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Logo of bmjThis ArticleThe BMJ
BMJ. 2007 July 7; 335(7609): 47.
PMCID: PMC1910641
Review of the Week

No laughing matter

Reviewed by Douglas Kamerow, US editor, BMJ

Sicko. Written and directed by Michael Moore. On general release in the US. Opening in the UK and Europe later this summer . Rating: **.

The writer, director, and actor Michael Moore has cleverly woven the funniest, saddest, and most gruesome of more than 25 000 healthcare horror stories submitted to his website into a powerful and affecting film. Sicko will inflame his supporters as well as his detractors.

In the film's opening scene a man without insurance sutures a gaping wound on his own leg with what looks like a regular needle and thread. We then hear from an uninsured man who cut off the tips of two fingers with a saw. As it was not a life threatening illness and he had no insurance, the hospital told him he could pay $12 000 (£6000; €9000) to reattach his ring finger or $60 000 for his middle finger, or both. “Ever the romantic,” Moore quips, “he chose the ring finger.”

But Moore's real target in the movie is not the amorphous healthcare “system” in the United States or even the government. The villains are the large health insurance companies that sell coverage but then use all manner of tactics to worm out of paying for needed care, leading to discomfort, suffering, and even death among their customers. A succession of sad health insurance stories follows: an elderly couple bankrupted by high deductibles and co-payments; a 79 year old man who has to work as a janitor for the free prescription drug benefits; and a woman whose ambulance ride to hospital after a car crash is disallowed for payment because she didn't get it “pre-approved.” Tears started flowing in the audience after we heard about a little girl who died because her mother took her in an ambulance to a hospital where her insurance company wouldn't pay for her care.

Who is responsible for this? Insurance company medical directors—doctors whose job it is to prevent “medical losses” by denying coverage—are shown tearfully recanting their efforts. A man smirks about his job combing old insurance applications looking for mis-statements and pre-existing conditions that would allow the companies to renege on the payments they made. And when Moore shows on screen the politicians who support the system, he superimposes tags indicating the amounts of campaign contributions they received from the insurance companies.

So now we know the problem—insurance companies—and it is time to learn the solution: universal health care that is financed and administered by the government. Moore takes us on an international tour of happy patients and doctors, starting in Canada. An American tries to sneak in for free care. Canadians are afraid to come to the US for fear they will fall and forever be in debt repaying hospital bills. In a perfect counterpart to the sad story that began the movie, a Canadian hand surgeon speaks proudly of leading a (free) 24 hour operation to attach all five fingers that one patient had severed, requiring teams of doctors and nurses.

In the United Kingdom, parents of a newborn baby are perplexed when Moore asks them “how much” their new baby cost them. A pharmacist tells Moore that all prescriptions cost only £6.65. A London GP speaks of how nice his life is, as he drives his Audi saloon to his lovely flat. He's a happy man. So too are the French, delighted with their nationalised healthcare system that brings them free care, evening house calls, and health visitors who will help new mothers with child care, cooking, and even laundry.

These sugar coated clips are topped by the final segment of the film, a stunt visit to Cuba. It begins with an attempt to take Americans needing health care to the one place where Moore has heard that the US government provides excellent free care—the terrorist internment camp in Guantanamo Bay. The intrepid band takes off in a boat, and Moore uses a loudhailer to ask permission to come ashore. That fails. He and his three patients then magically arrive at a lovely Cuban hospital, get checked in, receive compassionate, competent care from a handsome, English speaking Cuban doctor, and leave with their several problems well under control (and with cheap drugs to boot). One wonders what sort of reception they would have received had they landed without a film crew.

This is Moore's best crafted movie. It does a skilful job of balancing humour with pathos to portray the real suffering that ensues when many insurers compete to enrol the largest number of patients, while paying for the smallest amount of care. Moore cherrypicks examples of US problems and other countries' solutions to support his thesis. He takes a lot of cheap shots, but he doesn't, as in previous films, personally confront the bad guys. Throughout he is in his amiable, bemused, disingenuous, shaggy guy persona. It's a great piece of agitprop.

Which is not to say that Moore is wrong, at least in his diagnosis. Almost nobody disagrees that the US healthcare system has real, structural problems. And he personifies these problems brilliantly. The question is how to fix them. His answer is that single payer care funded from taxes is the best way to go.

For me, though, the most convincing part of the film is not the succession of sob stories but rather when Moore asks plaintively whether the current healthcare system is really what Americans want for America. “Who are we?” he wonders. He's right. We really should expect more and better from our government and each other.

Articles from The BMJ are provided here courtesy of BMJ Publishing Group