I heard about Jonathan Gruber’s Health Care Reform comic book on the Internet, so when I saw it in my library’s New Item Shelf I checked it out. It almost looks like a parody, as some opening pages show a movie-theater marquee announcing with great fanfare: “Everyone will be able to afford insurance… And we will do all this while reducing the federal deficit!” (There is a crowd of people yelling “Yay! Hoo-raay!”) But it’s a very serious graphic novel by a very serious MIT economist who wants to explain to laypeople how the “Affordable Care Act” is supposed to work.
Gruber does an admirable job explaining both the problems of the current American health care system, and the ways Obamacare will try to fix that. It also provides helpful context for understanding news about health care reform (like the recent birth control hoopla). From a technocrat’s point of view, or if you’re optimistic about the things government can do, this book makes the ACA look like an intelligent and pragmatic attempt to fix a real problem. There are a few things I find reasonably hopeful, and a few things I find commendable (like experimenting with five different methods of cost control with the flexibility to adjust these methods as we figure out what works. Reminds me of the Little Bets book I’ve been reading, and it’s pleasantly surprising to see the government trying to be more flexible than usual.)
But from my bias, it also makes the bill look like an insanely complex technocratic mess. To cite just one example: it explains how employers with 50+ employees that do not provide insurance plans will face fines of $2,000 per employee, and how this is supposed to incentivize employers to provide plans. Will this encourage 49-person businesses to delay hiring another person? Who will be deciding whether or not that incentive is effective enough, and how much the fine needs to be changed as time goes by to keep the proper incentives aligned? But that’s just an example of arbitrary complexity, and not a “problem,” per se; it’s just how government regulation works. However, I do have ten real problems with the health care reform comic book based on information it provides that either lacks context or is wrong or outdated:
10. Death Panels. “What about death panels…?” “There are no ‘death panels.’ That’s a political contrivance. It was a myth designed by reform opponents to scare people away from the facts.” (136)
The “death panel” talk came from statements in the health care bill about “end-of-life” counseling. Many conservatives exaggerated such statements or took them out of context, but it’s a little disingenuous to completely write it off as a “political contrivance” and a “myth.” But, hey, maybe Gruber just didn’t have room to explain that…
9. “Nobody questions buckling your seat belt.” (127) Gruber makes this claim while defending the individual mandate that everyone purchase health insurance. Apparently he hasn’t met many libertarians. Heck, he must not even be aware of Glenn Beck. Seat belt mandates aren’t exactly the most controversial issue in the world, but it’s a false statement to round down and say “nobody” questions it.
8. Car insurance analogy abuse. Also while defending the mandate, Gruber repeatedly refers to the existing car insurance mandate as a justification (46, 127). But there are technical differences (you only need car insurance if you are going to drive, not simply because you are alive) and legal differences (car insurance is required by the states, not by the federal government) that create important implications about what the health care bill requires.
7. Medical loss ratios. Gruber mentions the “medical loss ratios” as a new rule that is supposed to keep insurance companies from taking advantage of other new rules: “For every dollar they collect in premiums, they must pay 80% to 85% in medical claims.” (76) Gruber does not address claims that there is “no way” insurers can “still make a profit” under these rules, and he doesn’t mention the delays that are being granted to insurers that don’t think they can cope with that rule. Again, maybe he didn’t have room, but it would be nice to at least hear an explanation of why those claims might be false than to ignore them altogether.
6. “Successful programs.” To defend the government’s involvement in health care, Gruber refers to existing programs: “You’re conveniently ignoring Medicaid, Medicare, and Social Security. These are all programs run by our federal government. And they’re popular and successful programs.” (45)
OK, I’ll give you “popular.” And I guess a lot of people consider them “successful” over short time periods mostly in the past. Maybe it’s just my bias coming out, but when we’re talking about three programs that are quickly becoming the most expensive parts of the federal budget and require unsustainable demographic trends to remain solvent, “successful” is the last word I would use to describe them.
5. Trusting that initial conditions won’t change and make the bill more costly. On the expense side: “Virtually all proposed Medicare cuts have been enacted. There is no reason to think that Congress can’t keep its promises on this one.” (95) Has Gruber never heard of the “doc fix” that Congress passes every year to stop a 20-30% cut in payments to doctors? On the revenue side: The Medicare payroll tax will rise “on those individuals with incomes above $200,000 per year.” (96) I read this tax is not indexed to inflation, and based on Congress’s annual raising of the AMT, I wonder if this tax will be subject to the same fate. There’s also the “Cadillac tax” on the “most generous and expensive insurance plans…. This tax doesn’t go into effect until 2018…” (97) Gruber doesn’t mention that this tax was delayed until 2018 thanks to union lobbying, and I don’t trust that further delays won’t be justified by the time we actually get there. Every future change that lets someone pay less or stops them from receiving less only makes the bill more expensive and less effective.
4. CLASS Act. We don’t have to point only to hypothetical changes, either. Besides the mass of waiver delays, the Obama administration has already canned a program in the ACA that was supposed to “help cover the costs of long-term care” for seniors (122). I don’t fault Gruber for mentioning this when it was still part of the program, but that panel is now inaccurate. How many more panels will suffer this fate as time goes by?
3. Deficit reduction claims. “The Congressional Budget Office projects that the ACA will reduce the deficit by $143 billion in 2019… over its second decade the ACA cuts more than $1 trillion from the deficit!” (98) Well, sure, the bill was projected to reduce the deficit based on unreasonable initial conditions. But we already know that they cut a program that was supposed to be a money-saver part of the bill (see my #4), and there are a whole bunch of ways the government may delay and tweak things that were supposed to cut costs or raise revenues in the future (see my #5). So I don’t think it’s unreasonable to treat these deficit-reduction claims as highly suspect.
2. “Standard set of services”. “Insurance will be required to cover a standard set of services.” (70) I believe this is the context for the contraception deal we went through earlier this month. Gruber probably didn’t anticipate the political fight that would erupt over what constitutes a “standard set of services,” but I believe this fight is just beginning. This is what happens when you give the government the ability to provide hard definitions to vague terms, and I said everything I need to say about that in the link in this paragraph.
1. Constitutionality of the mandate. I give Gruber credit for mentioning the debate about the constitutionality of the individual mandate, and I give him credit for explaining why the big plan needs it. But he makes no attempt to defend the constitutionality, and simply explains why the bill won’t work without it and concludes “How is this sensible policy?” (126) To me, that reads “The ends justify the means.” To me, that justifies any government action based on something you have decided is good for us, and I think that is the most dangerous aspect of all.
Look, I’m sorry that your brilliant plan requires giving the government a lot more power. I’ve outlined some of the reasons I don’t think it’s such a brilliant plan anyway. But even if it was, that doesn’t justify removing the foundation of our limited government. There are some powers I just don’t think our federal government has, or should have, even if it’s for the “greater good,” because it creates too much of a chance that someone else could use those same powers for evil. And one of those powers is the ability to force private individuals to do business with private companies. I hope the Supreme Court feels the same way.
I still very much recommend this book if you would like to better understand the health care bill and the discussion surrounding it. It’s easy to read, laid out well, and does a great job explaining things. Just keep these things in mind while you read it.