Wednesday, July 11, 2007


The shame about Michael Moore is that he is a fat slob. In an era where there are a dearth of recognized figures advocating the plight of the less fortunate in our country, Moore has amply filled a void, but in the process become the all too easily lampooned poster boy of the American left. Even when making a good point, he finds a way to come off as either bullying or smug, and one loses the message in sight of the jackass messenger. As someone in full support of more stringent gun control, I wanted to enjoy Bowling for Columbine. Yet after his tangential swipe at the US bombing in Serbia—in my opinion the most successful case of limited intervention in the post-war era— his humiliation of a middle manager at K Mart headquarters, and his bullying of a senile and confused old man who had invited him into his home (ok, it was Charlton Heston), I didn’t want to listen to the guy, much less agree with him.

So I went to his latest film Sicko prepared to cringe at his tactics, hoping the interesting topic would rise above the smug. Surprisingly, Moore used more argument and less antic than in his previous films. He provides a thoughtful, on point attack of a health care system that falls short of the rest of the first world and which is shamefully bested by our communist neighbor to the south. Sicko is the best Moore film since Roger and Me way back in the Reagan era.

If that whets your appetite to see the film, go see it, else you’ll find spoilers in the rest.

While the camera closes in on a man in his living room sewing his own stitches to close a gash in his knee, Moore’s voice over tells the audience that the film it is about to watch is not about the 50 million people in this country without health insurance. Rather, the film is about the millions of Americans who, despite having insurance, struggle to receive the care they need. Moore investigates how insurance companies, driven by a profit motive that creates incentives to refuse service, routinely deny coverage or employ after the fact investigations to invalidate policies. Thousands of ‘insured’ Americans die every year because their insurers refuse procedures. Meanwhile, managers for these companies are rewarded for the extent to which they minimize payouts vis-à-vis their peers.

The second part of the film takes the audience on a tour of the single payer systems in Canada, the UK, and France. The modern facilities, short waiting lines, and customer satisfaction that Moore finds wherever he turns up contrasts with the agony and frustration of the Americans he portrays who Though tinted with his trademark smugness, the comparison of the European model to the American does yield some arresting statistics that reinforce the anecdotal evidence. The life expectancies of the poorest cohorts of the UK, Canada, and France are now significantly longer than that of the richest in USA.

One shortcoming of the film is that it consistently downplays the costs involved with a single payer model, and the challenges the depicted national governments have faced in providing adequate services to all. Again and again Moore interviews patients of national health systems who are delighted that their services are free. Comparing the tax rates between the US and these countries will show that national health is definitely not free, nor is it cheap. Several voices in the film do set up what could have been a meaningful debate about the relative costs involved. First, the doctors interviewed in Great Britain and Canada state with pride that they have never had to contemplate denying care. The British doctor goes on to say he would not consider working in a system like the American one, that his family has two cars and a nice home and that they do not need four cars and a mansion. This contrasts with the earlier footage of a congressional testimony where a teary eyed physician has come forward during the debate about HMO regulations with the heart wrenching admission that she made a decision to deny a procedure to a patient whom she knew would die as a result. Her decision was never questioned, though her reputation as a cost manager was secured and she was vaulted onto a fast track career path in her managed health firm. In addition to this distraught doctor, Moore interviews several managers within the insurance industry who have suffered the guilt of enriching themselves and pleasing their companies at the expense of their customers. Psychological stress is not limited to the under provided.

The film’s final sequence was a brilliant piece of political theater. Moore catches up with several of the rescue workers and clean up crew of the 9/11 disaster. Hailed as heroes 5 years ago, many of these men and women can’t get proper medical attention for the litany of respiratory illnesses they now suffer after breathing toxic fumes from the fallen towers. Moore fills up three motorboats with these patients and sets sail from Miami to Guantanamo Bay in search of the top notch medical care the government has boasted it gives to the terrorists held there. They have no luck getting into Gitmo, but upon arrival in Havana the Cubans offer medical care to all of Moore’s companions. Again, the shortcoming in this sequence is that costs—political and economic freedom and a cash starved society for starters—for the seemingly cheap and ubiquitous health care Cubans enjoy are not fairly presented. At a Cuban pharmacy the Americans marvel at the drugs they can buy for 5 cents a prescription. Cheap for them, but given the scarcity of currency on the island, the cost to ordinary Cubans in adjusted terms might well prove more draining on their incomes. Then consider that anywhere from 20-50% of pharmaceuticals found on third world shelves are counterfeits, Walgreen’s is not looking so bad in comparison. Nonetheless it is a glaring indictment on the inequities of our health system when a poor country like Cuba can afford first-rate health services for its entire population. America, on the other hand, does not adequately provide for its heroes, though according to Bill Frist excellent care is still available for those captive terrorists.

Universal health care is a costly proposition. Though our current system has priced millions out of comprehensive coverage and left millions more at the mercy of the all-powerful insurers, national health care, sadly, is not likely the answer in this country. Besides the obvious objection that it is not politically viable on the order of gay marriage in Mississippi, a national health scheme in a land that prides itself on the power of market based solutions would be doomed from the start. Those with the means would invariably choose private care and as those in power opt out, the system is doomed to stagnate into the dingy halls that the right conjures to mind with its collective shriek ‘socialized medicine!’ And maybe it’s a self-fulfilling prophecy. Look no further than public education to see how a universal model slides from the ideal when the elite does not participate in the system.

If single payer is not the solution, Moore’s film should at least sound a challenge for policymakers to come up with better alternatives than the status quo offers. The market failures that Moore points out in his film, the perverse incentives that save companies money at the expense of lives lost, must be addressed if a market based system has any hope of being palatable, much less equitable. There are no magic bullets. Many advocate medical savings accounts as a quick fix, but it is only a half fix. MSA’s will not address the perverse incentives insurers have for denying individuals services or insurance outright. Without the benefit of pooling, individuals with poor risk profiles will be left out to dry in the open market, and an MSA would quickly evaporate if a high deductible policy is terminated when an insurer deems a customer has become undesirable. Even with better rules in place protecting individuals in this intimidating environment, the galloping rate at which medical costs have been inflating the past two decades would seem to outpace the average individual’s ability to save for increasingly costly care.

If we can find the public money to spend trillions making bombs and patrolling war zones our disastrous foreign policy has created, surely a comparable amount could be found so that the residents of our nation do not fear the consequences of seeking medical attention when they need it. Kudos to Michael Moore for making a film that, if not providing the answers for our health care system, provokes the questions we should be looking to answer.

And thank you Michael Moore for reining your bull in a china shop gag. You even look less slovenly this time around. Perhaps more people will be compelled to take you seriously now.

1 comment:

LSC said...

"Look no further than public education to see how a universal model slides from the ideal when the elite does not participate in the system."

a very apt comparison i'd not thought of.