Making Better Choices
“It doesn’t want you to die and it doesn’t want you to get well. It just wants you to keep coming back for care of your chronic disease.” Like many observers, journalist Shannon Brownlea sees the American health care system as broken, more a “disease care system” than one focused on or delivering actual “health.” Costing about $2.7 trillion annually, the system produces an upside down effect: increased spending, Brownlea notes, has produced “worse health outcomes.”
At this point, it remains an “entrenched system,” according to Escape Fire: The Fight to Rescue American Healthcare. And it’s this characteristic that gives Matthew Heineman and Susan Fromke’s documentary its title. The film begins with a story told by Dr. Don Berwick, head of Medicare and Medicaid from 2010-2011, a story about a 1949 forest fire in Mann Gulch, Montana. As a number of firefighters were trapped, one of them, Wag Dodge, decided to light a fire at his own feet, an “escape fire” that allowed him to get away. His fellows didn’t trust in what he was doing, and when they didn’t follow him, they lost their lives in the larger, still spreading fire. “It’s tragic to think of the answer being there,” Berwick concludes, “But just in the moment, not able to see it. That’s how embedded people get in the status quo. They can’t recognize an invention when it’s among them, they can’t get rid of their old habits.”
Such old habits, the film contends, determine the current US health care system. Insurance companies, medical supplies companies, and pharmaceuticals companies have particular interests in maintain those habits, and they pay lobbyists handsomely to press legislators into maintaining them too. The film illustrates the continuing—and expanding—costs of these habits with a variety of stories, looking at effects on doctors as well as patients.
Erin Martin is a doctor in The Dalles, Oregon. As the film begins, she’s headed to work for her last day at the clinic where she’s worked for three years as a primary care physician. Her young son stands at their picture window, watching her go, pressed against the glass. “What are you going to do at work?” he asks. “What I do everyday, buddy,” she assures him, the camera pulling out and up to show the distance between them as she crosses the patio. “I love you,” she waves. “I love you too!” he yells, before the camera cuts to a close shot through the window, watching him dart away into the living room.
The exchange here is at once wrenching and poignant, not unlike the goodbyes shared by any number of working mothers and their children every day. But Martin is headed to a job that’s increasingly distressing, a job she can’t see a way toward fixing. And when the camera follows her into the clinic, you see how difficult it can be: she’s unable to spend enough time with her patients, as she’s expected to see a certain number each week; even as she tells one patient she’s not so inclined to prescribe medication to alleviate what sounds like a number of stressful facets in her life, she admits to her off-screen interviewer, “Instead of basing things on outcomes,” she says, “The government sets the reimbursement on how many patients we see.” Faced with the incessant demand to “get productivity up,” she ‘s choosing to go work elsewhere, leaving behind patients in rural Oregon with whom she’s developed relationships—even during their seven minute sessions.
Working with this “fee for service” system, Dr. Martin sees limits wherever she turns, even as companies building x-ray machines and manufacturing drugs reap profits (it’s estimated that the US spends $300 billion a year on prescription medication). She leaves Oregon to go work at Dr. Andrew Weil‘s University of Arizona Center for Integrative Medicine, where she feels more able to care for her patients individually. Likewise, Dr. Wayne Jonas, CEO at the nonprofit Samueli Institute, is seeking new programs of treatment, including acupuncture for soldiers suffering chronic pain and PTSD. Here the film offers examples of soldiers in treatment, by way of showing how at least some military doctors are seeking innovative, cost-effective means of treatment. Sgt. Robert Yates, rehabilitating from multiple combat injuries following his tours in Afghanistan, finds a way to reduce his use of medication at Walter Reed, and other, older soldiers with their faces scrunched at the very thought of needles aimed at their ears, then smiling uncertainly as they feel positive effects.
But such effects are too frequently precluded by the insurance lobby, as indicated by the story told by Wendell Potter, former Director of Communications for CIGNA. Following his participation in the blockage of the Patients Bill of Rights during the Clinton Administration, Potter says he suffered a crisis of conscience (“I had trouble sleeping at night”), and began speaking out about insurance companies pursuit of profits at patients’ expenses.
All this is to say that Escape Fire offers a wide range of stories, reports of frustration and efforts at resistance and also narratives of hope. This makes for an unwieldy structure, which animated graphs and allusive chapter headings (“The Dark Matter of Medicine,” “Good People, Bad System,” “Throwing a Different Pitch”) help to organize and also obfuscate. With so much ground to cover (some of it familiar, some of it in need of still more exposure), the film is most effective when it is most intimate, in its observations of Dr. Martin and Sgt. Yates. As they go through their days, the camera following, they reveal more about what’s wrong and what can be right about health care than any animated charts.