Observations Atlantic crossing

Getting America to take the shame

BMJ 2007; 335 doi: http://dx.doi.org/10.1136/bmj.39279.711748.47 (Published 19 July 2007) Cite this as: BMJ 2007;335:128
  1. Uwe E Reinhardt, James Madison professor of political economy, Princeton University, Princeton, NJ, United States
  1. reinhard{at}princeton.edu

    Film maker Michael Moore is to be thanked for holding up mirrors to the US healthcare system

    Long before American film maker Michael Moore's Sicko opened at cinemas around the nation on 29 June (review BMJ 2007;335:47), his oeuvre had triggered a firestorm of protests from the right of the political spectrum. Its inhabitants still unquestioningly regard America's health system as the best in the world and routinely write off all other nations' health systems as “socialised medicine,” a derogatory label in these latitudes.

    To be sure, Michael Moore's juxtaposition of the government dominated health systems in Canada, Europe, and Cuba with America's more private, market driven health system would hardly pass the requirement of balance and robust evidence demanded by any peer reviewed, scholarly journal. When his camera is on the US health system the lens is relentlessly focused on the system's warts and never on its unblemished parts. Moore does the obverse when illuminating foreign systems. A viewer could be forgiven, for example, for believing that under the British NHS doctors are exquisitely well paid, patients pay nothing for the excellent care they receive promptly, and the only function of the cashier's window in medical facilities is to provide cash to patients on the way out. Much the same impression is conveyed on the other health systems, including Cuba's.

    But Moore's series of movies on America's many warts do not seem to be intended as well balanced, scholarly treatises. Instead, like his earlier movies, Sicko should be seen as a plank swung squarely into the viewers' faces, to get their attention for one overarching question: “What have we Americans become as a people to allow so much callousness and outright cruelty in a health system that is abundantly endowed with resources—in many instances excessively well endowed—and, as most Americans must know, also is home to much human kindness and excellence?”

    Can anyone in Canada, Europe, or Cuba imagine a hospital that calmly quotes a patient showing up with two sawn off fingertips a price of $60 000 to repair one of the two fingers and a “bargain price” of only $12 000 to repair the other, and then to ask this hapless, bleeding, and uninsured patient to make on the spot a rational consumer choice between three options: no service, repair of the “low cost” finger only, or repair of both the low cost and high cost fingers? (The “consumer” in the vignette chose the second option.)

    To some dyed in the wool libertarian American economists, this scenario may be the ultimate dream of “consumer driven health care,” based on the theory that patients can be retrained to act as smart, well informed consumers of health care. Elsewhere in the United States, this vignette is apt to be viewed as a source of national shame. No well balanced scholarly paper and no equally balanced testimony before Congress could ever kindle that sense of shame among Americans as well as Michael Moore does in Sicko.

    Moore's vignettes should not be seen as rare and isolated instances. Several years ago the Wall Street Journal featured on its front pages a series of investigations by staff reporter Lucette Lagnado chronicling the plight of uninsured Americans in need of hospital care. One low income American, whose wife had been treated for cancer at a non-profit academic health centre, had incurred a hospital bill of some $20 000. In the five years after her death, her husband—an unskilled, low paid worker—was mercilessly hounded by the hospital for payment of that bill. Although over the years he did pay installments adding up to nearly the original $20 000, interest charges and legal costs had puffed up the amount owed to the hospital to over $50 000. In another vignette, an uninsured waitress working at a pizza parlour had incurred a hospital bill of several thousand dollars as the result of a miscarriage. Fearful that a judge might force her to agree to an unaffordable payment schedule, she had failed to show up at a court hearing, whereupon she was arrested and briefly jailed.

    To Canadians and Europeans it will be incomprehensible that in for-profit and non-profit hospitals alike, along with community pharmacies, bills for uninsured patients, who typically are from the lower income strata, are routinely twice or three times higher than the prices paid by private insurance companies. Jailing a mother of two over an unpaid hospital bill caused by a miscarriage would be even more incomprehensible. Surely it can fairly be asked, as Moore does, why these harsh edges are necessary in a system that spends almost twice as much per capita on health care as does neighbouring Canada and many times more than comparable European countries. Indeed, it can be asked what Canada's or Europe's health systems could offer their citizens if, like the United States, they chose to allocate 16% of their gross domestic product to health care, rather than the 9% to 10% these countries actually spend.

    It remains to be seen what impact Moore's Sicko ultimately will have on the forthcoming debate over health reform in the United States, and on the plight of underprivileged people in America on obtaining health care. Meanwhile, Americans should be thankful that Moore uses his talent and his financial resources to hold up mirrors in which they can behold the blemishes in their complexion. It is one necessary step on the way to a better countenance.

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