(UPDATE: Some commenters and friends think this piece is too analytical and donwplays my high regard for Michael Moore's work. We hear and obey! Here's my Memo to Michael on the film I wish he'd made.)
Michael Moore's SiCKO performs a valuable service by highlighting the need for health reform at a critical moment. Unfortunately it doesn't make its case for the solution very well. It documents the need for change compellingly, then loses momentum. It feels as if Moore couldn't trust his audience enough to lay out his case meaningfully and directly. As a result, SiCKO suffers in the second half, both as a film and as a work of advocacy. Still, the film is well worth seeing despite its shortcomings.
Let's get this out of the way up front: I'm a Michael Moore fan. I think he's a brilliant advocate for progressive causes. I appreciate his acts of political theater. He treats his political adversaries with respect, unlike those on the right with whom he's often wrongly compared. And I believe in a form of what Paul Krugman has described as "Medicare For All," although I think regulated private insurance is an acceptable part of the program.
SiCKO (why the odd capitalization? Am I missing something?) doesn't repeat widely-heard arguments about the problems of the uninsured, but concentrates on the shortcomings of our private-sector health insurance system. We hear about the difficulties people have buying private insurance, and see some heartbreaking stories of deaths caused by the current system. In one, a woman tells us of her husband's slow death from cancer because she couldn't get approval for the treatment that might have saved him. In another heartbreaking moment a mother tells of her infant daughter's death, caused because she first brought her to a nearby hospital that was not owned by her HMO.
So far, I'm with Moore. Then the movie takes us to Canada, where coverage is universal. We hear the happy stories of people with guaranteed public sector coverage that's free of the American system's ills. By this point, I'm still with Moore, although I wonder when he's going to address the commonly-raised objections that are usually raised to single-payer systems. Then he takes us to Great Britain, where we're treated to more of his patented "you-gotta-be-kidding-me!" reaction shots as people tell him about their free care.
He lets us know that a physician in the U.K. can make a decent income. That's new. Otherwise, the film's beginning to drag as we get more and more repetition of happy, well-insured faces. But I'm still with Moore, even though I'm pretty sure everyone in the theater has gotten the point by now.
Then we go to France, where - you guessed it - people are thrilled with their coverage. The overall result is a film that deadens its pace during the second half, and wastes valuable time it could be using in educating its audience.
I thought the Guantanamo gesture was a powerful idea, and the sequences in Cuba were effective (although the scripted political speeches from the Cuban doctors made me a little uncomfortable). While others may object to these sequences, I don't. My problem was with the overlong, one-sided hammering of the audience with too many "gosh, really!" sequences.
The problem seems to be that Moore doesn't trust his audience to weigh competing arguments and come to the right conclusion. That's a shame. If he had raised more of the arguments against single-payer and then responded to them, he could have made a much more compelling and effective film. If 60 Minutes can present both arguments in a debate and come to a conclusion in a 15-minute segment, Moore had time to do it here. Instead, he presents a glib and superficial one-sided position that's too easily shot down, even though there are compelling arguments in its defense.
How easily shot down? For one thing, Moore never addresses the issues of lengthy wait times in national health systems. Those wait times are real. To counter those arguments you need to do what Ezra Klein did and put them into context. Then you can go a step further and acknowledge that there could be greater wait times for the currently insured under a reformed system, especially for elective procedures. If that's true, then why not let people opt into private health care systems if they want?
No way, says Moore. According to Business Insurance:
"The insurance industry ... is a racket," Mr. Moore told a cheering Chicago crowd, which he said included nurses and doctors. "There is no room for profit when we're talking about people's lives."
He may be right, but the systems he promotes both include a significant private health insurance market. More than 12% of Britons have some form of private health insurance. And France, which is presented as the ideal, has the third highest level of private health insurance among developed countries, behind only the United States and the Netherlands (according to the OECD - pdf file). There most be some reason people are paying for private coverage.
If doctors are among those cheering Moore, there could be more than one reason for it. While Moore acknowledges the AMA's pivotal role in killing previous attempts at national health insurance, he ignores the key role doctors have played in creating today's health care crisis. There is a small but extremely costly minority of physicians who are responsible for massive overtreatments. Credible studies suggest that most back surgeries performed in this country are unnecessary, for example, and the critical work of Dr. John Wennberg and others have shown that many physicians in high-earning specialties create demand for their own costly services - services that have not been shown to improve health.
Nobody likes managed care, but it was originally created to address the very real problem of overtreatment. The concept took a bad turn and became a process for delaying, denying, and interfering with all care - needed as well as unnecessary. But any reform that doesn't address the overtreatment issue is destined to fail. The U.S. has not only created a fundamentally flawed for-profit insurance system, but it has a sister system of profit-driven health providers.
Nor does Moore address the pharmaceutical and fast food complexes that are working overtime to degrade Americans' health, creating new sources of revenue for the profit-driven insurance-and-provider health economy. Granted, one film can't take on all of these issues. But it can certainly acknowledge their existence.
In a U.S. News interview Moore says "Edwards is the only one who's come out with a really detailed plan, and his plan's no good because he wants to put taxpayers' money into the private health insurance system. We need to cut out the middleman." I disagree, but that's a debate worth having. And while we're having it, we should remember that the 1994 Hillary Clinton plan Moore praises in the film depended on the private sector more than the Edwards plan does.
"Healthcare should be between the doctor and the patient," Moore also told U.S. News. "And if the doctor says something needs to be done, the government should guarantee it gets paid for." That's a prescription for disaster, given the ongoing problem with overtreatment.
Every American should have access to Medicare-level coverage on a guaranteed basis without punitive out-of-pocket costs. Private-sector involvement should be regulated to protect everyone's rights. But getting there will be difficult. Our health economy is greater than the entire economy of Great Britain, Canada, or France.
I applaud Michael Moore for raising the urgent issue of health reform, even if don't find his take on the solution a compelling one. And while it's important to concentrate on our flawed system of insurance, let's not forget the problem of the uninsured. They're dying because they don't have coverage.
Today SiCKO opens in theaters nationwide. And today more than 50 people will die from lack of health coverage in the world's most powerful nation.