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“Sicko” is Michael Moore's latest documentary–this one proposing national health care. The movie argues that the US should have national health insurance just as we rely on the government to provide services like libraries, public schools, and fire departments.

The movie begins with a series of health care horror stories. A change of insurance companies can leave your preexisting conditions uninsured. That can happen from changing jobs, or when your spouse retires or qualifies for Medicare. A long list of medical conditions makes you uninsurable. HMOs and some insurance companies have been known to deny treatment to reduce their costs. We are shown a couple who was bankrupted by the co-pays from a series of catastrophic illnesses. A terminal cancer patient who wanted the insurance company to pay for experimental treatments. Uninsured patients are thrown out of hospitals or put in cabs and sent to public hospitals. One patient who lost two fingers in a saw accident had to decide which finger to reattach. One was $12K; the other $60K.

Moore cites the Canadian national health insurance plan. Following the usual Moore antics pioneered in “Roger & Me,” he follows a young woman with cervical cancer who was rejected for treatment by her insurance company because she was too young for this disease. She goes to Canada, claims to be the common law wife of a Canadian friend and walks in a clinic for treatment. But clinic personnel see the cameras and call the police. We don't get to see how this one comes out. Could a US citizen expect to be treated without documentation in Canada?

Canadian citizens are interviewed. Most are satisfied with their system. A few have gripes, but generally they are well cared for. Moore shows us visitors buying medical insurance at Sears in Canada to cover their travels in the US. Canadians tell horror stories of illnesses or accidents running up $100K hospital bills before they can get back to Canada. Not mentioned is the fact that Canadians pay for their system with a 15% national sales tax, the GST. And there are reports of escalating costs requiring supplemental taxes in some areas.

The movie moves to Britain, where they have had a national health care program since 1948. Most are satisfied with the program. A physician explains that he earns close to $200K working for the national health system and owns a $1MM home in London. Especially compelling is the ability to treat patients by need rather than by what is allowed by the insurance company. There is much less paperwork. Doctors can focus on treating patients. Hospitals don't even have billing offices.

Next we see France, which according to the movie has one of the finest family oriented health programs anywhere. In addition to national health care, doctors make house calls. Day care is inexpensive. Visiting nurses help with children and will even do the laundry. The French enjoy a 35 hr work week, and start with 5 weeks vacation per year, plus an extra week for a honeymoon. Liberal disability rules allow extended time with pay to recover from illness. Not mentioned was a bonus program that pays pregnant women to keep their doctor appointments. And the French have lifetime employment. A full time permanent job guarantees income all the way to retirement. Most new hires work under contract for several years before they are offered permanent positions. Free college education is also mentioned.

The negatives of this famous safety net are well known. Whereas Social Security and Medicare with employers match comes to about 15% of gross pay in the US, social costs in France (and much of Europe) come closer to 35%. That with income tax and the usual deductions would mean payroll deductions over 50% vs 20-30% typically in the US. Would US taxpayers tolerate these numbers?

The high cost of the French safety net is thought to be the cause of their slow economy. New businesses are reluctant to start in France, where costs are high. Efforts to scale back have so far been resisted, but some think the French system cannot be sustained.

The movie notes that in France, government fears the people; in the US, people fear the government. They don't explain the reasons for this, but I think they are clear. In the French Revolution just over 200 years ago, many aristocrats were guillotined. Those who survived were traumatized and well know the power of the people. They accept an obligation to provide for the common man. In contrast the US arose from an oppressive government imposed by the British from whom we rebelled. Hence, we have an ingrained tradition to keep government power in check.

The story shifts to Guantanamo, where Michael Moore has heard that prisoners are treated to free health care. He loads three boats with unfortunates from the start of the movie and brings them to Guantanamo for treatment. They are not admitted, but we see photos of the prison camp from afar. The patients are treated by Castro's Cuba. Even Cuba has free health care for its citizens. They have modern test equipment and low cost prescriptions. An inhaler costing $120/mo in the US sold for $0.05 in Cuba. A patient on nine medications was able to reduce medications to five. (This alludes to the problem of excessive medication and testing as physicians seek to game the US system to maximize their income. This practice increases costs with little or no benefit to the patient.)

The movie makes the point that the US is the only developed country without a national health care program. Even Cuba seems to do better than we do treating the health needs of its people. The movie includes several political references. It treats the Clinton's favorably. It implies that Labour in the UK is responsible for their national health program. The founder of national health care in Canada is named as a national hero. The movie even mentions Richard Nixon as signer of legislation that allowed HMOs to get started.

Overall the movie gives us a “rah! rah!” cheerleader approach to the problem of national health care. As documentaries go, this one is a bit superficial. There is no discussion of many well known aspects of the health care problem. How will we fund the program? Large sums are spent treating terminally ill patients in the last days of their lives. How do we control these expenditures? How do we moderate the rate of cost increases for health care? (They far exceed the average rate of inflation; the rate seems unjustified and unsustainable.) There is no mention of the cost of malpractice insurance? Will insurance still be needed? Or will doctors be protected by national insurance? What about coverage for catastrophic illness? Mental health coverage? Drug/substance abuse?

As to solving concerns about freedom of choice and what is covered, the exiting Medicare system provides a reasonable model. Provide basic coverage for all. Then allow individuals to buy whatever level of supplemental insurance they want for additional coverage.

Overall, the movie is timely. Health care is a problem that needs attention, if for no other reason because spiraling costs are unsustainable. But the essential issues of who pays for what and how much are not worked out. Until a workable system comes along, this issue may not be solvable.
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