facts obscure the effective thrust of Moore's filmmaking. When he asks staff members at a UK National Health Service hospital for directions to the billing department, their bewilderment is delicious. And when he finally finds a window marked “Cashier,” the punch line (painfully funny to Americans) is that the man behind the counter is not demanding payment, he is giving cash to patients to reimburse their transportation expenses.
Moore also interviews a man in Canada whose hand was severed by a power saw. Four surgeons took shifts over 24 hours to reconstruct his hand. There was no bill. Moore tells the man from Canada about an American who lost the tips of two fingers to a power saw and was told that reattaching both would cost $72,000, a price the man could not afford, so the American decided to discard one fingertip. The look of startled shock on the Canadian man's face is palpable.
SiCKO communicates essential human concerns and desires, not a treatise on health system organization. It is centered on values, dreams, and nightmares. Moore explicitly (and I think correctly) identifies the balance between the individual and the community as being at the core of the differences between the U.S. system and those of most other nations.
The movies, like television, are essentially emotional media — poor at conveying facts, powerful at making emotional connections. And when it comes to motivating people, I'll put my money on emotions over facts any day.
So I suspect that while most of the chatter about SiCKO will be about which of his facts are right or wrong, the real effect of this piece of motion picture communication will be to help clarify what we're really arguing about — not co-pays but care, not underwriting but responsibility.