Sick Around America

What exactly was Frontline trying to say?

It is not clear what message Frontline wanted to deliver in last night’s Sick Around America documentary. The show, conceived as a sequel to its acclaimed Sick Around the World special, was a limp, flat journalistic effort that did nothing to help the public understand the current politics of health reform. It both demagogued the insurance industry and then sent valentines their way, making me wonder if the show’s bad cop/good cop portrayal was a deliberate attempt to reflect the nation’s schizophrenic attitude toward the industry. In the end, it just made for a confusing and unfulfilling hour of television, and made me think that Frontline missed an opportunity to say something meaningful and new about the topic at hand.

The first half of the show piled on anecdote after anecdote about individuals’ experiences with health insurance. It was all familiar territory. We hear about a Microsoft employee whose super insurance paid a million dollars to help his premature infant survive. Then there was Paul Stevens, once a manager at a telecommunications company in Houston, who was in his late fifties when he lost his job. Stevens found COBRA too expensive and had to venture into the individual health insurance market where his diabetes disqualified him from coverage. When he had his heart attack, he had no insurance and got stuck with bills totaling more than $200,000. The Texas high risk pool was out of the question because it, too, was expensive and required a long wait for coverage. Stevens says he is trying to live long enough to get coverage from Medicare. But there was no talk of what problems await him once he gets there.

Interspersed among the stories are lessons about how the individual market works—sort of an actuarial primer for the public about medical underwriting. That’s the process of weeding out sick applicants for coverage. We hear about hundreds of people who declare bankruptcy each year, partly because of medical bills, and that others are hurt by a practice called rescission, where insurance companies drop those people whose applications failed to disclose all their medical conditions. The producer focused on California, where Los Angeles Times reporter Lisa Girion has written extensively about this subject. In Sicko, Michael Moore made the same point with a different carrier. Not much new territory here.

The documentary progressed to a discussion of consumer-directed health plans that, it said, were “loaded with caveats.” No kidding! Deductibles of $7500 or more and 40 percent coinsurance (that means you pay 40 percent of the medical bill) pinch the pocketbook, as Patricia Campbell of San Diego found out. OK, nothing new here either, as Campaign Desk has noted.

When the documentary addressed the subject of health insurance for everyone, it began by serving up a lot of confusion about health insurance provided through social insurance, as in Europe, and that provided by private carriers, as in the U.S. The narrator noted that many experts believe that a fairer system would cover everyone, just as all the other developed countries do for their citizens. He said that was “what insurers call guaranteed issue.” That’s a new one on me—referring to other countries’ social insurance systems as guaranteed issue. (When private insurers offer to guarantee coverage, they are saying they will do so generally without evaluating their applicants’ medical conditions.) Since there’s little private insurance in most of those countries, the concept doesn’t seem to track. There was no discussion of how social insurance works—that everyone pays taxes to fund health care; that everyone is guaranteed care as a matter of right; and that the national health systems pay for medical services in most cases, not private insurance companies.

The program did mention five states that have guaranteed issue coverage—that is, they require that insurance companies offer a policy to everyone, sick or well. But then it featured experts who talked about the problems with that approach. One said that the premiums were three times higher in those states because sick people often fall into the insurers’ risk pool because they may have waited to sign up for a policy until they are sick. FYI: It’s also true that they may have been in the pool all along and then got sick.

By now, viewers might think that covering everyone may be a bad idea, but the narrator asks Karen Ignagni, who heads the insurers’ trade group America’s Health Insurance Plans, why the U.S. couldn’t guarantee coverage for everyone. Ignagni replied that it could if we did what other countries do: have a mandate requiring everyone to have insurance. Then, she said, it would be reasonable to require her industry to guarantee coverage to everyone. The narrator summarized her thoughts: “That’s what other developed countries do. They make insurers cover everyone and they make all citizens buy insurance. And the poor are subsidized.”

That would certainly come as a surprise to anyone in Canada or the United Kingdom, for example. Insurance companies, making people buy insurance, subsidizing the poor? What’s the narrator talking about? The system that Ignagni imagines is nothing like the ones in Canada or England—but how is the poor viewer to know?

The documentary offered a sad story about a lupus sufferer named Nikki, who eventually died after being cut off from TennCare, Tennessee’s failed attempt to cover poor people. But there was little context to explain what happened in Tennessee, and nothing to help viewers understand that the state lacked the money to cover everyone who needed insurance—and that politicians refused to raise taxes to compensate, instead insisting that the poorest should assume responsibility for their own care. The anecdote, sad as it was, didn’t engender outrage the way a short documentary called Collateral Damage does. That film, produced by Talking Eyes Media, packs a wallop that never fails to outrage my students when I show it.

On the positive side, the film gave a fair assessment of one of the problems in the Massachusetts health reform law—too many people still fall through the cracks. They don’t qualify for subsidized coverage and still can’t afford what the state considers an “affordable” policy—a problem likely to surface in the national reform ideas being discussed. The documentary did mention the perils of cost containment, quoting blogger and former insurance executive Robert Laszewski, who for months has been asking how we will pay for reform. Said Laszewski: “I’ve never met anyone who would take less. Until we’re willing to have that discussion, we’re nibbling at the edges.” Too bad these comments came toward the end—by that time, some viewers might have tuned out.

So here are my takeaways:

• Employers who provide good insurance are good guys, but, boy, when you lose it, you’re in trouble.

• The individual health insurance market sucks.

• Insurance execs who have health problems couldn’t qualify for coverage from their own companies if they didn’t have good group insurance.

• Doctors and other providers may be making too much money.

• Unless we contain costs, we are just nibbling around the edges.

• Change is a-comin’. The President said so.

But what change? The documentary didn’t make that clear. Was it that we are headed toward more private insurance for the uninsured despite all the problems described in the documentary? An astute viewer could easily infer that from the conclusion. Near the end of the show came a clip from the President’s health care summit held in early March, where all the system’s stakeholders assembled to share in a moment of cordiality and cooperation. Ignagni stood up and told the President that she wanted to work with him and Congress on a bipartisan basis; that her group was here to play, contribute, and help pass health care reform this year. “Thank you, Karen,” the President said. “That’s good news.”

Part of the confusion in the piece may have stemmed from the departure of T.R Reid, a Washington Post correspondent who hosted Sick Around the World. Reid was to host this one too, but he left the show this February in a dispute with Frontline. Reid told me: “When I saw it, I didn’t agree with it. It took a different view of health policy than I have.” He refused to say what the differences were, adding that “it’s hard to reduce them down to a line or a paragraph. It’s perfectly legitimate to disagree about health policy.”

Indeed it is. It would have been helpful if Sick Around America had reflected more of that disagreement.

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Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR's healthcare desk, which is part of our United States Project on the coverage of politics and policy. She also blogs for Health News Review. Follow her on Twitter @Trudy_Lieberman.