The American healthcare system is one giant piñata. Everyone wants to take a swing. But no one ever seems to crack it.
Yet, despite that dismal track record of would-be reform, two players with pull are now taking aim at our uniquely American monstrosity, that powerful palace of profit: the $2.3 trillion-a-year healthcare industry.
Other than both being middle-aged white guys, these two would-be reformers could not be more different.
One, of course, is 53-year-old Michael Moore, the lumbering muckraker-turned-documentarian, whose latest film is the funny and fallible Sicko. Since its limited release in the United States on June 22, the movie has grossed $11.5 million—less than half the opening-weekend gross of Moore's Fahrenheit 9/11. But in just three weeks, the Michigan meshuggener has arguably done more to focus the debate on health care in this country than all of the 17 presidential candidates combined.
"The buzz about the movie is an indication of how urgent the healthcare issue has become in the minds of the American public," says Ron Pollack, executive director of Families USA, an influential healthcare advocacy group in Washington, D.C.
The other player enjoys considerably less name recognition beyond Oregon. He's Democratic Sen. Ron Wyden, the nebbishy 58-year-old politician who first made waves as the founder of the Oregon chapter of the Gray Panthers. Small waves, that is.
Think boogie boards. Wyden co-authored a June 26 commentary in The Wall Street Journal about his reform efforts. But Moore's film dwarfs the day-to-day coverage of Wyden's plan, which also on June 26 was featured in the Daily Dose, an emailed newsletter with a circulation of 20,000. That's not exactly the cover of Newsweek.
Here's the kicker: Moore's box-office power means nothing where actual change can be made—in the Capitol.
And while Moore may be galvanizing a disgruntled population, Wyden is one of only 535 Americans with a congressional vote. More than a vote, Wyden has a plan: his Healthy Americans Act, which proposes to help the uninsured, underinsured and middle class simultaneously. Which isn't to say it's perfect. Or that it will make everybody happy. And at a time when some would argue cracking the healthcare piñata remains a laughable proposition, the bill carries the unfortunate acronym HAA.
But it is ambitious, a needed trait when the diagnosis for health care is so bleak. Almost 45 million Americans—about one in seven—lack any health insurance. Millions more are just one catastrophic accident or health crisis away from financial ruin.
"By and large, we agree on the diagnosis in American health care," Wyden says of Moore. "People are paying too much. We're not getting enough value. And even the structure seems out of whack. We have sick care rather than health care."
With Moore's movie spotlighting the issue, it seemed a perfect time to turn the camera on the healthcare proposals shaping the debate. The problems are numerous. Even states like Oregon haven't been able to solve them all with bold projects like the Oregon Health Plan.
What follows is a comparison of Moore's ideas and Wyden's proposal for repairing our nightmarish system, the pluses and minuses of various presidential candidates' healthcare promises, an extra dose of information on health care in Oregon, and a piece about the premiere of Moore's film in a hidden Los Angeles neighborhood, the movie capital's Skid Row. In keeping with Moore's penchant for personal polemic over wonkish policyspeak, we've also included the story of one uninsured Oregonian who traveled to a Third World country to have the heart surgery he couldn't afford in the United States.
What's the problem?
MOORE: In two words, bean counters.
Most Americans probably don't need to see Sicko to shudder when they hear the phrase "insurance company." Faceless and seemingly omnipotent, insurance companies decide not only what cancer treatment is worth covering, but also how much of that cancer treatment will be covered.
The horror stories are plentiful, and Moore points his lens at just a few of the 25,000 anecdotes he collected by asking fans to email those terrifying tales to him. And then there are the Americans who don't have insurance, either because companies have rejected them for being too fat or too sick—or they're too poor to pay the premiums. These are the folks who, like an Oregon man in the opening segment of Sicko, are forced to decide which of their two mangled fingers they can afford to reattach with their own money.
WYDEN: The senator also takes aim at health insurance companies, but he's not proposing we junk them. Instead, he argues, our system fails because it burdens private employers with the responsibility of providing health insurance to its workers.
Wyden says this link between employment and insurance has three downsides for employees: The hidden benefit lowers workers' take-home pay, employees typically don't have a say in choosing their insurer, and, if they change jobs, they lose their coverage.
It's bad for employers because they pay the hefty tab, if they can afford it. And it's bad for the country, because it subsidizes the system each year with $200 billion in tax credits that favor wealthier Americans without providing adequate resources for the working poor and uninsured.
"Right now employer-based coverage is just melting away like a Popsicle on a summer sidewalk," Wyden says. "You have less coverage and higher premiums."
So what's the source of the problem?
MOORE: Health insurance companies that contribute cash to the politicians who return the favor by promoting legislation that increases profits for the companies. And pharmaceutical companies that get in on the action, driving up costs while peddling products that are sometimes of dubious worth.
Medicare Part D, the prescription-drug plan for senior citizens championed by the Bush administration, is Moore's prime example of a public-private venture that benefited the health insurance and pharmaceutical companies at average Americans' expense. His evidence: By 2016, Americans will have paid more than $800 billion for the program. Passing the bill cost the pharmaceutical industry only $3 million in campaign contributions over four years to George Bush and the 10 federal legislators largely responsible for crafting the plan in 2003, according to the Center for Responsive Politics.
WYDEN: His answer lacks as sexy a villain, but it is no less vexing: the federal tax code.
More than any other part of the tax code, the incentives greasing the wheels of our employer-based healthcare system are regressive and inefficient, Wyden says. "This one's in a league of its own," he says.
And we arrived at this point entirely by accident. After World War II, price and wage controls combined with a widespread desire to provide health insurance to returning troops and other Americans led employers and the government to strike a deal. Businesses would provide the coverage, and the feds would reward them for their generosity.
Now, 60 years later, the tax code provides deductions for employers who can afford to offer health insurance to their workers—who receive the benefit tax-free. Meanwhile, the boss man who can't pony up gets nothing. His workers? Zilch.
So, smart guys, what's your plan for fixing the problem?
MOORE: Easy. A government-run system like the one in Canada, the United Kingdom, France or—egad!—possibly Cuba.
Commonly known as a single-payer system (since government is ultimately responsible for forking over the cash under these arrangements), it's dismissed as a form of "socialized medicine" by critics who don't have Che Guevara T-shirts in their closets. Moving to such a system would eliminate health insurance companies and require revamping the entire healthcare industry—the largest American job sector in 2004, with 13.5 million employees, according to the U.S. Bureau of Labor Statistics.
WYDEN: His plan would create universal coverage by doing three things.
First, it would shift the responsibility of seeking insurance to individuals, who would be required to have coverage. New state agencies would act as clearinghouses to assist people in finding suitable plans. Meanwhile, employers would still be allowed to help their workers with this process if they chose. But the shift essentially cuts the link between employment and health coverage.
Second, it would revamp the tax code by erasing the old incentives for businesses and giving new tax breaks to individuals. At first, companies would be required to transfer the savings (from getting rid of health benefits) to their workers in the form of higher wages. Employees would then use that extra money to pay for insurance premiums. At the same time, individuals could deduct that expense from their income taxes. And since the plan calls for ending Medicaid, it would also fully subsidize premiums for poor individuals. (It would leave Medicare and military health care alone, however.)
Third, it would impose new rules on insurance companies to prevent them from cherry-picking the healthiest consumers and dumping the sickest clients. "A lot of people want to put them out of business," Wyden says of the health insurance industry. "They want the government to run health care. [Under his plan] insurance companies have to give...but they get something in return, and that's a chance to be in a big market."
What's the model?
MOORE: The filmmaker looks to France, where giving birth costs parents nothing; the U.K., where transportation to the hospital is a reimbursed expense; Canada, where emergency surgery to reattach fingers is free; and Cuba, where inhalers cost nickels instead of two Grants.
And it's this aspect of his film that appears to draw the heaviest criticism. His depiction of the Canadian system, for example, leaves out many of the unflattering side effects of a single-payer system, including wait times for non-emergency care.
WYDEN: The senator's model is the health insurance plan he enjoys as a member of U.S. Congress. Paid for with tax dollars, it still relies on private insurance companies to provide the coverage.
"My cure is to go with something that has been proven to work in our country," Wyden says. "I don't think you can just go out and import somebody else's system and just put it down on the United States."
His plan, Wyden says, also incorporates lessons learned from the Clinton healthcare disaster of 1993, an initiative torpedoed by Republicans and other opponents. To satisfy both Democrats and Republicans, the plan offers a chance at achieving universal coverage, but it does so in the private marketplace.
"You're not going to fix American health care—one-seventh of the U.S. economy—on a stark partisan vote," Wyden says. "It's not going to happen."
Who's on board?
MOORE: His championing the single-payer system is the equivalent of a pledge drive for advocacy groups like Physicians for a National Health Program, which has been lobbying for a government-run medical system for 19 years. In addition to supporting the ideas outlined in Moore's film, the doctors' group is critical of proposals such as Wyden's, which give a central role to private health insurance companies.
Other supporters include Democratic presidential candidates such as Dennis Kucinich and Mike Gravel, who have no hope of winning their party's nomination.
WYDEN: Wyden has made efforts to build bipartisan support for his bill; U.S. Sen. Bob Bennett (R-Utah) has signed on as a co-sponsor. He's also tried to please employers and unions. Andy Stern, president of SEIU, the healthcare labor group, and Steve Burd, head of Safeway, a Fortune 500 employer, both joined Wyden at the press conference to introduce the proposal in December.
What will it cost?
MOORE: Moore turns this question on its head in his film and asks what our dependence on private industry costs us in terms of human lives. Physicians for a National Health Program, which argues on behalf of the same system, says a single-payer system wouldn't cost taxpayers any more than they currently pay.
WYDEN: According to the Lewin Group, an independent consultant firm, all of the new program costs would be fully funded by savings from changing the tax code, getting rid of Medicaid, and other administrative cuts. In addition, total healthcare spending in this country would decrease because of price competition, Lewin's report says.
To read WW screen editor Aaron Mesh's review of Sicko, go to wweek.com/editorial/3333/9152/.
In 2006, WW's medical health insurance costs were $134,484. The newspaper is on track to spend a total of $142,487 this year.
The American Medical Association has a prepared statement outlining its response to Moore's film (it disagrees with him). But it has no statement on Wyden's bill (which just received a favorable hearing in the Senate Budget Committee).
About 576,000 Oregonians lack health insurance, according to the state. Of those, 116,000 are children.