Michael Moore's SiCKO

A couple things in reference to Moore's latest smirky docuflick where he picks a fight with the health care industry. The system is broken, Moore contends, because too many people are denied access, and even those that have access are victims of an unwieldy profit-driven bureaucracy that is in constant antagonism with our best interests.

I find Michael Moore entertaining although frequently over the top. He does seem to tap into the "next big thing", whether it's school violence, the Bush debacle or, now, health care access and cost. If history is any judge, this movie will usher in a riveting consciousness for nationalized health... and maybe it's time.

SiCKO makes salient points, many of which I find compelling, but the movie definitely has its faults. Moore correctly points out that Canadians may wait in line for non-urgent services, but the queue is long only because all their citizens are in it. Here in the US we have less waiting time for MRI's and surgery partly because 20% of those within our borders are not plugged into the system and are thus not getting any non-urgent care.

One issue I had with Moore's movie was his use of young American expatriots living in France to get their opinion of a comparison of the health care systems in France and the US. Their stories of the French medical care were overwhelmingly positive (of course), but the care they received was predominantly for pregnancies and pediatric care, which by and large are positive experiences. Conversely, the US consumers of health care interviewed by Moore had progressive debilitating diseases, and such patients are often dissatisfied with their health care and its efficacy. He compares apples and oranges.

I did agree with his portrayal of the US system as an unwieldy bureaucracy which is nearly impossible to navigate. Having had some personal experience as a patient and family member of a patient, I can honestly say the bills from hospitals, doctors, labs and diagnostic centers make no sense and I thanked heaven every day that I had a comprehensive plan that only asked for my deductible.

Now I'll go on my rant:

Critics of Moore point out that his figure of 45 million Americans without health insurance is misleading. The proper breakdown shows that many of the uninsured are either illegal aliens, so they are not “Americans”, or are uninsured by choice with many making middle-class salaries.

"We hear a lot these days about 45 million Americans who don't have health insurance.
...According to the US Census Bureau, 17 million of those without health insurance live in households having over $50,000 in annual income. That's 38% of the uninsured in America.(2)
In fact, 9 million - 20% of the uninsured - reside in households pulling down more than $75K a year. (3)
...And then there are the young invincibles. Over 18 million of the uninsured are people between the ages of 18 and 34. (4) They spend more than four times as much on alcohol, tobacco, entertainment and dining out as they do for out-of-pocket spending on health care.(5) They represent 40% of the uninsured in America.
...14 million people without health insurance are eligible for government health care programs like Medicaid and S-CHIP but choose not to enroll. (7) They represent %31 - nearly one third - of the uninsured in America.
...The U.S. has 12 million illegal immigrants who don't buy health insurance but still get health care.
...So, how many are truly uninsured? Around eight million. Just 18% of the 45 million that we hear about so often."

So what? The fact remains, at any given time 45 million people in this country do not have insurance. It doesn't matter why they don't have insurance, the fact is that they are not paying premiums and if they get sick they will be a burden on the system. The system is required to absorb all comers-- we do not turn away critically ill people-- and as such all people should be compelled to pay into the system. The “invincibles” and the wealthy poker players need to be taxed in order to pay for the care of the infirm.

Sure many folks choose to deny themselves health coverage, but that does not mean they will not get health care, it just means that they will either struggle to pay for it if needed, or they will default on the bill to the doctors and hospitals. Or, they will be lucky and never pay premiums and never get sick. All of these scenarios are counter-productive. Yes, we should all have free will to make choice in our lives, and the free market should be left to decide our fates. If someone wants to plays roulette with his finances and eschew health insurance, let him. The problem with this reasoning is that the hospitals and doctors do not have the reciprocal freedom to refuse treatment. Not a minute goes by that a middle class uninsured citizen doesn't enter an ER with a potentially life-threatening condition. Nobody denies them treatment. If a specialist is needed, one is assigned and the patient is attended. This is the law. Some specialists may be reluctant to come in on a dreary night to manage someone who they know will never pay the bill, but they come because they are compelled to come and they are compelled to take their turn covering the ER for such patients in order to maintain their hospital privileges. The charter of every acute care hospital mandates that they have specialists available to care for “unassigned” (read: uninsured) patients who need their care, so the hospitals by necessity transfer that mandate onto their specialist staff.. That means some physician will be called in to evaluate and manage this patient, using their hard-earned expertise, taking the risk of a bad outcome, fretting over proper care and perhaps staying up all night only to go into the office for a full day the following morning. And will the doctor get paid? Who knows? Perhaps. But they certainly won't get paid in any kind of timely manner. That's not a way to run a health care system. And I won't even go into the value of health maintenance and the reluctance of uninsured to seek preventive care. How many of those ER visits would have been unnecessary if the person had a regular physician? 38% of the uninsured population chooses not to pay health insurance premiums, and that's okay? We're talking about the middle-class who conceivably should know better, and that's okay?. Furthermore, any insurance program relies on healthy participants paying into the system thereby paying for the care needed for the sick participants. If only sick people have insurance, the system fails.

The second point is that fourteen million people are eligible for Medicaid but choose not to sign up. Again, those people are choosing to not provide an avenue to pay the providers of health care in the event it is needed. The ones who suffer are the providers who are compelled to care for the patients and can only hope that some paperwork is filled out in a timely manner so payment is forthcoming. The patients also suffer the consequences of denying themselves and their children preventive care. If someone is eligible for Medicaid, there's a reason. They are either unemployed by choice, unemployable or too young to have a job. Many of these folks do not have the wherewithal to seek help until it is needed, so to imply that they have access to care and their laziness is the main deterrent to such care is arrogant and counter-productive. The fact is they do not have insurance and that is all that is needed to know. I'll give a case study (named changed):

Carly is an 18 y/o female with a history of juvenile onset diabetes. Her family is dirt-poor, she was raised by a single mother, she just received her GED (government equivalency diploma) and her job pays $8.75 per hour. Fortunately, Carly has no kids (yet). She was told she was eligible for Medicaid, but since she has an income she must pay the first $800 of her health expenses. Before she was 18 her S-Chip Medicaid paid the entire amount. This means that all her diabetes tests strips, glucose monitor and insulin are paid out of pocket. If she has anything left over, she may pay for birth control. Maybe. Or she may decide to go to the beach. Who knows? When I saw her she did not have her Medicaid card, but I examined her and gave her birth control pill samples and told her that Planned Parenthood could provide birth control at a sliding scale cost. Who knows if she went. There are 34 ob/gyns in this town, but only a handful accept Medicaid as payment. Here are my questions:

Why do I have better health care coverage than Carly? Do I really deserve it more than she does? Why does Carly have to shop around to find a doctor to see her and then shop around to get her medicines and supplies at a reasonable cost? I don't. I just call any doctor in town, tell them which insurance I have and they welcome me into their practice. I take my prescription to any pharmacy and get it filled.

Let's assume that Carly really is just a lazy bum who fully understands the intricacies of the health care system, but just plain does not care about her responsibilities. Even though this is unlikely, let's make that assumption. Is it in society's best interest to put hurdles up for this young woman to get health care and birth control? From a pure self-interest standpoint, wouldn't it make more sense to lavish care on this person in order to keep her as healthy as possible and-- almost as important-- not pregnant?

In a perfect world, the perfect Carlies would all be self-reliant stalwarts who overcome their poor circumstances, pull themselves up by their boot-straps, finish college and go on to support their aging mothers and siblings. Unfortunately, the Carlies we all see everyday live in the real world. They don't understand Ayn Rand, Milton Freidman and the supposed free market (but then, who really does?) The real Carlies need their community to embrace them and look out for them. The real Carlies need their doctors and nurses who take care of them to be remunerated the same as the doctors and nurses who are taking care of me. I would argue that those providers caring for the indigent should be paid more. I know this may sound weird, but think about it for a second. Nobody would benefit more than Carly from an interaction with the health care system, and society would benefit immensely by keeping Carly healthy and unpregnant, so why not provide incentive for health care providers to seek these people out and welcome them into their practices? Why not pay Medicaid providers the same to care for Carly as for me? Or, how about this for a novel idea: Why not pay doctors and nurses more to care for Carly? Heresy.

The final group of people who have no insurance are the illegal immigrants, and hell, they don't deserve it, so screw 'em. The free market maniacs imply that this is a no-brainer. They're illegal, for chrissakes, you cannot actually expect that society-- taxpayers-- are responsible to pay their health insurance. NO way! We didn't invite these freeloaders in, and now we have to pay when they have the audacity to get sick? Come on, stop it now.

But hear me out on this. Illegals are here for a reason, and it isn't because they can live more lavishly in the barrios of LA or Chicago, comfortably sipping cervesas while watching the Cubs game on a plasma TV. No. Illegals are here for one thing and one thing only: to work. And for the most part they are underpaid and overworked and live in relative obscurity hoping to avoid the always looming potential deportation while their employers take payroll taxes out of their paycheck for benefits the illegal worker will never realize, or pay them in cash so as to avoid payroll taxes altogether. Every way you slice it, illegals earn their keep, in spades. What happens when a worker gets sick, say has appendicitis, and needs medical care? Well, they don't have insurance, they are afraid of deportation, and they only get paid if they go out into the field every day. Their employer may have a hunch that they are illegal, but heck, the paperwork looks legit and there's a profit margin to maintain here at the blueberry farm. If they get sick, well, they'll know what to do. We all know what they'll do when that appendix flares up: the worker will delay. They will delay because they are afraid and they are vulnerable. Even the most vibrant free marketer would agree that this person does not deserve to die, but nobody knows how to solve this dilemma. I know what not to do: don't put up a hurdle that will disincentivise this person from getting help. What if we had a system that would provide for all comers within our borders because we know that if they are on our soil there's a good chance they are contributing to our economic well-being? How 'bout that premise? Let's not assume these people are all free-loaders, because for the most part, they are not. Sure some engage in criminal activity, but most studies show it's at a much lower rate than natural born citizens. Illegals, for the most part, are the best bargain this economy has: they work hard, ask for nothing and keep quiet. Sure, once our compesano's appendix is yanked and thrown into the waste bucket, he's going back to Honduras or Belize or wherever, but at least he's alive to sneak back another day to pick cabbage or almonds or blueberries for our bountiful tables. Let's hope he makes it back ... we should only be so lucky.

And I won't even go into the weird rationale of expecting US physicians and hospitals to care for illegals while the federal government fails to adequately patrol our borders and looks the other way when business owners knowingly hire illegals and then don't provide insurance to pay for them.

Michael Moore is a showman who can spin a yarn and get your emotions bubbling. But he wouldn't be successful if there was not at least a kernel of truth in what he says. Bowling for Columbine showcased the gun culture that permeates our society; Moore didn't make it up. Fahrenheit 911 put a title to the cynical fearmongering by our administration which has led to an unraveling of our foreign and domestic policies and the American public has now realized six years too late. Likewise, SiCKO gives us a peak at the underbelly of our fatally flawed health care system. The US may have some of the best physicians, nurses, hospitals and technology to help patients, but the bureaucratic and business infrastructure, the system, fails to deliver the product in a fair and economical manner. That's the item for the next blog entry...