As we go to the polls this fall, many voters are galvanized by the U.S. Congress' key domestic achievement of the past four years, the Patient Protection and Affordable Care Act, better known as Obamacare. To be sure, it is a landmark that establishes, for the first time in this country, the notion that no one should go without health insurance.
But as the urgent, if hectoring, new documentary Escape Fire: The Fight to Rescue American Healthcare demonstrates, the bill was also largely written by the parties responsible for the most spendthrift, inefficient and poorly performing health care sector in the developed world: the insurance companies themselves. While they agreed to curb their worst abuses, like denying coverage to those with pre-existing conditions, what they got in return was more valuable: a captive market and an acknowledgement that there is a place for making profits from the delivery of vital services.
It is this fundamental point, the profit motive that encourages—requires—insurers and providers to increase revenue and maximize returns for their shareholders, that operates as a perverse enemy of a healthy populace. This point is driven home in the first of a series of profiles when we meet Erin Martin, a primary care physician working in an Oregon clinic intended to serve the underserved. She tells us she went into medicine to improve people's lives, but even at this humble socioeconomic frontier, her clinic is forced to churn through patients, racking up all the billable services it can. This means that Martin has no time to adequately confront the issues her often desperate patients face.
In this vignette, in which we see already-sick patients seeking treatments for preventable illnesses, we get the key themes of Escape Fire: an unhealthy America, riven by poverty and avoidable ailments like obesity, heart disease and diabetes, with no front-line support to encourage healthful habits. The profit-based structure does not allow for high-touch, low-cost preventative care. From the health care industry's point of view, the idea of primary care physicians working to counsel families on how to stay healthy is worse than inefficient—it drives away customers. The profits are to be found in ordering expensive tests and prescribing brand-name drugs.
American health care is thus a system of disease management, as journalist Shannon Brownlee tells us. "They don't want you to die, but they don't really want you to get well."
Escape Fire, co-directed by veteran filmmakers Susan Froemke and Matthew Heineman, is not a neutral documentary. It may not be a documentary at all, to the extent that some viewers have come to expect ambiguity, subtlety and nuance. It's more like a pamphlet being hawked at the fringes of public events, shouting for our attention. As a diagnosis of our profit-driven system's woes, this film is less ideological and more pragmatic than Sicko (and lacks Michael Moore's polarizing, gonzo stunts). With urgent, throbbing music accompanying the transitions, we meet a variety of other reformers and warriors. There's Don Berwick, a thoughtful, conscientious public health expert who was Obama's head of Medicare and Medicaid before being forced out by revanchist Republicans a year ago, who argues for lower costs and better outcomes. We meet a businessman who explains how his company set up incentives for his employees to become healthier. Two well-known activist physicians, Dean Ornish and Andrew Weil, argue for integrative approaches, with an emphasis on healthy lifestyles and primary care.
Perhaps the most original segment in the film, however, concerns the U.S. military, now a badly battered force with an unsettlingly high rate of drug dependency—from the top brass on down to the grunts. As it has been in other areas of our country's development, the military, operating out of necessity and desperation, is something of a laboratory for alternative therapeutic approaches. (The film includes some extraordinarily moving footage shot during a transatlantic medevac aboard a C-17 transport plane—a stark reminder of a decade of warfare abroad.) We meet a Special Forces lieutenant general who became dependent on narcotics after a back injury, and we meet a severely wounded Army sergeant from Louisiana who is desperate to kick the 32 prescriptions he's received to manage his ailments. Both the general and sergeant are testify to the efficacy of the alternative treatments they received, including acupuncture and meditation training.
Escape Fire tackles important issues, but little here will be news to observers of our dysfunctional health care system. We've seen the sausage-making that protected profiteering. Of course Medicare is the most efficient health care system our country has ever seen, but the elegant, logical and achievable step of simply extending this program to all was never on the table. Instead, a watery thing called the "public option" was floated for a while as a tease to progressives before it was drowned somewhere between K Street and Democratic Sen. Max Baucus' Montana ranch as policymakers affirmed the sacred right to extract profits from our health care delivery system.
To be sure, aside from a photo of Obama meeting with Big Health lobbyists, Escape Fire avoids overt criticism of Obamacare. The filmmakers doubtlessly would endorse the declaration by one of its key experts, departed Medicare chief Berwick, who told Joe Nocera of The New York Times: "Because of [Obamacare], our country is, at last, making health care a basic human right. It is a majestic thing."
This article appeared in print with the headline "A problem we all live with."