Kristian Niemietz Blog

Published in “Gesundheit!”, May 2008

The film Sicko is a frontal attack on America’s health care industry. It is not about the uninsured, but about those who do have health insurance and are let down by the companies when they desperately need them. Based on interviews with affected patients, health care workers and ex-employees of the insurance industry, Mr Moore paints a gloomy picture of health care in America. His central message: even if you have comprehensive health coverage, you are not safe in America. When you really need your insurer, he will look for a loophole to sneak out of his obligation. He will leave you alone with a severe illness, or, in the worst case, leave you to die. Some of the anecdotes are based on interviews with relatives of the affected patients. The person with the main part in the film has since died - as a consequence of denied care, according to Michael Moore. But things need not be like this. Mr Moore travels abroad allegedly to find free, universal and high quality health care in Canada, the UK, France, and Cuba.

Moore’s evidence is anecdotal. From these stories alone, we do not know if the affected persons were really denied care for reasons of sheer greed, or whether a medical, administrative or other error was committed. Foremost, we do not know how representative these lamentable cases are for American health care in general. But all of this is absolutely fine. Sicko is a movie, not a doctoral thesis, so it has every right to generalise, assert, exaggerate and polarise. The weaknesses are in the interpretation Mr Moore offers, and in the alternatives he proposes.

According to Mr Moore, American health care is the way it is because health insurance companies are private and for-profit. In their logic, Mr Moore asserts, denied care means saved costs, which in turn means increased profits. However, any for-profit business has an incentive to keep costs down, be that a brewery, a telephone company, or a gym. At large, this does not seem to work against the customer. Even if the health insurance sector was the grand exception, then it should be so everywhere, not only in America. Millions of Europeans, too, take out private insurance, some as a complement, and some as primary coverage. Interestingly, two of the places that Mr Moore praises to the skies have front row

seats: 66% of Canadians and even 87% of the French have private complementary insurance. Cuba, of course, is a different matter. In the 2005 election, a bill that would have abolished private primary insurance was debated in Germany – not because it worked so badly, but because it worked so well. Many of the publicly insured had the impression that the privately insured were being favoured. Does private health insurance work differently in Canada, France and Germany than it does in the United States? Possibly, but Mr Moore does not ask this question.

Also, Mr Moore obviously did not take the trouble of reading a UK newspaper during his stopover in Britain. Had he done that, he would probably have come across a story about denied medical care on the basis of costs, not too dissimilar to the stories he shows in his own movie. Nowadays such rulings often come from the National Institute for Health and Clinical Excellence (NICE) though before NICE came along cost limits were set in a more implicit way. Cost-based medicine is not uniquely American.

The bottom line is that Sicko is a missed opportunity. It is undeniable that Americans spend a lot of money on health care and sometimes receive mediocre outcomes in return. It would have been extremely interesting to explore the reasons. But unfortunately, Sicko did not provide any answers.