Sunday, August 26, 2007

Criticize Sicko, face the Thought Police

A recent tirade in NEJM on the U.S. health care system, ironically published as a Perspective piece, accused a USA Today editorial writer of blustering because she dared to criticize Michael Moore’s Sicko and defend the U.S. health care system. Citing many distortions and inaccuracies in the movie, she wrote:

Michael Moore's movies are provocative, but this one should be seen for what it is and is not. A no-holds-barred assault on our present health care system? Yes. A balanced documentary? No.

Moore wants a government takeover. To make his case, he relies on one-sided anecdotes — some dating back to the 1980s — that grossly distort the role of health insurance plans in providing access to care to more than 200 million people.

Are anecdotes from 10 to 20 years ago relevant to the state of health care today? The NEJM writer, Jacob S. Hacker, Ph.D., opens with a scene from 1993. Managed care, a player in this story, has been somewhat self correcting over the years and was a more formidable beast in 1993. The story is about an 18 month old seen in an emergency room with a “life-threatening bacterial infection” (I’m guessing sepsis or meningitis). The ER doc was appropriately suspicious and wanted to administer antibiotics. But a phone call to a managed care physician reviewer revealed that treatment was not covered and that the patient had to be transferred another hospital, where she died a few hours later after deteriorating and suffering seizures.

Very likely this tragedy was played out in court somewhere and analyzed extensively, but important details are missing from the NEJM article and, I suspect, (I haven’t seen it) the movie. The limited account we are given raises important questions. Did the first hospital really withhold antibiotics as implied by the article? If so, and if the doctor at the first hospital really recognized a life-threatening bacterial infection as the article states, then this patient suffered as a result of an EMTALA violation and not a deficiency in the U.S. health care system. EMTALA was enacted in 1986 specifically to avert this sort of outcome. Those are some pretty big “ifs”, but since we are to accept this anecdote as a reflection on our health system Dr. Hacker owes it to us to address that glaring question.

Dr. Hacker’s only criticism of Sicko, it seems, is that it doesn’t offer the solution he prefers, “Medicare for all”. While praising Medicare Hacker has this to say about private insurance: “Insurers erect obstacles to care, hassle patients and doctors….” It’s safe to say Dr. Hacker doesn’t take care of Medicare patients. If he did he’d be aware of daily Medicare obstacles to patient care and hassles and threats to doctors’ autonomy.

This piece would be more appropriate for USA Today, perhaps as an editorial counterpoint, than for the NEJM. Dr. Hacker seems more interested in propaganda than nuanced discussion. He writes “We could use more populism and less caution in our health care debate” and wants to see more “populist anger”. I hate to see politically motivated material such as this in the scholarly NEJM, and I hope the journal doesn’t devolve into a political rag.


steve7 said...

Any middleman will cause hassles. Reform needs to limit the role of the middleman and put the power with the physician and patient. Medicare is a hassle but no more than most commercial insurers. Look at the Health Access Card proposal at for a modest start.

coonism said...

It *is* unfortunate Michael Moore is sloppy about the examples he uses, because he has a lot of really good points that deserve better support than he gives. He does give people food for thought but he also provides a source of all-too-easy ammunition for his critics.

Dr. JW said...

I'm Dr. JW and I think "Dr." RW is and big phony and a shameless hack conservitive. Then again calling someone a phony and a shameless conservitive is being redundant.