Wednesday, October 24, 2007

London Film Fest Day 8 - SICKO - more polemic than substance

This review comes from El Capitain, who can usually be found here. El Capitain has extensive experience as a healthcare consultant and so is far better able to comment on this movie than I am....

Michael Moore does one thing well - and that is pulling at the heart-strings with (often factually questionnable) polemic. But the formula is getting old. His dumb stunts in Sicko are boring - his carefully staged interviews are predictable - and he fits in less "right to reply" than ever before. His analysis of the problems in the US healthcare system is incomplete and weak - his look at other healthcare systems (like France, UK and Cuba) is weaker - and he has no proposed solution to the problem he engages with.

Sicko will doubtless be a shock to the great unwashed of the USA - who don't even have a passport, far less having been abroad. Yes, socialised systems do exist in Europe, and yes, they do work better and cheaper than the (corrupt) American system. And in France, just about everything is socialised, and they have really employer unfriendly employment laws because of a really politicised workforce. That's why they have over 10% unemployment. But we all knew that, right? At least, I did.

And yes, the healthcare payment system is the USA is basically corrupt - with HMOs using any excuse to not pay for treatment - and penalising people living with long term conditions with co-pays, excesses and denial of service. Hence healthcare outcomes in America suck ass - and are in fact lower than many Cuban healthcare indicators. But is that news to anyone here? Don't our papers, civil servants, doctors, NHS employees and politicians already demonise the American system? Isn't "Americanised" just another word for "immoral and demonic" in the NHS?


Perhaps I'm being unfair. I'm an expert in healthcare - I've worked with the NHS my whole career. I've led up research projects on healthcare provision and payment worldwide, and benchmarked them to the UK system. I know more than the average Joe Bloggs in the street - and maybe that's why Moore's film was so yawnworthy and throwaway. Perhaps I was bored with references to the Cuban healthcare "miracle" because I already knew a whole lot about it - others may be surprised that Cuba is ahead in healthcare. It could be that I know too much about the foibles of the NHS and the French healthcare systems to be impressed by their positive portrayal. And maybe my wishing that Moore had investigated systems like Sweden and Denmark, where healthcare is localised, was just self-indulgent of me.

But then, isn't that what documentary making is all about? Investigating the facts from a broad viewpoint - looking in-depth at causes and factors and solutions? Moore cannot claim to have done that- and he's marred his work as a result. And that's a shame, because he has some good points. Cuba does have the best outcome to cost ratio out of any country - because they focus on preventative and community care - something US healthcare is sytematically misaligned to do. The UK does have far better health outcomes than the US for lower cost, because of its focus on primary care and health management - something a system with co-pays and excesses cannot hope to achieve. And yes, the French do benefit from more favourable employment laws - too favourable many might say - because of their militancy. But that isn't the whole picture.

The French healthcare system is on the verge of collapse because of patients being given too much choice, and electing to go straight into specialist care rather than through primary care. Healthcare in the UK is under considerable pressure because of overzealous financial reforms, stopping it from focussing on the basics. Cuba has excellent outcomes not just because they're socialised - but because they haven't the money to invest in acute care and therefore have no choice but to opt of prevention and community care - and because their population doesn't have the means to get fat on McDonalds. And not all French families are well off - as we saw from the La Haine style riots in the high density estates in the last year.

Not only that, HMOs like Humana and United Health aren't all bad. In terms of denying service, they are doing exactly what you'd expect from an insurer - trying to pay as little as possible. In countries with a less corrupt political system, where oversight is stricter, private provision and payment can work. Germany is a prime example - where a system of mixed provision and payment is in operation - yet the Germans have excellent health outcomes. Indeed, many UK health execs have been over to Kaiser Permanente to learn from them in terms of their approaches to care management. Humana and United are being invited over to work with NHS organisations to improve their processes, payment and use of data.


Moore doesn't investigate any of these points. He doesn't systematically deconstruct the problems with the American system, other than saying that it's "for profit" and therefore must be bad. He doesn't suggest an alternative, apart from saying that the USA should "learn from others", presumably those with socialised systems. And he even manages to get his favourite subjects of 9/11 and Guantanamo Bay in there, for no really good reason.

Yes, there are some tear-jerking personal stories that are genuinely tragic. And yes, the polemic works well most of the time, and you do leave the cinema believing (rightly) that there is something very seriously wrong with the US healthcare system. But this isn't a documentary. It's not quite fiction either - but it certainly isn't an honest or serious examination of the subject. And the problem isn't that I'm an expert - it's that I'm not completely ignorant.

This film is aimed at people who know nothing of healthcare systems abroad - or foreign economies and cultures. It is gimmicky, full of holes, and will doubtless be panned by powerful right-wing Americans who will gleefully point out its flaws, thus discrediting its message. That's a shame. In my view, universal healthcare is too important a message to fluff - to crucial to be left to Michael Moore's half truths and heavy-handed moralising. It's never a good thing to leave a cinema thinking you could have done a better job. But I could have. I would have. Another opportunity missed by so-called liberals - another piece of fodder for Guardian readers to feel better about themselves for having a social conscience.


SICKO played London 2007. It has already been released in Canada, Kuwait, Australia, Italy, Swizterland, Japan, France, Singapore, Argentina, Slovenia, Denmark, Norway, Sweden, Belgium, Germany and Greece. It opens in Hungary, Finland and the UK later in October and in the Czech Republic, Russia and the Netherlands in November 2007. It opens in Brazil on January 25th 2008.

1 comment:

  1. I'm not a healthcare professional and my only knowledge of healthcare systems is my experience of the NHS and one essay in Public Economics, so I guess I'm the sort of demographic that Michael Moore is really aiming at.

    But even I found this documentary superficial, overly selective and ludicrously starry eyed about the UK healthcare system.

    Seems to me that Moore has been providing diminishing returns since ROGER AND ME and that his legacy will not be any of his films but the fact that distributors are more likely to give a documentary theatrical release after the success of BOWLING FOR COLUMBINE and F 9-11.