Fact or Friction?
Two films that negatively portray managed care raise questions about
how closely life and art imitate one another
By Radha McLean
September 24, 2002
It's a simple concept, really. A father loves his critically ill son immeasurably and insists that he receive the best health care to survive. Reality, however, does not always jibe with such a concept, at least in the case of two films that criticize the managed care system in the United States. "John Q.," from New Line Cinema, was released theatrically in January and became a top video and DVD rental in July. A similar film, "Damaged Care," is a Showtime original that aired in July.
The release of these films raises many questions about their influence on the managed health care system: Do they simply spur public debate about the media's representation of managed care, or can they influence public opinion and health care policies as a whole in the United States?
Opinions vary among health care and media professionals. Most leaders in the health care industry agree, however, that these films do influence public opinion about the managed care system.
John Archibald (Denzel Washington), aka John Q., is an underinsured factory worker who finds himself in dire financial straits when physicians diagnose his son with a fatal heart condition. If the son receives a heart transplant, he might live, but John Q. does not have the proper health insurance coverage.
After arguing with hospital administrators about the $75,000 deposit for the transplant, John Q. accepts donations from friends and all but sells his every possession to come up with the total cost of $250,000.
Even after he sells his wife's wedding ring, he makes only a small dent in the cost. When his son's heart nearly fails and the hospital administrator threatens to send him home, John Q.'s wife insists, "Do something! Anything!" John Q. pulls out a gun and takes the hospital's emergency room hostage, announcing righteously, "The hospital is under new management now."
Despite the circumstances, John Q. gains the broader public support for his actions and changes public sentiment.
"Damaged Care" tells the fact-based story of a physician who works as a medical reviewer for an HMO, but quits her job after being cornered into denying coverage to a critically ill member. She takes another job as the medical director of a smaller HMO, only to find that it, too, denies coverage to chronically ill members as a cost-saving measure.
Dr. Linda Peeno (Laura Dern) quits the second job and becomes an advocate against the HMO system, speaking out to the media and the government about a system she views as immoral.
The film is particularly critical of HMOs, with lines such as a physician saying, "You and your people are murderers," when Peeno tells him that his critically ill patient will not receive coverage for a lifesaving operation. The movie ends with Peeno asking Congress, "How much suffering and death will we have before deciding to have the courage to change this reasoning?"
Media effects
Vicky Rideout, MA, is vice president and director of the Program on Entertainment Media and Health at the Henry J. Kaiser Family Foundation (an independent organization not affiliated with Kaiser Permanente) that provides facts and analysis of health care issues for use by policy-makers, the media, health care community and general public
"The entertainment industry is beginning to play a role in shaping people's views. People are getting their ideas about health care plans from the media and we want to explore how that might be impacting public perception," Rideout said.
That's why the Kaiser Foundation set up a forum in Washington, D.C., in July for discussing these issues and more. The forum, "John Q. Goes to Washington: Health Policy Issues in Popular Culture," featured James Kearns, screenwriter of "John Q."; Neal Baer, executive producer of "Law and Order: SVU"; Joseph Turow, professor at the University of Pennsylvania and study author; Karen Ignagni, chief executive officer of the American Association of Health Plans; and Ronald Pollack, executive director of Families USA.
At the forum, Kearns argued that the dramatic appeal of the plot drove his writing, not necessarily a desire to criticize the managed health care industry. "I don't know that I tried to change the health care system in America," he said. "I wanted to tell a story."
Despite his apparent lack of intention to spur public debate about managed care and how it is portrayed in the media, Kearns said he is pleased with reaction to "John Q."
"The response is beyond my wildest dreams," he said. "I think it's fantastic. If the movie helped to get people to stop and think and listen, that's a good thing."
The forum is a small dent in a big problem," Kearns said. "The managed care system has problems. I'm not the first person addressing them."
Nor is he the last, according to the Kaiser Foundation, which conducted a survey of hospital dramas in the 2000-01 television season. The survey found that hospital dramas often address issues relating to the health care policies, such as managed care, and that every reference to HMOs was negative. It also found that the issue of the uninsured was not covered at all.
Eighty percent of people are satisfied with their managed health care coverage, said Jeff Freeman, spokesman for the AAHP, yet portrayals of the managed care industry by the entertainment industry are negative on the whole. "The entertainment community plays a very important role in influencing public opinion," he said.
The Kaiser Foundation found what Freeman said to be true after conducting a second survey about the public's reaction to "John Q." and issues relating to managed care in America. The survey found that almost half of Americans believe that insurers refuse to pay for treatment a lot of the time, a third believe that it occurs some of the time and one in four people receive at least some of their information about health issues from entertainment shows.
The AAHP is so concerned about improving the way the managed health care industry is portrayed in film and television that it has hired the William Morris Agency, a leading talent and literary agency, to change that perception by working with directors, screenwriters and actors to represent managed care in a different-markedly more positive-light.
"I think it's important to reach out to individuals and tell them that we are doing well," Freeman said.
So, do these films influence managed care public policy?
"We have used both films to push policy for patients' rights in California," said Daniel Zingale, MA, director of California's Department of Managed Health Care in Sacramento, Calif., a department designed to protect patients' rights. Zingale explained that several key legislators attended a screening of "John Q." in Sacramento. "It did help keep the momentum going about the patients' rights movement … and will help the drive to expand patients' rights."
"HMO policies were already changing before 'John Q.' was released," said Rick Wade, senior vice president of communications at the American Hospital Association. "These changes were a response to a backlash against HMOs [and were] used to temper growing public anger against them."
Wade does not believe that either film will have an effect on managed care policy.
"I cannot think of any movie that has changed public policy," Wade said. "Health care is a very personal issue. Watching a movie is not the place to reflect on the issues."
Pat Marjavi, RN, of Kaiser Permanente Medical Center in San Francisco agreed. "The movies will not affect HMO policies," she said. "They will have an effect on the general public consciousness."
Skewed perceptions
Many health care professionals do believe the films reinforce a negative perception that the public already has about the managed care system.
"It exacerbates the public's already negative perception of managed care," said Pat O'Brady, Ph.D., Ed.D., RN, of Tim Porter-O'Grady Associates Inc. in Otto, N.C. "Personal choice is a critical democratic right in this country. Anything that limits personal choice creates a negative perception."
Freeman argues that the message portrayed in "John Q." is inaccurate and does not reflect reality. As a result, this may pose a threat to the managed care system, as it could skew people's perception of how the system is run.
" 'John Q.' is designed to take a situation that can occur and heighten it to its fullest possibilities. The film took the plot as far as it could," he said.
In addition, the way the hospital administration in "John Q." handled the son's illness was unrealistic, Wade said. "A team of people sits down with the family and tries to explore every possible avenue" for treatment and coverage. "There is a whole support system for families. You cannot equate any of [what happens in the movie] with reality."