US health: Sicko's grim diagnosis

With the NHS fast approaching its 60th birthday, Britain has all but forgotten the fear of the doctor's bill. So Sicko, Michael Moore's new documentary comparing the American way of medicine with other parts of the world - England, France and Cuba among them - is a useful reminder of what it means to have uncertain or non-existent access to medical care. Useful and timely, too, as the English NHS turns for 'advice' to some of the same health insurers that are the villain of Moore's polemic.

Here are grainy CCTV images of Carol, seriously ill, wandering hopelessly confused after being unceremoniously dumped by a taxi outside a Los Angeles shelter. Carol came from a Kaiser Permanente hospital, although its name had been erased from her still intact wristband.

They clearly have innovative ways of managing average length of stay in California, but it is hardly the stuff of Institute for Health Improvement storyboards.

Popular wisdom

And here is the desperately sad tale of Mychelle, dying from cardiac arrest at 18 months old after Kaiser refused to fund urgent diagnostics or antibiotics. Fully insured with Kaiser, she had been brought to a 'non-network' hospital by emergency ambulance with a 104F fever, but her insurer would not pay for tests until she transferred to one of its own hospitals. George Clooney would probably have treated her regardless, but this wasn't ER. Mychelle didn't survive.

Popular wisdom in Britain has it that the US health system can offer the best and the worst medical care in the western world: the best to those with money, the worst to nearly 50 million people with no health insurance. Sicko touches on the grotesque dilemmas of the latter group, as accident victim Rick decides which of his two traumatically amputated fingers he can afford to have re-attached and which is destined for landfill.

But this is not a movie about the trials of the underclass. Most Americans have health insurance. The film's principal theme is the quiet desperation of people who have medical insurance but nevertheless are denied treatment; of those trapped by fear of losing what insurance cover they have and of disillusioned people working within the healthcare industry.

For the insurance companies, it seems, can usually find an 'undeclared condition' that invalidates your policy. If your claim is large enough - and US medical bills can escalate so quickly that any hospital admission could swiftly become ruinous - your insurer is likely to review your medical notes, looking for a loophole that can be used to deny funding.

Moore traces the heartlessness and greed of his wicked health insurers, via a predictable litany of conservative bogeymen that includes the American Medical Association and Ronald Reagan's fear of 'socialised' medicine, to a deal between Richard Nixon and Edgar Kaiser (yes, that Kaiser) back in 1971. Cue footage and indistinct dialogue oddly reminiscent of the Watergate transcripts. Nixon is wary of 'health maintenance organisations like Edgar Kaiser's Permanente thing'.

Grass is greener

Equally memorable is an analysis of how much money slithered from the healthcare industry into politicians' back pockets during the 1990s campaign to block Hillary Clinton's planned reforms, or supporting legislation on prescription costs. Men in suits file into a room; computer-generated boxes with large numbers of dollars accompany each of them. The last to enter is the present White House incumbent: his price tag is $891,000.

Sicko's preoccupation is with inability to afford healthcare, so inevitably the NHS smells sweetly of roses in bloom. This is not the NHS of Clostridium difficile infections, of casual indifference, of queues.

Moore is hugely impressed by a standard 10 bucks charge for drugs (that is, an NHS£6.65 prescription charge). And spotting a hatchway marked 'cashier' at London's Hammersmith Hospital, he asks how much patients have to pay: staff gently explain that nobody has to pay and the cashier's role is to pay patients for their transport.

Nor is this at the expense of exploited doctors. A young Greenwich GP interviewed by Moore earns£85,000 a year, drives an Audi and models an enviable lifestyle in his million-dollar home. The doctor claims he has never yet had to say no to someone because of money, suggesting a disarming freedom from referral management.

World-weary NHS hands will sigh at the naivety. And perhaps wherever you are in the world, it is tempting to believe neighbouring countries do healthcare better.

There's an artful naivety about other aspects of Sicko. Like private healthcare marketing, Moore seems to focus on younger people with major illnesses rather than chronically ill older people. His sick Americans tend to be worthy, deserving cases: the industrious poor, 9/11 heroes and so on. No place here for schizophrenia or lower back pain.

Cheerless alternative

Some years ago I worked alongside a medical director who, in his mellower moments, would smile and say: 'I didn't come into medicine to do good; I came into medicine to do well.' Sicko offers a cheerless alternative: medical directors getting rich but unhappy as they save the insurers money - lots of money - in a perverse use of their training.

Before the NHS lets loose the undoubted talents of the insurance world to lend teeth to commissioners' demand management rhetoric, it may be worth asking: would we seriously wish to trade the security the NHS still offers the population for the fear that seems, according to Moore, to be inherent in the US model?

And before accepting that the NHS has 'failed' and the future is in private medicine, we should acknowledge the treasure we still have.

'One-sided but passionate': Sicko reviewed

After attacking big business, the gun lobby and President Bush's 'war on terror', Moore turns his attention to a problem that (as he paints it) costs more lives, ruins more livelihoods and threatens as much political freedom as all his former films combined: the US healthcare system.

The film opens with the problems faced by those without health insurance in the US - the man forced to choose which of his severed fingertips he could afford to have reattached, for example. It would be funny if it weren't so horrific.

But the real focus of Moore's criticisms are on behalf of those who have health insurance, but find themselves out of luck when it comes to getting the insuring health maintenance organisations to actually pay up.

Hence the couple who found their insurance cancelled, forcing them to sell their home, after suffering from cancer and heart attacks, or the woman billed for the ambulance trip to hospital following a car accident because she had failed to have the trip pre-approved.

Moore also hints at the wider social cost of the need for health insurance - keeping people in jobs they might otherwise leave and health maintenance organisations essentially bribing politicians to ensure their status.

He widens his focus to other countries, painting a glowing picture of healthcare systems in Canada, France and our own NHS. Certainly Moore has an agenda which he sticks to, glossing over the stuff that the US does well and ignoring any failings in the countries he visits (the visit to Cuba to seek medical treatment for 9/11 rescue workers would have seen him accused of Communist propagandism 50 years ago).

His lack of balance means you'll need to take this with a few pinches of salt but it is still inspiring to see the NHS praised for the high ideals that led to its creation, the sterling efforts of its workforce and its many successes instead of the usual tabloid headlines over its failings.

What this polemic makes crystal clear is that our system - from each according to his means, to each according to his need - is a thousand times better than the alternatives.

A little too long, and clearly one-sided, this is still a passionate, strangely entertaining and inspiring film.

Sicko is released on 26 October.