"SiCKO" tells sad story, but not the whole one

Financially, Michael Moore's "SiCKO" has fallen far short of his previous muckraking effort, "Fahrenheit 9/11," at the box office. But it has succeeded in stirring debate about how to cover the country's approximately 44 million people without health insurance.

Moore's new documentary chronicles the plight of uninsured patients who are offered unthinkable choices about their care and insured patients who must battle their health plans to receive benefits. The film then explores the health care systems in Canada, Great Britain, France and Cuba, which Moore lauds as superior to the American system.

In the movie's climax, Moore takes a group of uninsured Ground Zero workers aboard a rented boat to Guantanamo Bay to get the first-class medical care supposedly delivered to the suspected terrorists imprisoned there. When that effort fails, he takes them to Cuba, where they purchase cheap medicine and receive free hospital care.

AMNews asked five physicians to see the film and share their reactions. The panel:

• Douglas M. Farrago, MD, an Auburn, Maine, family physician and editor of the humor magazine Placebo Journal.
• Edward A. Hirsch, MD, a practicing family physician for 24 years and now medical director for a Peoria, Ill.-based managed care organization.
• Charles M. Kilo, MD, MPH, a Portland, Ore., internist.
• Colleen A. Kraft, MD, a Midlothian, Va., pediatrician.
• Wayne J. Reynolds, DO, a Newport News, Va., family physician.

What was the saddest moment in the movie?

Dr. Kilo: The entire movie was sad. I don't agree with the entire portrayal, but the U.S. health system is quite far from where it should be. It does not serve us as individuals, our families or our communities as well as it should, even though the public continues to believe that our health system is the best in the world. Whether you like him or not, Michael Moore clearly points that out.

Dr. Reynolds: That people think they would receive better health care in Cuba. Somehow, I do not see the average American national walking into a Cuban hospital and receiving all the health care, testing, etc., for free just for asking!

Dr. Kraft: Seeing the couple who had to move out of their house and into their daughter's house because of medical bills. This happens way too often.

What outraged you the most?

Dr. Kilo: Having worked on health reform for over a decade, what angers me most is that Michael Moore made this film in 2007 and the health care establishment, physicians in particular, have done virtually nothing to make health care better.

Dr. Hirsch: Moore is very clever. There really are not any lies in the movie. There are a few places where his information is wrong, but mostly his data are correct. The real issue is that he only tells one side, using only the data that fit his point of view.

How accurate was the movie's portrayal of insurance companies' denial practices?

Dr. Kilo: The insurance industry is an easy target. Pointing fingers at others is not going to help us solve the problems we face. Hospital and physician behavior is equally problematic.

Dr. Reynolds: Insurance companies constantly fight with practicing physicians on the tests and procedures they order, all in the name of saving the health care dollar. The time and energy spent on doing this just seems like a colossal waste of time. ... Denial practices are actually understated in the movie.

Dr. Hirsch: Both physicians and patients want to do what they want, when they want it. Almost all health insurance today is employer-sponsored. When a denial is made by the health plan, it is implementing the plan purchased by the employer. ... The system is broken, and focusing on Band-Aid fixes like blaming the insurance company is not helpful, but it's a lot easier.

What did you think of the portrayal of health care systems in other countries?

Dr. Kilo: Having worked with health care professionals in Sweden, Canada and the [United Kingdom], I believe that working in those countries has definite advantages, not the least of which is a much lower administrative burden. ... In those countries, health care, like education, is seen as a necessity for a productive society. Making sure everyone has access to good care is not seen as socialism, but rather as being smart.

Dr. Reynolds: One aspect blatantly missing from the film was a discussion of the tax burden of these countries and how these so-called perfect systems cover the cost of health care for all without some form of rationing. I must admit, however, if Moore's portrayal of the "average" family physician in Britain earning $200,000 a year, driving a nice Audi and living in a million-dollar home is true, this would be very attractive to most family physicians in the U.S.

Dr. Hirsch: Americans are snobby. They want the best care right now, whether they need it or not, and they want someone else to pay for it. ...What Moore doesn't say is that the wait times for care in foreign countries is way too long and Americans would never stand for it. ... The way they get away with it in foreign countries is that they allocate only so much money for health care, and that's it. It truly is rationed care and would never be tolerated here.

Dr. Kraft: Medical care will always have two tiers. As a nation, like other nations, we can only provide a basic tier. There is a place for universal coverage as well as private insurance to create public-private partnerships. There will always be a way to obtain enhanced services for those who can afford them. In this country, we need that basic tier for everyone.

What was left out of the film's assessment of the American health care system?

Dr. Reynolds: I'm surprised Moore did not focus more attention on the high price of medications in this country, compared with others.

Dr. Farrago: As much as I enjoyed the movie, I was bothered by the absence of the malpractice lottery being discussed. ... Doctors are leaving states or stopping high-risk specialties altogether. This is very real. If we want to fix the system, I am in, but we all need to roll up our sleeves and leave no issue untouched.

Dr. Hirsch: First: misaligned incentives. The system is set up to reward for use. ... We need to stop this and start incentivizing quality, evidence-based care. ... The other issue is our provider system is upside down. In foreign countries, their primary care base is just that -- a base. They typically have at least 50% of their docs practicing primary care, and can manage easily 90% of the care needed by patients.