When Managed Care Rage Went to the Movies
Public reactions to the fatal shooting of a health care insurance company executive in front of a hotel in Midtown Manhattan on December 4, 2024, revealed a deep, seething antipathy across the country directed at the health insurance industry, an antipathy that has existed for at least thirty years. Its persistence brings to mind four movies: As Good as It Gets, Critical Care, and Rainmaker, released in 1997 and John Q in 2002, each depicting scenarios where rage against the healthcare system play a key role.
As creators in the arts often do, the makers of these movies were picking up on trends and signals before they were appreciated throughout society, and envisioning how they might play out in real life
How it starts
“Fucking HMO bastards, pieces of shit…sorry.”
This is how Carol reacts to the pediatrician who tells her the HMO should have covered certain tests for her suffering, asthmatic son. “Actually, I think that’s their technical name,” is the doctor’s response. This is from a scene in the 1997 movie, As Good as It Gets, directed by James L. Brooks. The movie won major awards from the Academy of Motion Picture Arts, Hollywood Foreign Press Association, and Screen Actors Guild. It also drew attention from the mainstream press for revealing a building rage about to boil over.
Ruthe Stein, from the San Francisco Chronicle, sensing the importance of the scene, wrote on December 23, 1997,
As Good as It Gets may be the first movie to take on HMOs…Brooks strikes a chord when he has Carol use four-letter words to describe the HMO that has mangled her son’s case. The audience hoots and claps its approval.
Then- President Clinton pointed to the scene as representative of real life while speaking at an event involving the Health Care Bill of Rights.
Movies Raging Against the Managed Care Machine
As Good as It Gets (1997, director – James L. Brooks). The movie mostly concerns the relationship between an author with obsessive compulsive disorder and a waitress whom the author depends on for a routine set of practices around his breakfasts. A side story involves the waitress’ young son who has severe asthma. At one point he needed certain tests done, but his health plan refused coverage. This situation led to the scene in which the boy’s mother reacted to this news in a way that attracted widespread public attention. The scene lasted for less than a minute, yet its effect on the image of managed care activities continued for years.
The Rainmaker (1997, director – Francis Ford Coppola). The movie plot involves a scam operation posing as a health insurance company. A young lawyer, fresh from passing the bar exam, takes on the company through the case of a plaintiff. The plaintiff is a young man who has a form of leukemia that can be successfully treated but will kill him otherwise. The insurance company denies coverage for the needed treatment and denies seven subsequent appeals. The lawyer eventually ascertains that the company denies all claims as a matter of course. Although a judgment is made against it, the company declares bankruptcy and goes out of business, thereby vitiating the settlement awarded. The patient dies. The movie is perhaps best-known for a line said by the lawyer’s assistant which fueled the growing public sentiment at the time: “There’s nothing more thrilling than nailing an insurance company.”
Critical Care (1997, director – Sidney Lumet). The setting for the movie is mostly in a hospital critical care unit. As in As Good as It Gets, a particular scene feeds the fury to come about managed care. A resident physician taking care of a terminal patient who has been clear about not wanting to continue treatments that only prolong suffering, argues with a senior physician and mentor about the advisability of putting the patient through yet more futile interventions. With his guard down from a combined state of inebriation and dementia, the senior physician tells the resident that the patient is fully insured and is thus a source of guaranteed revenue. He goes on to explain the economics (and immorality) driving these decisions.
[With HMOs] we get paid not to perform medical procedures. It’s a little like when the government pays the farmers not to grow crops. However, with insurance we get paid to perform medical procedures. Do you understand the difference?
On that basis, and that basis alone, he demands that the resident proceed full speed ahead.
With this scene, the moviemaker is going further than pointing to just the managed care organizations as the source of rage, but also to the health care providers who can spot opportunities for self-dealing. Viewers already sensitized to managed care activities could become even more worried, incensed, or nihilistic about the situation.
John Q (2002, director – Nick Cassavetes). About the same time John Q. Archibald’s full-time factory job is cut in half, along with his health insurance, his son collapses from heart failure while playing in a Little League baseball game. After a cardiologist tells John about his son’s need for a heart transplant and the financial requirements which he can’t meet, a nurse he asked why his heart condition had not been detected before tells them, “HMOs pay the doctors not to test. That’s how they keep costs down.” This comes up again when John asks the cardiologist how it could be that his son’s condition had never been discovered. An accompanying intern chimes in saying,
HMOs pay their doctors not to test. That’s their way of keeping costs down. Let’s say Mike did need additional testing and insurance says they won’t cover them. The doctor keeps his mouth shut and, come Christmas, the HMO sends the doctor a fat-ass bonus check.
The surgeon qualifies the intern’s assertion as possible but unlikely.
Try as he might, John Q cannot come up with the $75,000 down payment. The hospital administrator will not put his son on the transplant list, and he is released to be taken home where he will die. John pulls out a gun and takes the emergency room hostage. No one is killed, no one is shot, and a solution is found in the end. However, the movie raised the level of rage to one that produced the possibility of gun violence.
How It Ends?
Nearly thirty years have passed since these first movies depicted the rage that came in response to aggressive measures directed at managing health care costs, especially when they involved restrictions on certain products and services health care providers ordered and patients expected. Did these movies get it right? In large measure, they did. Management activities got more aggressive over the years and indeed many of those portrayed that were particularly egregious became a reality for some. As a medical affairs executive in a large pharmacy benefit company before, during, and after these movies were released, I witnessed (and fought against) the scenarios they depict as well as many others as bad or worse (with the exception of gun violence).
Where the movies helped to identify the problems early and possibly stoked the existing rage by bringing attention to them, they, along with professional health organizations, news media, and consumer advocates, pushed legislatures and regulatory agencies into creating laws and rules concerning how these activities are managed. These measures helped some, but media stories, books, and movies highlighting the problems appear regularly, keeping the rage alive, and maybe even intensifying it to the level anticipated in John Q. Maybe, even, to the level that played out on an early morning Manhattan street in December 2024.
As Good as It Gets Trailer
John Q Trailer
The Rainmaker Trailer
Critical Care Trailer
Web photo by Christian Harb
