"Sicko" is a revelation.

Sick and Twisted
by Atul Gawande July 25,2007

The documentary filmmaker Michael Moore has more than a few insufferable traits. He is manipulative, smug, and self-righteous. He has no interest in complexity. And he mocks the weak as well as the powerful. (Recall his derision, in "Roger and Me," for an impoverished woman in Flint, Michigan, who slaughtered rabbits to make ends meet.) For all that, his movie about the American health-care system, "Sicko," is a revelation. And what makes this especially odd to say is that the movie brings to light nothing that the media haven't covered extensively for years.

Few will be surprised, surely, to learn that insurance companies routinely deny people individual coverage, or jack up applicants' rates, if they have diabetes or are obese or produced a weird blood-test result in the sixth grade. It's just that a lot of us haven't met those people, or seen what happens to them afterward. Moore makes sure that we do.

Their travails are by turns depressing, blackly comical, and infuriating. There's the twenty-two-year-old who was denied reimbursement for her cervical-cancer treatment because someone at her insurance company thought that she was "too young" to have the disease; the seventy-nine-year-old on Medicare who works picking up trash at his local Pathmark store to pay for the medicines that he and his wife need; the thirty-something-year-old who matter-of-factly sews up a trickling five-inch gash in his leg with kitchen thread, because he doesn't have insurance to cover an emergency-room visit.

These have become ordinary tales in America. Just this year, in my own surgical practice, I have seen a college student who couldn't afford the radiation treatment she needed for her thyroid cancer, because her insurance coverage maxed out after the surgery; a breast-cancer patient who didn't have the cash for the hormone therapy she needed; and a man denied Medicare coverage for an ambulance ride, because the chest pain he thought was caused by a heart attack wasn't?-it was caused by a tumor. The universal human experience of falling ill and seeking treatment?-frightening and difficult enough?-has been warped by our dysfunctional insurance system.

"Sicko" doesn't really offer solutions. Yes, it visits France. But it doesn't discuss the difficulties of reforming a system that encompasses sixteen per cent of the economy. It doesn't investigate the tradeoffs that universal health care will inevitably require. It's an outrage machine. Moore hopes that once people grasp the inhumanity of our system we will replace it. But will we? The movie is so effective in depicting the inhumanity that it makes our failure to act seem baffling. Moore blames the familiar villains: insurance companies, pharmaceutical-industry lobbyists, politicians. But plenty of countries have private insurance?-not to mention politicians and lobbyists?-and nonetheless have health-care systems that cover all their residents, at a lower cost, and with higher levels of satisfaction. Israel, the Netherlands, and Switzerland all provide universal coverage through multiple private insurers and, like Moore's France, spend between half and three-quarters of what we do. The finger of blame points to an obstacle different from the one the movie suggests: us.

Our health-care morass is like the problems of global warming and the national debt?-the kind of vast policy failure that is far easier to get into than to get out of. Americans say that they want leaders who will take on these problems. Large majorities profess support for fundamental change. Yet when it comes to specific solutions we balk. A big reason is the cost. Even though universal health coverage can reduce the system's over-all expense?-for instance, by granting everyone access to preventive care and to prompt, consistent treatment for chronic illnesses?-any plausible approach will shift substantial costs from the private sector to taxpayers. The cheapest proposals circulating would still require more than a hundred billion dollars a year in public funds?-around a thousand dollars per American household. Taxing millionaires or cutting "waste, fraud, and abuse" won't pay for that. Then we get bogged down in the innumerable, wearying complexities: whether abortions will be covered, whether states will be allowed to design their own systems, what's an acceptable co-payment for drugs?-and on and on. Finally, Americans are deeply skeptical about government, and it doesn't take much to sow doubts about expanding its role.

Health care confronts us with a difficult test. We have never corrected failure in something so deeply embedded in people's lives and in the economy without the pressure of an outright crisis. The welfare reforms of 1996 made changes that profoundly affected people's lives, but only those of the poor, which was why voters supported the experiment. We adopted rules to protect clean water, clean air, and endangered animal species, but the costs seemed small and were largely hidden from taxpayers.

In the past few months, John Edwards and Barack Obama have put forward coherent proposals to achieve universal or near-universal coverage. For the first time in a decade and a half, the prospects for reform seem genuinely promising. But the fight is about to begin. For example, Rudy Giuliani recently outlined a tax-credit-based health plan that would come nowhere near covering everyone; for one thing, he would let insurers continue to exclude people with preëxisting conditions. Its main purpose, it seems, is to let him attack other proposals as involving a big government takeover of medical care.

If, in 2009, we actually swear in a President committed to universal health care, the fight will turn ugly. The plan most likely to gather broad support will look something like the Edwards/Obama approach, which would subsidize health insurance for everyone who does not receive coverage through work or through existing programs. It would provide a choice of private insurance options, as in the Netherlands, and would probably add a Medicare-like government option as well. And it would require Americans to obtain coverage for, at a minimum, their children.

People on the right will attack the plan as a tax-and-spend nightmare, because it will have to include some mixture of increases in business and personal-income taxes. And they'll say that it dictates your medical choices and gives government too much control. People on the left?-Moore included?-will attack the plan as a boondoggle for insurance companies, because it isn't single-payer, and will say that it gives government too little control. Others will attack it for what it does or doesn't do about malpractice litigation, birth control, acupuncture, and so forth. The debate will become angry and murky and mind-numbingly complicated, and the temptation will be to put off reform yet again.

That's exactly when you'll need to remind yourself of what's really at stake. So if, in the throes of the debate, you find yourself experiencing blurred vision, headache, and vertigo, here's a prescription: go visit an emergency room, clotted with the uninsured, and see what's it like to try to get care. Or watch the movie. Either way, you'll be outraged again. ♦

The New Yorker