My wife and I went to see Sicko during our date night last weekend.  I liked it, thought it had several good points, although I’ll admit that as a democrat I’m more inclined toward the Michael Moore polarized view of the world (we live in Seattle, after all).  However, I don’t think I’m going out on a limb in saying that Moore’s films tend to over-simplify complex issues in portaying the “good guys” as saintly and the “bad guys” as pure evil, when in fact I think there are a lot more shades of gray and that even the people with whom we don’t agree aren’t likely to be kitten torturers. 

   I’ll say that I agree that the US system is definitely imperfect, to say the least.  There’s too much emphasis on money, as we discussed in one recent thread on the forum section that got a lot of people involved.  One of the reasons I started this site is that the reality is that giving chemo is reimbursed but answering questions and spending time with a patient and their family is not incentivized by the US system, so I wanted to have a place to remedy that shortfall of available information for patients and families.  And then there’s the health care insurance companies: the fundamental issue is that there’s a very large industry in the US that serves as an intermediary between the money people spend on health care and what the providers receive for it.  The incentive of the industry as a whole must be to authorize enough care to not violate our standards enough to have people leave for another company, but to shave enough between revenues and reimbursed expenditures to make a healthy profit.  I wouldn’t say that they routinely deny my treatment recommendations, but there are many companies where treatments like avastin or tarceva are covered only very narrowly.  Reviewing the forms they send, it reduces cancer treatment to a paint-by-numbers approach to health care.

   The movie provides some very incendiary stories of medical directors at insurance companies being rewarded and pressured to deny care to patients as much as possible, in order to boost profitability.  That may be the case, but fortunately, I must say that I don’t get major interference in my treatment plans for most of my patients unless it’s a red flag item like avastin or tarceva or a stem cell transplant.  And speaking of bone marrow transplants, one of the key vignettes was about a man who was denied a stem cell transplant for advanced kidney cancer.  The problem is that this is really pretty “out there” as a treatment, and it’s also incredibly expensive.  It’s exactly the kind of thing an insurance company would likely resist covering.  And the movie portrays the insurance company as being unreasonably inflexible and uncharitable in denying this approach.  But my knowledge of this field leaves me with an understanding that this approach is so experimental and so expensive that it’s certainly not an automatic requirement that any insurance company provide it.  Because the movie so oversimplifies this issue, it makes me skeptical about how clear-cut some other aspects of the movie are, such as whether most medical directors at insurance companies receive bonuses for denying claims.  Or was the implication of that practice being widespread actually based on a very selective editing job?

   The stem cell transplant issue also raised another problematic issue for me.  Along with his being critical, in many ways appropriately, of the US health care system, Moore highlights the wonders of nationalized single-payer systems like Canada, the UK, and France, among others.  The movie includes not only the impressive statistics about how much better other industrialized countries do in terms of life expectancy and infant mortality rates compared with the US (which is barely debatable anymore — the US can’t claim to have the best health care system), but it highlights the happy people who receive prompt and comprehensive health care in these nationalized systems.  But there’s no way on earth that the Canadian (or NHS, or French) health care system is going to cover an early investigational stem cell transplant in kidney cancer.  OncTalk members are writing about their struggles just to get tarceva, an agent that has been clearly shown in international trials to significantly improve survival in advanced NSCLC.  Avastin is also much more readily available in the US than in most other parts of the world.  I would say there’s no way these systems would even have a serious discussion about covering an investigational and extremely expensive approach like a stem cell transplant for solid tumors. 

   So we can’t have it both ways.  In the US, we provide incredibly expensive care to a subset of the people, while leaving 50 million ununsured Americans.  Our debates include whether anything should be denied to our insured patients, but in nationalized systems there is a recognition that broad coverage requires prioritization and some real limitations in what is covered.   We can’t afford our health care system now, even without absorbing all of the underinsured and uninsured people.  If we were to tackle universal health care, it would involve imposing more significant limitations in the care that is offered routinely, or we’d have to abandon paving our roads or having fewer than 40 kids in public school classrooms, or we’d at least have to accept a significant increase in our taxes.  We can’t have it all without any limits. 

   And then there’s the question of whether the folks in Canada, the UK, France, and other countries where health care is nationalized are as happy with their systems as they appear to be in Sicko.  The patients shown in the movie definitely appeared to have short waits and to be very pleased with their care.  But from what I hear from people who have relied on the Canadian system or NHS in Britain, there are real problems that were glossed over in the movie.

   So I’ll invite people to comment on the movie or their sense of what works and doesn’t work in the health care system they experience now.  I’m especially interested in whether the single-payer systems in Canada, Europe, and elsewhere live up to their billing, and if not, what are the greatest shortcomings; for the folks from the US, how much does the financial side permeate health care, and what are people’s thoughts about providing unlimited care for some vs. more limited care for all?  I don’t think we can dispute that there are major problems with the health care system in the US, but is there really a system that we can and should emulate, if we had the infinite power to change what we have in the US now?