The Affordable Care Act may seem like an unlikely topic for a comic book, but Health Care Reform: What It Is, Why It’s Necessary, How It Works, written by MIT economics professor Jonathan Gruber and illustrated by Xeric Award winner Nathan Schreiber, is nestled comfortably on the New York Times graphic book best-seller list, alongside The Walking Dead, Avatar: The Last Airbender, and a graphic novel adaptation of Stephenie Meyer's Twilight.
Now in its fifth week on the best-seller list, Health Care Reform is one of a string of nonfiction graphic works published by Hill & Wang’s Novel Graphics, a nonfiction line of comics at Farrar Straus Giroux that is also responsible for the The Beats: A Graphic History and The 9/11 Report: A Graphic Adaptation and other nonfiction comics works.
Gruber, who helped draft the Massachusetts health care law and was one of the key voices in creating the Affordable Care Act, was initially reluctant when Hill & Wang publisher Thomas LeBien (who has since left FSG for a post at Simon & Schuster) asked him to create a work of graphic nonfiction that explained the health care reform.
"[LeBien] said 'Would you like to do this?' and I said 'No.' Then he called back and said, 'Look, this is a great medium to explain things. When you are on an airplane and they want you to know what to do in an emergency, they hand you a comic!' And I still said no." In the end, he said, his family sold him on the idea. "They said, 'You are always complaining that people don’t understand this,' so I thought I would give it a whirl," he said.
The book takes a very abstract subject and makes it concrete in a number of ways. Gruber began by putting together a 30-page outline of the topics he wanted to cover in the book, and then he worked with writer H.P. Newquist to write the script. "He and the editor and I spent time thinking about what images made sense," Gruber said, "and for maybe one-third of the book we had suggestions for what kind of images we were looking for, and Nathan did the rest."
Gruber appears as the narrator in the book—one of LeBien's ideas--and LeBien also came up with one of the central metaphors of the book, the image of health care as a two-headed alligator, with one head marked "Rising Costs" and the other "Number of Uninsured." He also had the idea to illustrate the inequities within the health care system by creating four different characters with the same ailment but very different coverage: One has employer-sponsored health insurance, one is on Medicare, one pays for his own insurance in the non-group market, and one is uninsured.
The book follows each of them and explains the different problems each of them faces, but it also makes an important point: Health care inequity affects all of us, even the "winners" in the system. This point is driven home visually when Anthony, the character with employer-sponsored insurance, loses his coverage and is forced to buy non-group insurance; Gruber and Schreiber show him trapped in a scary fun-house, surrounded by bad choices.
"To me, the single most important thing in this book is the insecurity Americans face today," Gruber said. "Most of us have employer sponsored health insurance, but if you lose that you face this unfair market. The law was designed to fix that."
Schreiber, who is currently in residence at Angouleme, came up with a number of the visuals as well, including the image of Gruber hanging off the back of an ambulance. On the other hand, making the many panels and committees in the story visually interesting presented a challenge.
Schreiber has a degree in economics and said he knew "a fair amount" about the Affordable Care Act before he started working on the book, but that it was interesting to learn the specifics. "As a freelancer who is going to be required to buy insurance through the mandate, it is particularly relevant to my life, so it wasn't something I could afford to ignore," he added.
Surprisingly, for a book about economics, Health Care Reform has no obvious graphs or charts. When Gruber and Schreiber illustrate how the amount of the Gross Domestic Product that goes to health care has increased over time, they use shaded dollar bills—with people tugging on either end, and one group standing on the two-headed monster—to get the point across, rather than a straight bar graph. "For an economist, I'm kind of humanistically oriented," Gruber said. "A lot of the concepts haven’t come easily to me, and that makes me a better teacher." When he tells strangers what he does, they often say "Economics was the worst course I ever took," he said, and that's because they shy away from the numerical aspects. "They like the intuition," he said, "and I have become good in my regular life at explaining things without graphs or numbers."
While the book has a definite point of view, Gruber said he took pains to ensure that all the images are accurate. " I didn't want people to say 'Look, this is not a serious book, the facts are wrong,'" he said. "I wanted it to be fun but also cross checkable and fact-based."
That doesn't mean he doesn't have a point of view. "One nice feature of this topic is that the truth supports my view," he said. "If you explain the facts, people like what's in the law. It wasn’t that everybody had the evidence and I had to spin them, it's that people don’t know what's in it, and if I explain it, people will come to share my view. In many ways it's advocacy, but it's also fact based. I tried to be honest about what the law does and what it doesn’t do."