Book Review

‘Health Care Reform’ by Jonathan Gruber

"Health Care reform" by Jonathan Gruber.
"Health Care reform" by Jonathan Gruber.

Riding the Toronto subways in the early ’80s, nothing pleased me more than finding religious pamphlets - comic books, really - on the trains. Even though their content was predictable they were wildly entertaining, and best of all: They foretold the future.

Or someone’s idea of the future, anyway: one in which those who did not find salvation in Jesus Christ suffered eternal damnation. Being Jewish, I didn’t see how the text spoke to me. The illustrations, however, remain etched in my mind 30 years later, such was their power.

“Health Care Reform’’ is an attempt to distill the 1,900-page Patient Protection and Affordable Care Act signed into law by President Obama in 2010 into a common-sensical, easy to understand book in graphic-novel form less than a tenth of the length.


Jonathan Gruber, an MIT economics professor, was one of the architects of the Massachusetts health care overhaul initiative of 2006 and a consultant to the Obama administration and Congress during the crafting of the federal plan.

In the book, Gruber serves as narrator and explains how and why Obama health care reform came to be and how it works, by following four imaginary citizens with representative needs through their dealings with the health care system, both as it is and after reforms take full effect. One has employer-provided insurance; another Medicare; a third has self-purchased coverage; and the fourth is uninsured.

Gruber juxtaposes, for instance, the dilemmas each would face under the old system in the case of a heart attack - the insured would pay indirectly for the uninsured and all would likely have to deal with future denial of care for a preexisting condition - most of which would be negated by the new plan. He also discusses the serious problem of waste, which he says constitutes a third of all health care spending.


The ideas are presented clearly, and although the subject is a serious one, the book is humorous in many places and contains lots of special effects you can only find in the comics. Neatly dressed, with glasses and tie, Gruber manages to escape the clutches of the gigantic “bloated and out of control . . . Goliath’’ that is our health care system - drawn as a hunchbacked giant on crutches - and to ride the two-headed crocodile helpfully labeled “Rising Costs’’ without even breaking a sweat.

As a firm believer that access to health care is a basic human right, and that costs in this country desperately need to be curbed, I was reassured to see just how sensible so many aspects of the health plan are, especially those that will extend coverage to an additional 32 million Americans currently without insurance.

Demonstrating how similar reforms in Massachusetts reduced nongroup insurance rates by 50 percent relative to national trends, it also convincingly explains why the individual mandate - the requirement that people without coverage purchase some - is critical to successfully expand coverage without excluding those with preexisting medical conditions.

The book was less successful at addressing downsides of the program. No, there are no death panels. But as Grace-Marie Turner and coauthors point out in “Why Obamacare Is Wrong for America,’’ planned Medicare reimbursement cuts to physicians may make it difficult for seniors on the program to find doctors willing to take them. Likewise, expanded government regulation of medicine through bodies such as the planned Independent Payment Advisory Board sparks fears it will restrict what doctors will be able to do for their patients, and stifle research and development of new treatments and drugs.


By putting more effort into engaging the sizable number of Americans who continue to harbor deep misgivings about Obama’s plan and focusing more attention on seriously addressing their legitimate concerns, “Health Care Reform’’ would have been more effective. It would also have gone a long way toward improving the political discourse in this country which, sadly, is all too often characterized by people painting opponents as heartless villains without stopping to listen to what they have to say and perhaps learning a thing or two in the process.

Dennis Rosen, a pediatric pulmonologist, can be reached at dennis.rosen@childrens.harvard.edu.