[Note: HCFA Policy Coordinator Paul Williams is our resident comic book guy, and he penned this review of Connector Board member Jon Gruber's new comic book, Health Care Reform.]
Peanut butter and chocolate, macaroni and cheese, Batman and Robin, all things that go great together. With the publication of Jonathan Gruber’s book “Health Care Reform: What It Is, Why Its Necessary and How It Works” we can add graphic novels and health care policy to the list of great pairs.
We in health care policy often wrestle with taking very wonky concepts and attempting to translate them to a language that is people friendly. When it comes to the ACA and its 1,900 pages this task becomes even more difficult.
Gruber (along with co-author HP Newquest and illustrator Nathan Schreiber) manages to lay out in clear language and pictures how four very different people that are insured differently would deal with the aftermath of a heart attack. He narrates the possible scenarios in a Scott McCloud-like manner presenting the outcomes of an employee who is fully insured to the senior citizen on Medicare to the uninsured working poor. Gruber then lays out the double headed monster of rising costs and growing numbers of uninsured. His manner of presenting the opposition of the ACA in the form of four movie monsters both guarantee a laugh and key points to remember. He even manages to suss out the details of what an insurance exchange is and what it does in only a few effective panels.
Of course I was delighted to see that Massachusetts health reform was used often as the example on how this could be done, and it gives a great primer for those wanting to know more about our past successes as we move towards payment reform next legislative session.
All in all I would recommend people pick up this graphic novel for those looking for a clear and understandable explanation of health care reform. It would also make a great holiday gift for that one person in your life that wants to argue about the ACA but doesn’t understand what it entails.
-Paul Williams
Gruber’s health care comic book leaves out much of how the national plan a/k/a Obamacare a/k/a ACA works. He does mention that some at certain FPL levels will receive help from the gov’t to pay for coverage and others will be put into a public health plan. That would be the Obamacare expanded Medicaid. I don’t recall if he actually says Medicaid.
He does say what the penalty for remaining uninsured will be in 2014 and 2016 but he neglects to inform readers that since eligibility and affordability are based on prior year income, anyone who earns over the prior year income in the current taxable year – which may knock them by even $1 (maybe less) out of the FPL bracket they were in – could owe a substantial tax debt to the IRS when said person reconciles his/her tax return – a payback, if you will.
Essentially, the “tax credits” are a loan, and leaving this most important part out is detrimental to a person’s understanding of how Obamacare really works. The paybacks are $695, $1,500 and $2,500 depending on the current year FPL a person or family may be at. I don’t have amendment in front of me at this moment or I would quote the FPL brackets for those payback amounts. And if someone earns just over 400 percent of FPL and, thus, is no longer eligible for this gov’t loan a/k/a tax credit to help pay for coverage a/k/a subsidized plan, the entire amount must be paid back.
Because the income of workers often changes from week to week, including the income of a self-employed person or someone with several part-time jobs (there are also other examples), excess tax credits will be the norm. Most people will not be able to pay this tax debt because of the ever increasing cost of basic necessities, repayment of auto, education and other loans and will then find themselves subject to IRS interest and penalties. They will also be shunted into a more expensive plan with higher cost sharing which they probably won’t be able to afford either for the extra buck or $100 that they earned and may have to drop coverage. Then they will have to pay the tax penalty for being uninsured and will still owe the payback.
Many MA residents in the subsidized plans bounce in and out of coverage because they can’t afford food, a car repair, heat, etc.. This leaves hard-working people with untenable choices. About two or three years ago, disenrollment in Commonwealth Care outpaced enrollment over a three-month period. Sorry I don’t have the numbers in front of me at the moment but if my memory serves me well, it was in the thousands.
People who need to earn more to put food on the table and heat their homes, repair the family car, pay the increased property taxes, etc. will find that the extra money they earned to help with all of that will end up in the hands of the IRS and they still won’t have enough to satisfy that debt.
This is despicable. It is a heist. It will devastate people as it keeps them locked into never-ending debt in the name of “health care reform.” It is regressive and unhealthy for the economy not to mention the people affected by it.
Gruber also doesn’t explain that those found eligible for Medicaid will have no other choice for coverage unless they can afford to purchase a plan on the open market. They will not be allowed to “shop” at the Exchange (they will be “encouraged” and “helped” to enroll in Medicaid). Obama said all Americans will have choice. Seems that will not be the case unless by that statement he meant a choice between Medicaid and a tax penalty for remaining uninsured.
Although estate recovery (federally required under OBRA 1993 for all states that receive federal Medicaid funding) is not mentioned in the Obamacare law, the expansion of underfunded, overstretched Medicaid as the dumping ground for poor and low-income Americans is an integral part of the scheme. Therefore, those who end up in this plan and who use benefits at age 55 and up will be getting a mandated collateral loan. The amount of their assets that will be recovered upon death will depend if they reside in a state that takes only the minimum required by OBRA 1993 – RX and hospital – the maximum – or a mix.
This, too, is despicable and unconscionable, particularly because Obamacare does not provide another viable coverage choice for this income segment of the population. Pity the person who was dumped into Medicaid, used benefits at 55 and up so started racking up a tally for recovery of assets, then earned some extra money and was booted out of Medicaid but can’t afford the new plan, the payback or the penalty.
It is important for all Americans to know what is at stake and I’ve only touched on a few details that Gruber left out of his comic book. He also didn’t mention that the cheapest plan at the Exchange will have 60 percent actuarial value with a yet-unspecified annual deductible. The premium may not be affordable for many even though the gov’t has decided it is, but it certainly won’t be usuable and will leave the policyholder unable to seek care and in dire straights if they become seriously ill or injured. This has also been an ongoing problem in MA and, I believe that the MA plan has not stopped medical bankruptcy cases.
Does Obamacare have anything to do with access to affordable health care with decent benefits for all Americans? It appears to be a class-based, punitive system that forces people to purchase the broken products and uses the very same people as the funding mechanism for the scheme. It also contains no cost containment and, like the MA plan, premiums will continue to rise as will health care costs – the latter mostly due to the fact that people will have coverage they can’t afford to use or will end up with no coverage because there won’t be “affordable” plans for their incomes. Or they’ll be trying to pay off the tax credit and won’t be able to purchase or use any coverage.
Shared responsibility is merely political speak, but, in the real world, the gov’t is not sharing. It’s revenue comes from the people (taxpayers), and per the paybacks and penalties, the people further fund this nightmare. Employers aren’t sharing because, typically, they put their health care costs onto the backs of their employees. So the only people footing the bill are the people who can least afford it.
Last week, I read that the latest percentage of people who will not be covered under this law is now estimated at 33 percent. That is more than half of the 50 million uninsured, if the latter is even correct due to the number of unemployed. I would go into some detail on the spin regarding “more than 98 percent insured in MA” but I don’t have the stomach for more on the topic of “health care reform.” It is too gut wrenching.
So I will end by suggesting the Gruber write a sequel to his comic book and include the important details mentioned above and all others that he left out because those are where the devil resides. After all, one of the goals of his comic book was to inform the American people how Obamacare works, and he didn’t cut the mustard.