U S Healthcare System – Reality vs Reform

Author’s website:  1. https://www.cartoonstudies.org/ ; 2. https://economics.mit.edu/faculty/gruberj ; 3. https://www.populareconomics.org/

Where to buy: 1. www.cartoonstudies.org/healthcare  ; 2&3. https://bookshop.org/shop/graphicmedicine

Book Review by Kevin Wolf

I’m going to be geeking out a bunch in this book review. The topic covered, the United States’ healthcare system (USHCS), overlaps a lot with my professional life as a health actuary. I’m sorry if you find this review a bit statistics-heavy, but I can’t address the U.S. system without such information. This graphic medicine triple-book review will be time traveling backwards from today to the early 2000s. In 2019, the most recent with data available, the USHCS employs sixteen million people, costs $3.8 trillion in total (over $11,000 per person), and is well over seventeen percent of U.S. economy (gross domestic product); by far the most expensive healthcare system per capita anywhere in the world. And what does the U.S. get for all this spending? Not much. We spend on administration per person for the USHCS over three times the cost of any other of the 38 Organization for Economic Co-operation and Development (OECD) member countries; the U.S. has the tenth worst life expectancy from birth (of 37 countries), fifth worst infant mortality (of 37), fifteenth worst control for asthma (of 35 countries), and eighth worst of uncontrolled diabetes (of 35) to name a few parameters. Other OECD countries typically spend about 11.5% or less of their GDP on health care. In 2019, the Federal, State, and Local governments paid for about 45% of total U.S. healthcare costs.

Out of all the OECD member countries, only the U.S. does not view healthcare as a right for its citizenry. The USHCS has been and continues to be ad hoc, messy, inequitable, mostly employment-based, partly socially-insured (e.g., Medicare), some joint-federal/state-administered (Medicaid, CHIP), alphabet-souped (PPO, HMO, FSA, HSA, ACO, HRA,  …), opaque, unhealthy, tremendously expensive, and hopefully fixable. It’s so complicated, I can’t even give a simple explanation of who’s covered by Medicare [1, see endnotes]—the U.S.’s pre-eminent social health insurance program.

This brings me to my review of three graphic works about the USHCS. Health and Wealth is a comic book recently published in July 2021. Health Care Reform came out in 2011 to explain the Patient Protection and Affordable Care Act (ACA; aka, Obamacare); and the illustrated Field Guide to the U.S. Economy, was published in 2006. The latter provides some healthcare statistics to compare how much (or little) the USHCS has changed since the late 1990s or early 2000s.

Health and Wealth, a comic book, published by Center for Cartoon Studies and authored by many[2], provides an excellent, detailed picture of the current USHCS and offers some prescriptions for improvements. In twenty-seven pages, often with double-page explanations of difficult subjects (e.g., insurance), the authors/cartoonists provide a wealth of information; though some information might be too abbreviated or sometimes in error (e.g., see discussion about relative value units later). Health and Wealth mimics Richard Scarry’s illustrated books by showing—in his drawing style (sample below)—lots of anthropomorphized animals who speak or join the narration. Health and Wealth starts with an ideal scenario (including a doctor giving an oath[3]), and ends with requiring action for the close-to-ideal to come to fruition. A lot of important information about the United States’ healthcare system is packed into this comic book with a variety of imagery to keep it entertaining and fairly absorbing. I highly recommend Health and Wealth. The creators are hoping this comic will be widely distributed; it can be found here.

From page 9 of Health & Wealth (more sample pages here)

Unlike an ideal healthcare system (pages 1-3), the USHCS is shown metaphorically (& apropos) as an unworkable mix of board games (Life, Chutes & Ladders, and Monopoly) glommed together haphazardly with band aids. (4-5) Health and Wealth explains where or how some people fit into the USHCS (6-7).

A brief history of U.S. hospitals is provided from seemingly aged-sepia imagery of walled almshouse (hospital of 1800s for the poor) to colorful, modern, glassed hospitals of today (10-11). Hospital billing practices are explained through a facility’s open cross-section (12-13); with a lot of details: for example, “Medical students graduate from school with a mean debt of $170,000. In other countries medical school is far cheaper or free. [So] Doctors are under pressure to generate revenue from the get-go.” (12)

The comic does go too far at times. For example, it indicates that there are fees for just sitting in a waiting room (12); there aren’t; but part of the bill—when services are rendered— is for overhead and facility costs. The fees charged without discounts from insurers, Medicare or Medicaid can be outrageously high and bankrupting for the uninsured. Health and Wealth does an excellent job of reinforcing how confusing the USHCS is (e.g., in-network vs. out-of-network reimbursement, often not known without research on patients’ part); and how costs are virtually unknown until bills arrive. The comic does confuse hospital reimbursement with physician reimbursement (Post-review correction: Before the comics books went to the printer, this reimbursement was changed to physicians not hospitals), and the creation of how physicians are reimbursed[4]. It’s true, as the comic states, “The entire system lacks transparency, standardization and comprehensive patient protection.” (13)

The comic for its size, does a great job explaining difficult topics. Health and Wealth shows that health insurance’s founding was connected with Dallas Texas’ Baylor (University) Hospital (administrator) Justin Ford Kimball[5]. There’s an excellent discussion (16-17) of Truman’s attempt at national health care; and politicized pejoratively as “socialized medicine” by the American Medical Association. And outside Health and Wealth, there were cartoonists on the other side—or at least hired to be—of the national health care debate at that time.  Famed-cartoonist Will Eisner was hired by the Baltimore City Medical Society in 1950 to produce The Sad Case of Waiting-Room Willie (reprinted in The Comics Journal, Issue 267, April/May 2005, pages 151-165, The Will Eisner Issue) to fight socialized medicine. Jared Gardner, professor at The Ohio State University, wrote an excellent article on cartoonists and President Truman’s attempt at national healthcare posted here.

There are three major groupings of USHCS covered/uncovered persons (2019 counts): publicly insured (Medicare—58 million people, Medicaid—64 million, Veterans—7 million), privatly insured (employer—179 million, individual—42 million, military—9 million), or uninsured—29 million[6], for a total of 323 million; note there is some overlap, such as some people covered by both Medicare and Medicaid.

Health and Wealth shows some photographic images of Americans protesting against the American Medical Associations attempt to stop the passage and others marching for passage of Medicare/Medicaid social insurance programs (16-17). Medicare/Medicaid were signed into law by President Johnson and implemented in 1965.

The final story (22-26) of Health and Wealth, A Tale of Two Snakes, has both a reality-based and hopeful, reform-minded aspect when the wider community of patients and the public provides questions and solutions[7]. At the end of Health and Wealth, there are useful Resources (27) including Kaiser Family Foundation, Physicians for a National Health Program—a distant cousin-in-law of mine was a leader of PNHP—and our very own Graphic Medicine International Collective; and a few books for further reading. Page 28 shows discussion/activities guide and page 29 has a glossary of terms. As best I can recall, some terms are only mentioned in the glossary (e.g., the Affordable Care Act (ACA), Health Maintenance Organization (HMO)). Therefore, the reader should think of the glossary as going beyond the narrative of Health and Wealth.

Health Care Reform: What It is, Why It’s Necessary, How It Works is written by Jonathan Gruber (Economics Professor at MIT, Member of Institute of Medicine, and former Assistant Deputy Secretary for Economic Policy in U.S. Treasury Department) with HP Newquist and illustrated by Nathan Schreiber. Professor Gruber is one of the primary creators of the Patient Protection and Affordable Care Act (ACA for short or Obamacare); and is a character and narrator of Health Care Reform. This graphic work provides simplified information about the USHCS, such as insurance is for not having to pay the “full cost for expensive medical treatment … (12)” Health Care Reform indicates that in the first decade of this century those in the U.S. fortunate to have employer-provided coverage had little out-of-pocket (the amount patients pay) expenses.[8]

Before the ACA people in the U.S. could be denied coverage for a pre-existing health condition; and the uninsured often couldn’t afford to get sick. According to studies, about two-thirds of the people in the U.S. filing for bankruptcy pre- and post-ACA still indicate medical issues (healthcare cost or time off work) contributed to their bankruptcy. Professor Gruber also explains how a Massachusetts experiment[9] was a source of the ACA.

Professor Gruber gives examples (38-42) of very inefficient spending with little positive health benefits such as overuse of emergency rooms and under use of preventive services; and doctors were paid for quantity—not necessarily quality—of services rendered. These fee-for-service payments may lead to over-prescribing services, testing, and medications (43-44).

Without explanation, Professor Gruber declares there are problems in both potential system extremes; implying that the ACA is “just right.” He creates strawmen by claiming that a single-payer-government-developed plan on the left or, alternatively, ending government supported healthcare (i.e., Medicare/Medicaid/etc.) on the right equally has problems without explaining what those problems might be (48-49). (Had I been the artist, and able to draw, I would’ve drawn straw men at this point, but alas it didn’t happen.) Therefore, his proposal, which became the ACA, works best. He advocates for what Massachusetts implemented under Republican Governor Mitt Romney (50-58) which had relied on Professor Gruber’s, among others,’ advice at its creation.

I won’t go into depth to explain the ACA[10] and how it works since it was implemented between 2010 and 2014, so you probably already know about it. Keep in mind Health Care Reform was published in 2011; years before the ACA was fully implemented. Gruber narrates, “The major accomplishment of the ACA is to provide true security to the insured in the U.S. [67]” There’s a minimum standard of ten categories of benefits that must be covered (called Essential Health Benefits).

Unfortunately, a public option (e.g., Medicare-like) was missing from the ACA, so only private insurance through insurance companies is available under the ACA. Had there been a public option, then it would’ve been easier to gage how many people wanted to buy private insurance vs. signing up for or being put into a government-designed public option benefit package like Medicare. Full disclosure: Pre-ACA, I had proposed a public/private mix of coverage with those not selecting either being automatically enrolled in the public plan.[11] Without the public option, some areas in the U.S. offer very few (possibly only one) exchange options and might have very narrow healthcare provider networks as the private option.

Health Care Reform discusses the fearmongering surrounding the ACA before and after the law passed; but couldn’t know if any of those fears would occur. I’ll show the fears shortly and whether they occurred through 2019, the most recent year with data available.

• Fear: The uninsured won’t be covered. ACA initial claim[12]: uninsured population will decline by 32 million before 2020. Fact: The uninsured count decreased about 17.5 million by 2019; partly due to twelve states[13] not accepting one aspect of the ACA: Medicaid expansion. One state (Missouri) hasn’t implemented their Medicaid expansion yet.
• Fear: Employer’s providing insurance will decrease by 2% (Employment-based health insured were 55.1% of U.S. population in 2010; and fact: 56.4% in 2019 were covered by employers).
• Fear: Government takeover of health insurance. Fact: Increases number of those with private insurance; and public—government—option wasn’t created.
• Fear: Insurance premiums will increase; but CBO[14] expected the ACA to have little effect on health insurance premium increases. Fact: Insurance premiums increased 54% between 2009 and 2019 (about 4% per year compounded; which is reasonable compared to higher historical trends).
• Fear: ACA would explode the deficit. Fact: Original estimates by the CBO concluded that by 2019 ACA will reduce the deficit by $143 billion; and the second decade is supposed reduce the national debt by $1 trillion. Actual fact is unknown because ACA wasn’t implemented as planned (e.g., the tax penalty to individuals was eliminated with President Trump’s 2017 tax reduction which increased deficits; Cadillac tax was deferred from 2018 to 2022 under Trump administration; and twelve states didn’t implement Medicaid expansion; among other changes.

ACA included several experiments to see if any might control costs, but it’s unknown how much they might’ve worked to control costs.

• Mislabeled as “Cadillac Exchanges” —in Health Care Reform—should’ve been Cadillac Plan Tax. This tax penalty was to be on extremely comprehensive plans with very low out-of-pocket-expenses (aka, Cadillac plans), but it’s impact was deferred by Trump administration until 2022
• Exchanges – supposed to provide competitive marketplace for coverages. There’s competition in many locations, but some locations might have only a single offering (e.g., Delaware has only a single insurer on the exchange).
• IPAB – Independent Payment Advisory Board (no members have been appointed to its board); so its impact is unknown.
• CER – Comparative Effectiveness Research; I couldn’t find an explanation of what this is, nor if it was implemented.
• ACOs – Accountable Care Organizations—rather than pay for each service as they occur, ACOs pay a global capitation payment for all covered services. By 2019 there were about 1,600 ACOs, 60% under private insurance and about 40 million lives in total covered by them.

The illustrations in Health Care reform are rather pedestrian with almost no shading, shadows, or backgrounds. Health Care Reform uses many metaphors in the imagery. For example, an ocean might toss about the non-employment-based insured with increasing costs or decreasing benefits. The ocean could become a tidal wave, so a lifeboat (personal health; or low cost/high deductible coverage) may not help if one doesn’t have a lot of personal assets. A two-headed alligator has one head for rising health costs, and the other labeled uninsured.[15]

There are some annoying aspects to Health Care Reform. One example has Professor Gruber flippantly sending off an uninsured woman to an emergency room for the second time (first was a heart attack and second was being hit by a car) to demonstrate how the rest of us pay her cost through higher hospital bills or insurance costs, but doesn’t mention that her unpaid-for-emergency-services are already subsidized by higher payments (called “Dish” for disproportionate share subsidies) from Medicare reimbursement. The emergency room is the only place an uninsured person can’t be legally turned away from healthcare services in the U.S.. Health Care Reform is presented like the Socratic method where other characters are sometimes either manipulated by Professor Gruber to be a misguided example or to allow the professor to explain why we should believe that he has the answer for the problem they encounter. There’s an amusement park (28-29) of lousy insurance coverage if one loses their job, but no mention of COBRA[16]. Health Care Reform ends smarmily as a glorious day of ACA providing coverage for everyone at lower cost. The ACA didn’t fulfill this promise partly because it was politically eroded and partly because it wasn’t set up to give coverage to those who refused to sign up. On the positive side, Professor Gruber views the ACA as a first step which can be adjusted as the need arises. But given that one political (Republicans) party is against it, it’s extremely difficult to fix and easy to chip away from it. He implies we’re marching toward a positive future; while, even back in 2011, it was more likely to be an uncertain one!

If I didn’t have the other two graphic works, above, to review, I would’ve put the Revised & Updated Field Guide to the U.S. Economy: A Compact and Irreverent Guide to Economic Life in America by Teller-Elsbergg, Folbre, Heintz, and The Center for Popular Economics in the graphic medicine Medical Mentions category. From its back cover, the Field Guide reflected “the collective wit and wisdom of more than forty progressive economists affiliated with the Center for Popular Economics.” The Field Guide has one chapter (chapter 7, pages 109-126) with sixteen charts, cartoons and commentary on Health. There were several other health related issues elsewhere, such as homicide rates (10), losing employer-provided health insurance (27), workplace deaths (29), reproductive rights (53), federal spending by category (77), health & environment (132), and climate change (143). Medical Mentions are graphic works whose primary topics are not medical, and yet they cover a medical topic with some depth at some point in the work (examples can be found at I, II). This Field Guide was illustrated with comic strips/panel cartoons by over forty cartoonists The Acknowledgements included websites (some may no longer be active) for many cartoonists on page x. I recommend the Field Guide for its historical value, and sadly, finding many disparities that have worsened since its publication.

Since the Field Guide emphasizes charts of statistics (with sources provided) and commentary from about fifteen years ago or earlier—being published in 2006—I am going to quote from the introduction, The Bottom Line, at some length to benefit the 2021 reader:

“Economic experts are far more likely to extol the virtues of the [U.S. economy] than criticize it. … Some economists (like us) disagree. We believe that economic power in the U.S. is unevenly distributed and easily abused and that current economic policies are inefficient as well as unfair. We also believe that good citizens should be good critics, and that controversy and debate over economic issues are central to the democratic process. This book compiles useful information for non-economists … who want to know more about the U.S. economy. The facts and figures we highlight reflect our personal values and our political concerns. But we stop short of developing any one interpretation of U.S. economic trends or advocating any particular social policies. (xiii-xiv)

“[Regarding the health Chapter 7] … The U.S. health care system has been sick for years, but political bickering and special interests continue to block an effective cure. The problems are chronic: many Americans lack health insurance, prices for care keep climbing at a rapid pace, and the quality of care too often depends on a person’s ability to pay. … Other countries are able to provide their residents with health care for a smaller fraction of gross domestic product. They also get more bang for their health care buck … (109)”

The words above about USHCS could have been, and are being written today they’re only much more costly today. Chart 7.1 shows U.S. health care spending was 14% of GDP in 2001; 11% in Germany and Switzerland, 10% in Canada, and 8% in U.K. and Japan; the U.S. has had the biggest change with it now being 18% of a much larger economy in 2020. Chart 7.2 shows healthcare spending-per-person in 1999 was about $4,500 with life expectancy at 79.2, while the same countries plus France and Italy had much lower per person spending and greater life expectancy than the U.S. The latter table goes with a comic strip of a large quilt blanket covering a Canadian in bed while the American is covered by a small American flag (Barrie Maguire editorial cartoon) to protect him. Other topics with their imagery include average price increases between 1980 and 2004 were for all goods (129%), for healthcare (314%), physician’s services (254%), prescription drugs (365%), and hospitals (504%) with Where I’m Coming From’s comic strip creator, Barbara Brandon-Croft, providing her iconic visuals of arms gesturing African-American women’s faces saying: “can you believe my premiums have gone up and my coverage has gone down?” [and one woman is disappointed at negative lab results because] “I have to pay for that lab test … I hoped something at least would be wrong with me.” (114) With data showing people of color having a greater percentage uninsured (Chart 7.7, 117) with an editorial comic by Khalil Bendib showing a health clinic window Yesterday for “Whites Only,” while for Today it’s for “Insured Only;” with his often-appearing bird sarcastically saying “Not the same difference.”  Infant mortality was worse for African-American/Indigenous people than whites by over 100%/40%, respectively 1984-2001 with Jeff Parker editorial (Chart 7.8, 118). Bankruptcy causes are often medically-connected (Chart 7.12, 122) even for 76% who had health insurance at the start of their illness with an editorial cartoon by Jen Sorenson. Chart 7.14 (124), back in 2001 major drug companies had revenue portions of 11% / 18% / 27% spent on research & development / profits / marketing, advertising & administration, respectively with a Carol Simpson (collaboration between artist Estelle Carol and writer Bob Simpson) cartoon with pharmaceutical executives discussing “This one shows great promise … it keeps the patient alive until their money runs out.”

Unfortunately, missing from all the graphic works reviewed here is a discussion of any other country’s universal healthcare system. That would’ve been helpful to read/see what’s done elsewhere, its cost, how paid for, and health outcomes. Fifty-One other countries (including Europe, Canada, Mexico, Japan, many in South/Central America and the Middle east) have a universal healthcare system where everyone is covered, except perhaps non-citizens; and, even then, at least some countries have reciprocity agreements among themselves to provide healthcare services to traveling citizens of other universal-healthcare-system countries with typically very low out-of-pocket expenses.

The more things don’t change the more they stay the same! When I graduated college in 1979, U.S. healthcare spending was 9% of GDP; it was 14% in 2001 (Field Guide); 17% in 2010 (Health Care Reform); 18% in 2020 (Health and Wealth); and projection from the CMS Office of the Actuary estimates it will by 19.4% (almost ⅕ of the economy) by 2027. Perhaps Health and Wealth can start a reversal … hope springs eternal![17]

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[1] Medicare covered-persons are typically those at least age 65, or meeting the definition of disabled under age 65 for 24 months, unless it’s ALS (Amyotrophic Lateral Sclerosis; aka Lou Gehrig’s disease) then there’s no wait, or suffering from end-stage-renal-disease under specific conditions; but you also have to be a U.S. citizen or “lawfully present immigrant” which has its own list of qualifiers.

[2] Including Lead Cartoonists: James Sturm & Kazimir Lee; Research, writing & editing: Dominick Contreras, Marissa Diggs, Emma Forbes, Sam Nakahira, Ava Salzman, & Alisha Yi; Design assist from Ivy Albe; and various Harvard students.

[3] Health and Wealth uses an oath different from the Hippocratic Oath; and doctors don’t actually take the Hippocratic Oath—which have classical and modern versions—and is non-binding, anyway. Others have boiled it down to “Do no harm.”

[4] The primary form of hospital reimbursement is not relative value units (mentioned on page 12), nor was it developed by hospitals. The Centers for Medicare and Medicaid Services (CMS) developed RVUs for reimbursing physicians not hospitals; while CMS reimburses hospitals based on MS-DRGs (Medicare severity – diagnosis related groups), but the point the comic makes about up-coding (13) is a valid one. Insurance companies typically mimic CMS’s reimbursement methodology for hospitals and physicians, but usually at higher than Medicare reimbursement levels. Unless you’re an actuary and know the coding for particular healthcare services the reimbursement calculations are very difficult to understand; and generally unknown to the patient in advance of services being rendered.

[5] Kimball helped develop the first “insured” coverage for the Baylor teachers for 21 days of hospitalization at a small annual fee. My addition: within ten years 3 million people across the country were in similar hospital plans, which became unified under the Blue Cross symbol.

[6] The uninsured pay 100% of health care bills—possibly after ad hoc negotiations with the billing department—out of their own pocket.

[7] The chapter being “inspired by the Caduceus, the staff carried by Hermes, the patron of commerce and traders as well as thieves, liars, and gamblers …” and the two-headed snake entwining the staff of Asclepius—Greek god of medicine and healing— which has become the western symbol of medicine (26).

[8] In contrast to today where, According to Society for Human Resource Management (SHRM), the average estimated employee’s  healthcare costs for themselves, spouse & children in 2021 will be $4,650, while the employer’s will be $10,850; this is about a 40% increase since 2010, when the ACA was signed into law by President Obama.

[9] Though Massachusetts (MA) had a fairly low portion of uninsured (6% in 2006), the rising costs for their care was a concern. Professor Gruber of MIT and others were asked by MA’s Gov. Romney to develop a solution. In 2006 MA healthcare reform law (aka, Romneycare) passed and created the Commonwealth Health Insurance Connector Authority (aka, MA Health Connector). By 2010 the uninsured in MA was about 4%; and about 3% in 2019. MA healthcare reform had three requirements: pre-existing conditions to deny coverage weren’t allowed by insurers, people were penalized if they didn’t buy insurance (aka individual mandate), and a premium subsidy was provided for low-income persons. The uninsured could pick their own private insurance health plan This was funded through existing taxes on insurers and hospitals plus federal monies for the uninsured.  Professor Gruber indicates there were pluses (e.g., number uninsured declined), and minuses (e.g., costs weren’t controlled).

[10] In summary under the ACA, all citizens can get coverage; individuals were penalized if you don’t get at least ACA coverage (this mandate penalty was later terminated in 2017 under President Trump and effective in 2019; and found constitutional by the U.S. Supreme Court in 2021). There’s a financial graduated subsidy—to reduce premiums and increase healthcare benefits—for low-income families. The amount of coverage varies with premiums covering from 60% to 90% of healthcare services (or higher for the lowest income eligible families). Aside from the actual coverage available on state exchanges, the ACA immediately ended annual of lifetime maximum benefit payouts, denying coverage for any pre-existing conditions; extended children coverage to age 26. For those Medicare-covered persons in the prescription drug donut-hole (having to pay 100% of drug costs), they at least get a 50% discount on brand-name drugs. There’s no out-of-pocket costs for preventive services (including annual physical, mammography, vaccinations, and well-child visits. There were small-business (less than 25 employees) tax-credits available, if the employer offers them health insurance.

[11] For the outline of my proposal, see my published entry for 2009 (pre-Affordable Care Act) Society of Actuaries’ Visions for the Future of the U.S. Health Care System article entitled: U.S. Health Care System Proposal: Private and Public Choice and found at https://www.soa.org/globalassets/assets/files/resources/essays-monographs/future-us-healthcare/health-essay-2009-wolf.pdf

[12] The Congressional Budget Office—(non-partisan arm of congress which estimates the impact of legislation—expectations at time ACA was proposed in Congress

[13] Not all states accepted the Medicaid expansion, so the reduction in uninsured would likely have been greater had they. States that didn’t accept Medicaid expansion as of July 23, 2021 include: Alabama, Florida, Georgia, Kansas, Mississippi, North & South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming. Texas has the largest uninsured population (18.4% uninsured in 2019). TX had 23.7% uninsured in 2010, pre-ACA. NV had 22.6% uninsured in 2010 pre-ACA; similar to TX; but they accepted the Medicaid expansion and in 2019 had 11.4% uninsured. Those states not accepting the Medicaid expansion still had to offer the Health Care Exchange under the ACA.

[14] Congressional Budget Office: non-partisan arm of congress which estimates the impact of legislation.

[15] Professor Gruber found the percent of GDP spent on health care was 5% in 1950, and 17% in 2010, but it hasn’t gone down since the ACA was implemented; it’s now about 18% of GDP and expected to continue to rise; the ACA has reduced the uninsured population from 46.5 million (17.8%) in 2010 to 29 million (9.0%) in 2019 primarily due to Medicaid expansion under the ACA[13], the creation of the ACA Health Insurance Exchanges, and economic improvement.

[16] COBRA is time-limited-coverage available to most employees, who lose their job, if they can afford to pay 102% of their employer’s premium rates

[17] Whew & Congratulations! You made it to the end of this review.