Director: Michael Moore
Reviewed by R. Srivatsan
People in the United States are less healthy, have more chronic disease and disability, and die at a younger age than people living in other wealthy nations, concludes a new report by a panel convened by the US National Research Council and the Institute of Medicine. The panel found that the US fell short in health outcomes at every age from birth to 75 years and that the deficiencies were found at all levels of society. Even high income, college educated, white Americans tended to be sicker and die younger than their peers in other rich countries. So many problems were identified in so many areas that it indicated that “something is fundamentally going wrong,” said Stephen Woolf, professor of family medicine at Virginia Commonwealth University…
British Medical Journal 2013; 346:f215
Sicko is a two hour film that examines critically the abysmal health care system in the United States. It records, asks questions about, and analyzes the critical failure of medical care. It shows through comparisons with Canada, England, France and Cuba that it need not be so.
The film starts with a shot of Adam, a wageworker, on a chair in his shack. He has a gaping cut on his knee, which he is stitching by himself with a sewing needle and black thread. His cat watches and yawns. Adam has no health insurance and cannot pay for emergency medical treatment. Cut, to Rick a carpenter who has lost his middle and ring finger to an electric saw. He too has no insurance. The American medical system gives him a choice – pay $ 60,000 to sew on his middle finger or pay $ 12,000 and reconnect his ring finger. He chooses the latter. Fifty million people in America don’t have health insurance, and 18,000 of them will die each year for that reason. But the soothing voiceover (Moore’s) assures us that the film isn’t about them. It is about the 250 million Americans who are covered by the health care system.
Larry and Donna, a once well to do elderly couple, are forced to sell their comfortable house and move to their daughter’s spare den/work room. Larry’s three heart attacks and Donna’s cancer have caused insurance premiums and other expenses to literally go through the roof, destroying their homes and throwing them on the street. Cut to Frank, who at 79, continues to work as a janitor, in order to ensure that he has excess money required for his medicines which cost more than the senior citizen’s health care reimbursement he gets. Four insured women, who have various life threatening ailments, are refused care by the major American health insurance companies like Humana, Cigna, Blue Cross and Blue Shield on the basis of different trivial reasons. One of them dies. The movie traces the appalling callousness of the health insurance system that refuses medical care to insurance holders even if it means their destitution or death. An email appeal for such negative experiences with American health care brings Moore 25,000 responses in a week!
Having set the stage with these introductory stories, the film asks the question, what is happening? It suggests that the reason for this is that the medical insurance companies are profit-making businesses. They fatten their bottom lines by finding legal but unethical means to refuse cover to critical acute health care expenses of people who have insured with them. Their clerical staff is equipped with the stamped signatures of the company directors. They deny coverage in a routine manner for a targeted percentage, and the bureaucratic system has no sympathy for the people who lose their health and sometimes their lives. The film interviews three employees who leave the insurance companies due to the guilt caused by the cold heartedness of the system. One of them Linda Peno, Medical Director of the Humana insurance company testifies at a judicial hearing, how the system sets an average of 10% as the rate of denial of insurance payment sanctions, and how employees have incentives to deny more than 10% if possible. She expresses profound regret for the loss of lives due to these inhuman insurance policies. All these are due to the system of managed care in the USA through the Health Management Organizations (HMO).
The next part of the film traces the degeneration of health care to Republican politics in America. It starts with a reconstruction of Richard Nixon’s dubious and dishonest role in the establishment of the system of privatized health management organizations. It goes on to politicians like Ronald Reagan who see socialized medicine as a first step toward communism. The power of a health bureaucracy to determine where a doctor might practice and which hospital a patient might seek treatment in are portrayed as the first steps of governmental control over the sacredness of free enterprise and living freedom. Hilary Clinton, when she is First Lady, starts a Democratic campaign for free universal health care. This is shot down by Republican counter-propaganda, which uses the bogey of communism. The counter-propaganda is funded by the health management organizations and medical businesses to the tune of 100 million dollars. Ultimately, Hilary Clinton too is bought over. The finale of this section of the film is a documentary clip of George Bush, at the signing ceremony of the programme on health care for senior citizens, with a caricature twist. As each official walks on to the podium, the film shot carries an arrow showing who has been bought off, and by how much – Bush tops the list with a pay off of nearly 900 thousand dollars. The politician who steers in the new senior medical care programme, which in actuality makes it more difficult and expensive for senior citizens to get health care, joins an HMO with an annual salary of two million dollars.
After this expose of the rot in the US health system, with its espousal of economic liberty of the health care industry, Moore deals a series of body blows to the logic of US health care. He does this through vignettes of health care in Canada, England and France. In Canada, a US woman citizen who crosses the border and seeks treatment for her cancer under false pretence of Canadian citizenship is treated free of charge and with no fuss. The rumor of month long queues for medical care in Canada is a myth. In stark contrast, Moore’s Canadian relatives take out health insurance even if they want to cross the border into the US for a few hours. He then goes to England to examine the home of ‘social medicine’. Pharmacies there sell all drugs—any quantity of any number of them—prescribed by the National Health Service (NHS), and charge a fixed bill of £ 6.65 (regardless of whether they are cheap antibiotics or costly anti-retroviral drugs). Social medicine takes a large chunk of citizen’s salaries as taxes and provides medical care. It pays the doctors well enough for them to live in comfort in London. The NHS hospitals have cash counters, not to collect payment from patients, but to pay out money for transport if needed so that the patients can get back home after treatment. In Paris, Moore finds out to his (and our) surprise that the government has doctors who make free house calls to patients in times of need, within an hour of a request, 24 x 7. France also provides all young mothers with the service of a free nanny who will do the laundry for the whole house (and even cook at an extra charge)!
Why is there this difference between the US and these countries? Tony Benn, the English parliamentarian argues in the film interview that it is democracy, which from the nineteenth century takes power away from the market and to the ballot. Benn shows Moore how in the UK, there was immense loss of life and limb, and economic catastrophe during World War Two. This he says led to a common spirit between politicians, parties and people, setting the stage for universal health care. Even Thatcher didn’t tamper with the NHS. French interviewees say that the reason for good health care in France is that the people are intensely political – they agitate for every thing (and have extremely high industrial productivity too). In France, political traditions of protest, revolt and organization make the government afraid of the people. The film suggests that in the US in contrast, the people are demoralized, indebted and afraid of government, and there is no common spirit. American liberalism has the citizen by the throat. The result is that the US has some of the worst health care indices in the developed world.
Has the US no socialized services? Moore shows us the many common socialized services that are overlooked in the everyday gaze – libraries, the fire service, the police service, etc. He wonders why the US doesn’t have socialized medicine. And in a final thrust, he asks a simple question that brings the viewer to tears – “Who are we?” It is a question that perhaps took considerable time to craft and perfect to its absolute and deadly simplicity. “What kind of Americans are we who let our people die because they cannot afford health care?” And he continues, “It is usually said a country is best judged by how it treats its weakest citizens”, but perhaps the US could be understood by how it treats its heroes? The heroes of 9/11 were the professional fire servicemen and the many brave volunteers who went in to ground zero at time zero, just after the blast, to help the survivors and retrieve the bodies and parts of the dead. Those who did so suffered many ailments (breathing, accidents, persistent nightmares and chronic stress) as a result of working through the rubble. It is characteristic that the system of compensation for these professionals and volunteers who risked their lives was clearly designed to deny many claimants if they couldn’t prove with legal certainty that they had worked at ground zero.
At this point, Moore provides one more astonishing and ironic twist to his tale by asking the question, who in the US has universal access to health care? The answer is that the terrorists who perpetrated 9/11 in Guantanamo Bay, the US naval station in Cuba, have universal access to health care! Moore, in a representation of documentary activism, loads three boats with some of the heroes of 9/11 and some of his earlier sick interviewees and tries to take them to Guantanamo Bay for treatment. On approach, sirens sound out from the facility, and they quickly divert their boats to Fidel Castro’s Cuba, the ‘devil of communism’ off the eastern seaboard of the US. All the sick people in Moore’s contingent are treated free of charge, and the heroes of 9/11 are honored by the local fire department. No comment needed here. The film ends with a shot of Michael Moore carrying a basket of dirty clothes up the steps of Capitol, to ask the congressmen to do his laundry for him, French style.
From my perspective here in Hyderabad, there are many ways in which his picture of American health management organizations reflects what could happen in India if health insurance were privatized. Corporate hospitals and private insurance companies could find ways to refuse coverage after taking the insurer’s money. However, the current picture is a little different. Firstly, there is very little health care to boast of. Secondly, as the papers on Aarogyasri in this broadsheet show, in a state financed insurance system with the government paying the premiums, the emphasis is on hospitals tapping government funds, even if the medical or surgical intervention may not be quite necessary. This is proved by the recent rash of unnecessary hysterectomies resulting in a scandal. Thus, rather than being refused medical care, the governmentally insured populations in India are likely to get risky medical care they don’t need, suffer due to it, and at the same time, not have their basic needs covered. Thirdly, as the surpluses of the Employees State Insurance Corporation demonstrate (described in this broadsheet), even when a potentially good state insurance system exists and is financially robust, health care is not offered unless there is a political struggle to get into the system. This confirms in our own political language the correctness of Sicko’s analysis – it is only when the government is afraid of its people that it will do some things right, and universal access to health care is one such.
We need to think more carefully about Moore’s vignettes of different Western countries. How have their diverse histories lead them to different commitments to health care? What are the political and civic cultures of those countries? For example, the French and the British tolerate different kinds of socialism both of which do not see the communist variety eye-to-eye. Their welfare states provide general and medical care to citizens through taxation and state run insurance. Both countries are anti-communist, and have free economies. In Cuba, where there is a communist regime, health care has a very different structure. Cuba’s health indices are nearly as good as those of the USA, at a fraction of the expense. Cuban health care works through preventive care (one of my problems with Moore’s film is that all his examples of the US are for accident care or for advanced medical care – neither primary health care nor preventive medicine is focused on). The USA has long been the bastion of the spirit of free enterprise in the world, where all problems tend to be interpreted in terms of individual freedom. Moore is right in saying that the Republicans are the root cause of privatization and devastation of universal health care. However, it is important to realize that they are being voted into power by the people, and that means that the mood of a considerable proportion of the people is pro-free enterprise. There is staunch belief in ‘each according to his ability’ (including the access to medical care). There is no consideration of what people who are sick may need in terms of health care if they can’t afford it. It is interesting that the difference between being socially responsible and being reliant on oneself results in two different civic cultures: one, in Canada, the UK and France (for example), where people consent to taxation and ‘free’ health care for all on the one hand; two, in the USA, where people have such a culture of fierce self reliance that they refuse and detest any form of state interference. Both these forms of conduct seem distant when we see them from India, but what will happen in India becomes clear.
What are we, here in India? How have we treated our poor? We have an inborn, implicit condescension for those beneath us in social station, a discrimination that has historically been legitimized by the operation of caste. For a long time to come, this subterranean disdain is bound to limit the way in which we think of our fellow citizens. We tend to think of them as lesser human beings who don’t have a right to health care, but may be offered it as a charity. As long as such a perspective exists and tends to dominate our culture, we will have sub-standard health care with its enormous social costs in terms of population-wide morbidity. When and how things will change is any body’s guess, but mine is that they are going to remain the same for at least the next fifty years – unless we have a socio-cultural revolution.
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