Book Review: Health Care Reform: What It Is, Why It Is Necessary, How It Works by Jonathan Gruber

Beverly Smaby

Obamacare is suddenly big news now that the U.S. Supreme Court is considering challenges to the 2010 law underlying it.  There is considerable sentiment against it.  All the Republican presidential candidates have vowed to repeal it, and recent polls show that around 53% of Americans agree with them.  We all seem to have an opinion about it.  Some of us oppose it because we think it does too little, and some of us, because we think it does too much.  Only around 40% of us think we should keep it.  But, no matter what we think, most of us have to admit: we don't understand it and we don't even know much about what it includes.  Given this state of affairs, Jonathan Gruber's comic book Health Care Reform: What It  Is; Why It's Necessary; How It Works is a happy find.  It presents the details in easy-to-understand language and offers a convincing argument about why we keep this law.

When Hill and Wang publishers asked Gruber to write this book in graphic novel/comic book format, he wasn’t enthusiastic.  But his 16-year-old son said, “Dad!  That would be way cool!”  And even his wife agreed, so he changed his mind, and they were right.  The pictures (engagingly drawn by Nathan Schreiber) help us understand and remember the points.  Gruber introduces himself in the book as narrator (with a slight hint of Superman, sailing in and out of frames).  He is a professor of economics at MIT, who worked as a key designer of universal health care with Romney in Massachusetts and with Obama at the national level. 

To show us what our current system does and doesn’t do, Gruber introduces four main characters

Each one gets a heart attack; each one gets the same first-rate treatment; and each one recovers.  But they end up with very different financial outcomes, depending on what, if any, medical insurance they carried.

  • Anthony has great health insurance through his employer, so he owes nothing. 
  • Betty is retired and has Medicare plus a supplement, so most of her costs are covered, too.
  • Carlos bought his own, lesser quality health insurance because his employer does not provide any.  He is not in such good shape.  He has to pay several thousand dollars out of pocket and now that he has a known health problem, his insurer is likely to raise his premiums dramatically or drop coverage altogether.  And since he now has a pre-existing condition, he won’t be able to get any other health insurance.
  • Dinah has a low paying job with no health insurance and decided she couldn’t afford any insurance.  So, she is stuck with all the expenses for her treatment.

Clearly Carlos and Dinah are in deep financial trouble.  But Gruber shows why all of us, even people like Anthony and Betty, are in danger of losing some or all of our coverage.  Anthony’s company might stop paying for health insurance, or, worse, he could lose his job.  In either case, he would no longer have his great health insurance, and since he has a pre-existing condition, he’ll be in the same pickle as Carlos and Dinah.  And since waste and inefficient management are causing health care costs to skyrocket, Medicare cannot continue to pay the increasing costs, so they will pay doctors less, who will then start refusing Medicare patients, meaning that Betty could run into trouble, too. 

So, the paradox of health care in the U.S. is that even though we have the best health care technology in the world, a huge number of us have less and less access to it.  Our challenge is to make sure everyone can get the health care they need, without bankrupting our governments. 

Now that Gruber has the attention of all four main characters (and us readers), he explains how Obamacare will help nearly everyone.  People like Carlos (and Anthony, if he loses his health insurance or his job) will be able to get affordable insurance through the health insurance exchanges in their state, where they can choose among the various private insurance companies in the exchange.  Diane can, too.  She may qualify for the Medicaid expansion part of the bill.  If her income is too high for that, but below $43,320 as a single person (or $88,200 if she has a family), she will qualify for a subsidy to pay part or all of her premiums.  None of them can be denied insurance because of pre-existing conditions, and their premiums will not be more than anyone else's.  People like Betty, who are on Medicare, will be helped with 50% payments for their prescription drugs, if they fall into the “donut hole”.  Everyone will be granted free preventative care like blood tests and screenings for various kinds of cancer and diabetes.

Other people will be helped, too.  Among other things, children under 26 will be covered by their parents insurance, whether they are working or in school, single or married, and living on their own or with their parents; babies born with birth defects can't be denied coverage; and there will be no limits on how much coverage people get during any one year or over their lifetimes.  Small businesses with less than 25 employees will get tax credits to help offset insurance premiums.

After describing Obamacare, Gruber takes on every criticism we’ve heard.  He introduces angry characters, who shout at each other and at Gruber.  Some argue that we should have passed a bill with single payer insurance through the federal government; others say that amounts to socialism and is un-American.  In fact, they claim the existing bill amounts to socialism.

But as a good comic book hero, Gruber stands his ground and answers the angry criticisms unflinchingly, undefensively, but convincingly.  He says we can look at how Romneycare managed to resolve similar disagreements and provide a very popular system which insures 98% of Massachusetts residents.  There is good reason to think that Obamacare will become equally popular and effective once it is implemented, because it is based on Romneycare.

This includes the well-known “mandate” – the requirement that everyone needs to have insurance or pay fines if they choose not to have insurance.  Mandates are necessary, he explains.  We can't expect insurance companies to meet the new requirements if a lot of young, healthy people decide not to get health insurance, just because they think they won't need it.  If people can afford it, it is their responsibility as citizens to get coverage and pay for it, so that the rest of us won't have to pay for their care if they get sick.  If they can't afford it, subsidies will help them pay premiums.  And we all need to do our part to improve public health in our country -- if we all get regular health care, we are less likely to become public health hazards.

Gruber also explains how Obamacare will pay for itself and even reduce the deficit.  It does so by increasing revenue and cutting waste.  Revenue will be increased by adding a 1% tax on earnings of individuals who earn more than $200,000 and families.   And there is a lot of room for cutting waste, since our current system includes so much of it.  Right now we cover treatments that don't actually improve our health and pay doctors and hospitals for procedures they administer rather than for healthier outcomes, and Medicare overpays private insurance companies for the Medicare Advantage policies they offer.  Obamacare will put procedures in place to correct those wastes.

Anthony, Betty, Carlos, and Dinah (and I) all ended up convinced that Obamacare could be a big step forward in reforming health care in the U.S., if only we get the chance to implement it.  Here’s hoping that the U.S. Supreme Court and/or the next Congress don’t gut it.  We need Obamacare!