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SICKO
Michael Moore’s new film “Sicko” is every bit as much
of a horror movie as its Hitchcockian name suggests. To British citizens,
brought up with the concept of free access to healthcare as the norm,
the realities of medicine delivery in the US are truly appalling. The
early images show what happens at the very bottom of the social ladder.
A carpenter with 2 severed fingers in an industrial accident is told that
it would cost $12,000 to restore the ring finger, $60,000 to restore the
fore-finger. He can only afford the cheaper option, so no attempt is made
to save his vital fore-finger. A young man tries to sew up a gash in his
own knee, having no money for hospital treatment. We would be horrified
to see these vignettes even in a Third World country; but this is the
US, with some of the most advanced medicine in the world. Or is it truly
so advanced?
Moore acts as his own Greek chorus throughout the documentary, relishing
his role as the shambling, overweight, improbable crusader chasing the
fat cats of the system. He wants to discover why the US, the largest and
most affluent western industrialised nation, lacks free, universal, compassion-driven
health coverage. “Why us? What is it about us?” he asks with
genuine concern but hammed-up bafflement. He was aware that when word
first spread of his plans for this film, when “Michael Alerts”
went skimming round the drug companies and healthcare corporations, that
the villains in his sights were in meltdown with paranoia and anxiety.
For it is they who, in his view, are responsible for the “sick,
seedy, grubby system” that is American healthcare.
45 million Americans are without medical insurance, not because they are
feckless or even because they lack the means, but because they are rejected
by a profit-obsessed insurance system. But even those middle-class, prudent,
forward- planning Americans, 250 million of them, can fall foul of the
system if they are unfortunate enough to fall sick with a high-cost or
chronic ailment. On screen,
we briefly see a rolling list of the clinical conditions which exclude
you from coverage; pages and pages flash by. I caught sight of one, Addison’s
disease, which would have excluded past-President Jack Kennedy had he
come pleading for help. Being ill in the US is a double whammy as your
health and your means crash together, and how outrageous is it that your
countrymen and government are prepared to exploit that fear while passing
by on the other side of lives in terminal collapse. Moore dubs the gang
of health care businesses and the government an “Axis of Evil.”
He concentrates his strictures on the insurance companies themselves. Their
raison d’etre is not to facilitate treatment but to deny it. It
is they who make the decisions as to whether any individual “qualifies”
for investigation and treatment. We see a young deaf child who needs to
be able to hear at a crucial time in development, otherwise her speech
will be permanently impaired. The grudging allowance is one cochlear transplant,
but not two. A woman collapses in the street and is taken to hospital
by ambulance. She is charged for the cost of the ambulance because it
was not “pre-arranged.” Impossible conditions are imposed
on the hapless clients, and wherever an excuse (such as obesity) can be
found for treatment-denial, it will be used. In fact, insurance companies
have the right to go back into a person’s past history and ferret
out excuses there. One woman’s undeclared, trivial fungal infection
from years past is used to deny treatment for a current, more serious
condition.
There are, of course, doctors who advise the insurance companies, and who
make a career of keeping sick folk distanced from their care needs. These
doctors are carefully trained in the way of business, any remaining compassion-responses
being thoroughly extirpated. Their work is minutely monitored, and 10%
DENIAL to clients is the accepted standard. Much less than 10% requires
reprimand and retraining, while more than this figure attracts praise
and bonuses. Many Americans, comfortably trusting in their very expensive
insurance, do not discover until too late the bias towards denial. Moore
wheels out a female doctor who had sold her soul to the insurance world,
but has a “Road to Damascus” moment, perceiving that her reputation
as a Good Medical Director and accompanying 6-figure salary has been won
at the expense of doing the dirty work of managed healthcare. She admits
her guilt, her responsibility for the death of a man to whom she denied
surgery. The system even runs heavy hit-men, to investigate ways of retrieving
money if possible.
When Americans have surmounted the difficulties of getting health insurance,
they sign up with a Health Maintenance Organisation. HMOs were set up
by Richard Nixon, since when the cost of healthcare has spiralled, while
on all measurable factors, quality has nose-dived. One particularly gut-wrenching
scene shows a barefoot, elderly, confused patient wandering in the street.
She has just been pushed out of a taxi that promptly accelerates away,
on the doorstep of a Charity Centre. She had been ejected from hospital
because of lack of financial backing. She is a patient of the biggest
HMO in the US, Kaiser Permanente. As they waved her away, the hospital
staff had said to her “Look after yourself.” They meant it
literally, one presumes. But watching the film at this point, I pricked
up my ears, for the name Kaiser Permanente (KP) rang a bell.
In 2003, the Blair government in the UK invited the chief executive of
KP to advise it and the NHS Modernisation Board on how to model the NHS
on a KP style of funding and provision. American HMOs like KP are facing
intensified competition and saturated markets at home, and are all too
anxious to be given opportunities abroad, especially where tax-funded
health care could provide rich pickings for them. This meeting of minds
coincided with a series of papers in the British Medical Journal on how
superior this HMO was than the NHS at integrated care and efficient use
of hospital facilities. I read those articles with disbelief and outrage.
It was blatant brain-washing. One such paper states loftily “(Kaiser)
doctors have a commitment to the success of the organisation.” Success,
in the light of the ordinary Americans’ experience, is clearly not
measured in units of quality of care. How tragic that a Labour government
should thus seek to dismantle that most inspired piece of philanthropy
of the radical post-war Labour government, the NHS. But our situation
is not so different from that in the US; any government’s prime
objective is to stay in power, and to do that they must harness the interests
of big business. Indeed, Moore shows a queue of happy American statesmen
and women with mega-dollar labels attached, indicating the amount of electoral
support they receive from the health industry. In the UK, our political
leaders wish to distance themselves from any accusations of “tax-and-spend,”
so creating their own commercial dependency.
The artistry of “Sicko” demands that the American system should
be compared unfavourably with others, and Moore takes us to Canada and
France as well as UK. His credibility suffers a bit here. Certainly in
the UK, our situation is a million times better than the fear, uncertainty
and anxieties of ordinary US citizens. But the NHS is far from utopia
in its present poorly managed and supported state. We have the terrible
problems of debt incurred by PFI hospitals and consequent service cutbacks,
we have rampant MRSA, filthy wards, understaffing, neglect of the elderly.
We see the distorting effects of government targets, most recently in
patients delayed in ambulances outside hospital, so that A and E targets
for speed of care should not suffer. Moore actually interviews a British
GP, motivated to prove that “socialised medicine” is not about
impoverished professionals slaving for a communist-style state, an image
that is actively perpetuated in the US. But he glosses over the GP’s
smug admission that government targets are a great extra earner.
The UK GP contract of 2002 ensured that GPs and Primary Care Trusts (PCTS)
could link their remuneration to market-based financial incentives. PCTs
and NHS Direct derive from transatlantic HMO models. They can opt out
of certain services (like out-of-hours cover) provided these are sub-contracted
to commercial deputising companies. And recently it has been reported
that such companies often employ fly-by-night doctors from mainland Europe,
working under conditions unlikely to give quality service. Independent
Sector Treatment Centres have been introduced, designed to supplement
hospitals while challenging the NHS to greater efficiency - an ideological
leap-in-the-dark, as a report from the House of Commons own multi-party
Health Committee observed as they looked in vain in 2006 for a genuine
benefit from these expensive market models. They preferentially cream
off the easy, cheap-to-run operations with minimal complications (like
cataracts), and are likely to destabilise the NHS in the future, directing
care to the comparatively well and away from the seriously needy, as they
have been seen to do in the US. Indeed, all these new developments are
moving us toward a US system. It is dreadfully obvious that the UK government
fully intends to shed its fiscal responsibility for healthcare onto the
open market.
While “Sicko” is an impressive expose, it falls short of the
whole explanation as to why, in the US as in other industrialised nations,
healthcare costs soar while there is no comparable improvement in well-being.
The US has high rates of obesity, diabetes, heart attacks, lung disease
and cancer, and its infant mortality rate is worse than Cuba or El Salvador.
The flip-side to under-treatment of the poor and needy in an insurance-based
system, is the gross over-treatment of the wealthy, the worried well.
Indeed, one recent book (“Overtreated” by Shannon Brownlee)
believes that this perhaps is the biggest scandal of all in the costly
distortions of US healthcare.
On a sea-cruise in the summer, we made friends with a number of exceedingly
wealthy Americans, who boasted of the yearly, very searching, well-person
check they underwent, with almost mystical belief that this would keep
all challenging illnesses at bay. Their exposure to the advertising of
the health industry has turned medical practice into a faith-based, religious
dogma. People who have everything want more, they want immortality, and
are prepared to pay for it. They would not brook any discussion that it
was possible to be over-investigated and over-treated, yet this is a phenomenon
that is increasingly recognised, most particularly where health is perceived
as a marketable commodity. It is estimated that 20 to 30% of clinical
tests done in the US are needless, a figure that is augmented by the defensive
medicine that must be practised in a litigious country. Exposure to unnecessary
radiation, false-positive diagnoses and long term “preventive”
treatments such as anti-cholesterol medication (swallowing the false persuasion
that these are 100% safe and side-effect free) are the results of this
misperception. The marketing of CT scanning in the US is highly sophisticated,
persuading people that this can “beat your silent killer.”
But research shows that people thereby often made more anxious rather
than less; and perhaps rightly, for computed topography is responsible
for an estimated 2% of cancers in the US.
The same phenomenon is seen in Japan, one of the most medically advanced
countries in the world. Japan’s system of payment positively encourages
the ordering of more MRI and CT scans and prescription of more drugs,
and that is exactly what happens. Their numbers of scans per head of population
are way ahead of other developed countries, while their patient consultations
are characterised by a “three-hour wait, three minute contact.”
Moore does no more than touch on the over-treatment angle. It is not really
his agenda. “Sicko” finishes on a marvellously histrionic
note when heroes of 9/11, failed by their own country, are taken to Cuba
for treatment. The film sets you laughing, crying, thinking by turns.
For us in the UK, the message has to be, lets us do ANYTHING rather than
go down the road, or across the Pond, to an insurance-based healthcare
system.
MARGARET COOK
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The NHS Consultants' Association
