The Soul of Biotech

Ok, I’m back, and I spent a lot my Sunday putting this together just for you! There are lots of spoilers in this post. There, that’s your warning. Now let’s dive in. I’ve decided to give a synopsis of the movie and intersperse my own comments and responses.

SiCKO starts out by focusing on a couple of individuals among the uninsured in America (about 45-50 million by current estimates) and how tough it is to have to deal with your own illness, whether by paying an enormous amount of money like Rick, or by suturing your own wounds (!) like Adam.

The problem of the uninsured is a fascinating one. For a long time, most assumed that the American uninsured population did not get health insurance because they could not afford to do so. But according to a recent Aetna study of the American uninsured population, about 14.2 million of the 44 million uninsured last year came from households with incomes at or above $50,000. That’s nearly one-third of the uninsured who can (most likely) afford their own health insurance, but decline to get any.

The study also revealed a significant number of college student without health insurance, prompting new “hip” health insurance programs aimed at young people, like Wellpoint’s Tonik (I mean, just look at the graphics on that site!). Finally, the study revealed a large number of immigrants working for small businesses that were uninsured, spurring cross-border programs, like Health Net’s Mexi-Plan. The cross-border programs allow immigrants in Southern California to get health care in Mexico should they wish to do so.

Of course, as Moore explains, the movie isn’t about Rick or Adam — it’s about the quarter of a billion Americans with health care coverage. He launches into a litany of stories of people whose claims were expertly denied. Or whose coverage application was denied for being high-risk. Or whose coverage was cancelled because of a vague pre-existing condition. The consequences are lives of penury, working long past retirement, flights to other countries, or death from lack of care. All of these stories are heartrending, of course, and show how the system provides incentives toward the least or worst health care possible. Moore summed that point up well in his conversation with Linda Peno, who as a claim reviewer for Humana, detailed her company’s incentive program in her 1996 congressional testimony. Humana reviewers, Peno says, were expected to maintain a ten percent denial rate, and were provided with individual performance metrics, with bonuses for the best performers (most claims denied).

I confess, I had a brief consulting flashback when I heard the words “performance metrics.” I’m better now. But there’s nothing here I didn’t already know — just more color commentary. Moving on.

Moore asks how we got onto this path. The answer is in the somewhat infamous 1971 tape between President Nixon and John Ehrlichman, his Assistant for Domestic Affairs. The tape shows how Nixon incorporated Kaiser’s HMO model (which provides incentives towards the least amount of care) into the HMO Act of 1973, thus setting up much of the private health care industry as we know it.

Moore also shows how close we came to overhauling this system, when Hillary Clinton’s committee to examine universal health care was born in the early 1990s, and how adroitly Republicans and MCO lobbies defeated efforts toward public medicine.

Of course, not everyone stays on the same side for long. First Lady Hillary eventually became Senator Hillary, and warmed to MCOs. And Republicans suddenly didn’t mind swinging to the more populist side for the gray vote when they approved the Medicare Modernization Act of 2003, which created the prescription drug benefit for seniors, also known as Medicare Part D.

Moore didn’t do a great job of explaining Part D. For example, he claims that Part D allowed drugmakers to charge Americans as much as possible. That’s not really true. Drugmakers could already charge what they believe is a competitive price. Part D just added more covered patients to the system. Moore neglects the fact that there are downward pressures on price, too. If a manufacturer charges too much for a drug, then the MCO might give it “disadvantaged status,” meaning that the MCO provides fewer benefits for that drug relative to other therapies. Surprisingly, the point that Moore didn’t quite explicitly make is that the senior prescription drug benefit is administered by MCOs, even though it is paid for by the federal government.

Moore also takes this moment to deliver a jab at direct-to-consumer (DTC) drug ads. I haven’t come to a hard decision on how I feel about DTC, but there is no doubt that for the right drugs, it works, and works well. So should we ban it? I don’t know. Maybe I’ll expand on DTC in a separate post.

Moore gives several examples of systems that are already public and either free or cheap: the police department, the fire department, the library, and the US Postal Service. He then wonders why the health system isn’t the same.

What he could have also pointed out is that many of these are really public / private mixes: I can send something by USPS, or I can choose to pay more for FedEx. I can use the police, or I can pay more for my own personal security. I can go to the Santa Monica Public Library (and I do, because it’s gorgeous there) or I can go to Barnes & Noble. A public / private mix is my ideal solution. Basic coverage for all, with better coverage for those who can afford it.

Moore also goes overseas and explores other countries’ approaches to universal health care, such as Britain’s NHS and services in France and Canada.

Unfortunately, he grossly oversimplified all three systems as completely perfect, which they are not. To start, most public health systems have very long wait times, because governments pass on the non-monetized costs (waiting time) to citizens in place of the monetized costs (the actual cost of care). A quick Google search reveals a long list of stories about NHS failures, and even a nascent complaint forum. Canadians are actively considering switching to an all-private system. Not to mention the potential tax implications.

Finally, he shows the high quality of care given to Guantanamo Bay detainees. So he takes noncovered 9/11 rescue workers to Gitmo, leading to the best quote of the film. Moore stands on a boat with a megaphone, and asks a watchtower for health care: “They just want some medical attention, the same kind that Al Qaeda is getting. They don’t want any more than you’re giving the evildoers, just the same.” The theater cracked up, and I did, too. Having been turned away, the group heads to Cuba, where the rescue workers receive high-quality, cheap care. (Hard to say whether or not that portrayal is realistic, though. I’d imagine that both Mr. Castro and Mr. Moore would have wanted to show Cuba’s healthcare system in the best possible light.)

Overall, I really enjoyed the movie, and would recommend it, provided that you take it with a proverbial grain of salt. I think Moore did a great job of identifying the problems with the system. Namely, that critical care is often denied because it’s unprofitable for MCOs to pay for it, and that a large swath of people can’t get coverage at all. I do think that he was a little quick to suggest that we throw out everything and start over with a single-payer model. In reality, a lot of the foreign models are public / private mixes, anyway. What would a good public / private model look like? In short, start with a free or cheap coverage package for every American citizen that includes a fundamental level of care. Then let the MCOs compete with that. The more money you have, the higher quality of care you can get.

More importantly, though, I am hopeful that SiCKO will trigger a larger debate on the direction of the American health care system. It’s a critical and challenging problem for our country, and if we needed a movie to jumpstart the discussion, then it will have served a wonderful and very important purpose.