Each week, Dr. Aaron Carroll, one of the bloggers at The Incidental Economist, releases a 5-10 min video called "Health Care Triage," in which he discusses current issues in health. This week's installment will be of special interest to single payer advocates, since it concerns the French health care system, which he considers the best in the world. You may not know whether to laugh or cry.
In “Bigger Hospitals, Higher Prices” (Feb. 23 Forum) Shannon Brownlee and Vikas Saini present a strong indictment of the rapid consolidation of health care systems, essentially creating monopolies and concentrating power, as we’ve experienced in Pittsburgh. This has resulted in unsustainable cost increases without an accompanying improvement in care. Many researchers have noted that the United States’ health care system ranks poorly in lifespan, infant mortality and social inequality compared with most other developed nations.
Ms. Brownlee and Dr. Saini write that hospitals that dominate a market could be turned into “common carriers, regulated like utilities with transparent pricing and community oversight.” They add: “The most efficient way to achieve this goal would be through a single-payer system.”
Pennsylvania and the United States have single-payer systems in waiting, ready to transform our health care so that it is affordable, improves quality and is available to all. The state legislation is SB 400 and the federal is HR 676. More information about the solutions can be found at www.healthcare4allpa.org.
Healthcare for All PA board member Will Ferrell (not the star of Anchoman 2) has shared the great clip above of NBCs medical analyst Dr. Nancy Snyderman endorsing single payer. I had to share with you all. Will Ferrell has also had an Op/Ed posted in the Delaware County Times on Dec 13 seen at the bottom. Below is comedian Larry the Cable Guy telling Sean Hannity his opinion of the Affordable Care Act. Unlike other rantings and ravings on Fox News, this is actually funny.
SINGLE-PAYER, MEDICAL INSURANCE, and the CORBETT PLAN
Recently, Governor Corbett unveiled a Medicaid expansion plan called Healthy Pennsylvania. Few would disagree with the Governor’s objectives of increasing access, improving quality and making healthcare affordable for all Pennsylvanians.
Medicaid is a healthcare program funded by both the state and the federal government that provides direct care to individuals with limited income. The fastest growing population group in this category are seniors whose income falls within the threshold of income limits for Medicaid. In effect Medicaid supplements Medicare which is for all people over the age of 65. Medicaid has income limits, while Medicare does not. Most of the Medicaid supplement is used for long term care facilities.
Under the Affordable HealthCare Act, states may expand the eligibility for Medicaid, with the Federal Government picking up much of the cost. This expansion is optional for the states, although many states have already agreed to sign on.
Note, it is important to distinguish between health insurance and healthcare. Healthcare programs such as Medicaid and Medicare pay directly the doctors and hospitals that provide healthcare services to people.
With health insurance, people pay premiums to private insurance companies, who then pay the doctors and hospitals for healthcare services provided to those paying the premiums. Under Governor Corbett’s plan federal Medicaid funds would be used to buy health insurance for eligible participants, rather than providing direct healthcare.
HealthCare 4 All PA (HC4APA) believes this is a poor use of money that only increases the cost and limits the funding pool available to pay for actual healthcare. The reasoning is simple-health insurance has administrative costs in excess of 15%, meaning that 15 cents of every dollar does not go to pay for healthcare. Contrast this with Medicare and Medicaid where administrative costs are about 3%.
Therefore, under the Governor’s plan to turn Medicaid healthcare into an insurance program, more money will be spent and fewer people will be treated due to this disparity in administrative costs. HC4APA also believes that decisions about your healthcare should be made by you and your doctor, not by an insurance company whose primary motivation is to receive more money in premiums than they must pay out to doctors and hospitals.
HC4APA does agree with the Governor that the best healthcare delivery solutions are developed at the state and local government levels. States have often been called the laboratories of the nation. Following this ideal, HC4APA has developed a Single-Payerhealthcare delivery system. Single-Payer simply means that Pennsylvania would develop a healthcare delivery system modeled after Medicare, meaning doctors and hospitals would be paid directly for healthcare services provided to each of us.
The system would be funded by taxes paid by all businesses and by all individuals. It is clear, however that such taxes would be significantly lower than individuals and businesses are already paying in insurance premiums, deductibles and co-pays for healthcare. We can be confident of this because HC4APA contracted and paid for an Economic Impact Study (EIS) performed by several leading healthcare economists. This study demonstrated that Pennsylvania’s healthcare costs could be reduced by some $17 billion each year under a single- payer plan.
Currently, the costs of healthcare are very high and growing well ahead of the rate of inflation. If we, collectively, do not address these costs, the healthcare system will become unsustainable in its present configuration. A single-payer plan attacks those costs.
In addition, many other forms of business and personal insurance include healthcare cost components. These include vehicle and homeowners insurance and for businesses, workers compensation and liability insurance. The costs of these insurance policies would also decline when the state implements single-payer.
The bottom line is that a single-payer healthcare plan costs less and fosters free and open market competition. Single-payer moves the marketplace competition from the insurance company to the medical providers who will have to compete directly for your healthcare needs.
We encourage you to visit www.healthcare4allpa.org to learn more about the single-payer plan and to read the EIS that will document the value of the plan. Then become an activist by networking with family and friends, asking them to support the bill by calling their Legislators and ask them to vote for Senate Bill 400 and House Bill 1660. This will only happen if we the people want it to happen. We have the power.
Be prepared for a barrage of conservative criticism of the Affordable Care Act (ACA) that may be assumed to have negative implications for single-payer health care as well.
As I've noted before, the Oregon Health Experiment is a randomized control group design, far superior to most health care research. In 2008, Oregon hoped to expand Medicaid, but didn't have enough money, so they held a lottery. They invited everyone who was eligible to apply. Of the 90,000 applicants, 30,000 were randomly selected to receive Medicaid, while the losers became eligible for the control group. In previous data analyses, it was found that the Medicaid group spent 35% more on health care than the control group. They visited primary care physicians (PCPs) and were admitted to hospitals more often, and spent more on prescription drugs. They were also healthier and freer of financial worries, although most of the health differences are not statistically significant due to insufficient sample sizes in the study.
This should not have been a surprise. If you reduce the cost of a service, people are more likely to use it. However, some ACA proponents claimed that Medicaid expansion would save money by reducing ER use. Although the ER accounts for only 4% of health care spending, an ER visit is more expensive than visiting a doctor. The pro-ACA argument was that if patients established a relationship with a PCP, they would have a place to go for medical care and these doctor visits would prevent potential emergencies. For example, Health and Human Services Secretary Kathleen Sebelius said in 2009:
Our health care system has forced to many uninsured Americans to depend on the emergency room for the care they need. We cannot wait for reform that gives all Americans the high quality, affordable care they need and helps prevent illnesses from turning into emergencies.
It is important to note that these results are not due to the fact that Medicaid provides health insurance for poor people. Private health insurance patients are also more likely to use the ER than the uninsured.
Increased ER use might not be seen as a problem if the visits were real emergencies. However, the study found ER use to be higher even for non-urgent care that should ideally have been treated by a PCP. These results could be used by the opposition to suggest that single-payer might cause an massive influx of people outside the ER waving torches and pitchforks and demanding free care.
There are several considerations that may place these results in clearer perspective.
The time frame of the study, 18 months, may not have been sufficient to change uninsured people's lifelong habits of going to the ER every time they were sick. A three-year study of Romneycare in Massachusetts found an estimated 5-8% reduction in ER use.
Medicaid expansion could have been accompanied by education regarding when to go to the ER and when to visit your PCP. Of course, some may argue that education is not enough and should be supplemented by punishment, such as a co-payment, for “inappropriate” ER use.
Taking a broader view, the problem may be with the health care system rather than the patients. PCPs tend to be available Monday through Friday from 9 to 5—times that are inconvenient for most employed people. You can't always get same-day appointments with a PCP. A 2012 survey by the Commonwealth Fund found that in the US, only 35% of PCPs see patients after hours. In nine European countries and Canada, the average was 80%.
This study is one of a growing number that show that providing health insurance to the uninsured alone does not save money. The ACA contains some cost controls, such as the Independent Payment Advisory Board, which may eventually reduce costs. Single payer eliminates the cost of private insurance, which will save much more. Other changes may be needed. One of them may be asking PCPs to become more consumer-friendly by seeing more patients on evenings and weekends.
When it comes to persuading the Pittsburgh Post-Gazette to publish my letters, I'm batting about .050. My one success, almost ten years ago, was a note about music. Of course, newspapers get many letters, and it's their right to choose which ones to publish. Ordinarily, I wouldn't bore you by griping about their decisions. However, I've managed to persuade myself that my latest experience may be of interest to other letter writers, so I'm going to risk playing the fool.
My story begins on December 8, when the P-G published Molly Rush's letter advocating single payer health care. This was followed on December 16 by a reply from Jim Roth—a pharmaceutical salesperson(!)—implying that single-payer is too costly and denies health care to some citizens. If you're going to continue, you should stop and read Mr. Roth's letter.
The next day, I wrote the following:
Mr. Roth notes that all countries with single-payer finance it with a value added tax. However, the type of tax used to fund health care is irrelevant. The important point is that single payer costs those countries considerably less than our complex system of public and private insurance. According to a 2013 report of the Organization for Economic Cooperation and Development (OECD), the US currently spends on average $8,508 per person each year on health care, compared to an OECD average of $3,322. Yet the US is 26th out of 40 OECD countries in life expectancy. The amount Americans spend on health care due to the combined burden of taxes, insurance and out-of-pocket costs would be greatly reduced under single-payer.
Mr. Roth claims that people in single-payer countries have longer wait times for elective surgery and are sometimes denied such care. This depends on the country and what you consider “elective surgery.” US insurance companies also refuse to cover some elective procedures. However, if these were serious problems, you would expect residents of single-payer countries to be dissatisfied with their country's health care system. A 2013 survey by the Commonwealth Fund compared consumer satisfaction in the US to nine European countries and Canada, all with single-payer. Americans were by far the most dissatisfied,with 75% saying the system needs fundamental changes or should be completely rebuilt.
Finally, Mr. Roth suggests that we could lower health insurance costs by allowing it to be sold across state lines. It is true that if some states were to deregulate health insurance and if residents of any state were allowed to buy that product, premiums might come down. But those people would be buying insurance with little value should they become seriously ill. The Affordable Care Act is intended to prevent exploitation of consumers by establishing a baseline definition of adequate health insurance.
Of course, the primary purpose of single-payer is not just to save money, but to save the lives of some of the millions of Americans who are currently uninsured.
On December 29, the P-G published two replies to Mr. Roth. Both offered primarily anecdotal evidence suggesting that at least one family—the author's—had lived in a single-payer country and was satisfied with their health care system. The main difference between them is that the first referred to the British system and the second the Dutch. While both were well-written and persuasive, I thought they were redundant, and might have been better supplemented by my data referring to larger numbers of people and countries.
It's possible my letter was rejected because it is poorly written or exceeds their 250-word limit. However, Mr. Roth's letter, at 318 words, also breaks this rule, as do many others they publish. They could easily have edited my letter. Clearly, exceeding the word limit was a mistake. In retrospect, I should have dropped the third paragraph.
My hypothesis, based on this and other previous experiences, is that my letter was rejected because it contained too much data. Imagine an experiment in which parallel letters to the editor are sent to a random sample of newspapers. Both letters would make exactly the same points, but one would support each point with research, while the other would support them with anecdotes or merely claim that these were the author's personal opinions. My guess is that fewer of the data-driven letters would be published.
I have two possible, though somewhat inconsistent, explanations for my hypothesis. The first assumes that the editors wanted to present the single payer argument sympathetically. It's based on a common cognitive error known as the base-rate fallacy. People find anecdotal evidence more persuasive that statistical base rates, even though the base rates summarize data from larger, more representative samples. The people who made the decision may have found the two letters they published to be more persuasive than mine.
My second explanation makes the reasonable assumption that the gatekeepers at the P-G are opposed to single-payer. If so, they may assume that my inclusion of data makes the letter too persuasive. That is, they may be willing to acknowledge that there are some Pittsburghers who favor single-payer, but it may be unrealistic to expect them to publish statistics suggesting that the arguments of single-payer advocates are factually correct.
I hope I'm wrong. I really want to encourage the use of research evidence to change the health care system, and society in general, for the better. If this strategy is counterproductive, that's genuinely disturbing.
Letter
writer Elizabeth Stelle of the Commonwealth Foundation sees
government involvement in health care as a disaster and regulations
and mandates as the cause of rising health care costs in this country
(“Medicaid
Is High Cost for Low Quality,”
Dec. 2).
Rather
than dealing with inadequacies of Medicaid she seems to support Gov.
Tom Corbett’s refusal to extend coverage to 542,000 Pennsylvanians.
She
fails to note that private insurers, drug companies and providers,
whose primary interest is profits, are mainly responsible for rising
health care costs.
The
Department of Veterans Affairs pays 40 percent less for drugs because
of its buying power.
I
share Ms. Stelle’s concern about poor quality and high costs. As an
analyst, is she aware of a recent study of state Senate Bill 400 by
Gerald Friedman? He found that Pennsylvania could provide
comprehensive care to every Pennsylvanian and save $17 billion a year
through a single-payer system provided in the bill. Vermont just
passed a single-payer system.
There’s
nothing new about the idea. Every other industrialized country in the
world has some version of government health care. They also have much
healthier citizens. The United States is far behind these countries
in health outcomes. Here, 120 people a day die due to a lack of
health care. Half of all bankruptcies are due to medical bills. While
Obamacare does provide some real improvements, it falls short due to
its complexity and failure to cover everyone.
Go
to www.healthcare4allPA.org.
Then tell your state legislator to serve his or her constituents by
co-sponsoring single-payer legislation.
It was a great talk by Dr. Friedman last night with a large crowd of 70. The outrage was definitely there. A video by Julie Sokolow will be forthcoming of the talk. Posted here is an interview with former Green Party Presidential Candidate Jill Stein and Physician Margaret Flowers on how to use the information gained from researchers like Friedman and this site.
Drs. Peter Ubel, Amy Abernethy and Yousuf Zafar, all medical doctors, published an editorial in TheNew England Journal of Medicine entitled “Full Disclosure—Out-of-Pocket Costs as Side Effects.” An abbreviated version by Dr. Ubel appeared as an op-ed in The New York Times as “Doctor, First Tell Me What It Costs.” They argue that, just as doctors typically discuss negative side effects of drugs and medical treatments with their patients, they should also discuss the financial cost of drugs and medical treatments before the patient makes a decision. These costs should be treated as a potential side-effects because stress from the threat of financial ruin can adversely affect the patient's health. They note that cost is sometimes not discussed because both patients and doctors are too embarrassed to bring it up.
Bevacizumab (or Avastin), a drug which extends the lives of colorectal cancer sufferers an average of five months beyond chemotherapy alone, has a median price of $44,000. A patient on Medicare would be responsible for 20% of that cost, or $8800.
A breast cancer patient with a high deductible health insurance policy faces average out-of-pocket costs of $55,000—obviously, more than the life savings of most Americans. A person with a high deductible plan faces a bill of $40,000 for myocardial infarction, and $4,000 per year for management of “uncomplicated” diabetes. (Meanwhile employers are increasingly shifting workers to insurance policies with higher co-payments and deductibles.)
The authors state four reasons it would be beneficial for doctors to inform patients in advance of the cost of treatment. My comments on each are in parentheses.
Informing the patient of the cost of treatment may cause some patients to switch to a less expensive alternative treatment that is just as effective. (Why would a doctor ever recommend a drug or treatment if there is an equally effective and less expensive alternative?)
Some patients may be “willling to trade off some chance of medical benefit” in exchange for lower cost. (This possibility, which the authors refer to as “complex and ethically charged,” gets to the heart of the matter. Some patients may choose to forego treatment rather than leave themselves or their families bankrupt. It is implied that knowing the full cost of treatment may persuade some folks to commit passive suicide.)
Patients could attempt to obtain financial assistance in advance of the treatment. (An example is given of someone who was able to obtain help from a charity—a rare event, at best.)
“A growing body of evidence” suggests that if patients take cost into account, it “might reduce costs for patients and society in the long term.” (However, there is no citation to this body of evidence and the authors do not elaborate. They may mean that if everyone became more cost-conscious, prices might come down, but does the health care industry operate the same way as other more competitive markets?)
It seems so obvious that doctors should discuss costs with patients that it hardly seems necessary for NEJM to publish an editorial suggesting that they do so. But the most revealing thing about this article is the issues Ubel and his colleagues don't even mention.
First of all, they don't ask why the costs of drugs and medical treatment are so much higher in this country than in other industrialized countries. Medical costs are treated as if they were merely an uncontroversial feature of the natural environment, and no mention is made of how they might be reduced.
My colleague Paul Ricci has blogged frequently—for example, here—about how we're spending much more per person on health care than other countries, and getting mediocre results. Ezra Klein has posted 21 graphs with comparative data on the costs of specific drugs and medical treatments. Medical bills account for over 60% of U. S., bankruptcies, and 75% of people with medically-related bankruptcies had health insurance. A 2013 survey of 11 countries by the Commonwealth Fund found that Americans were more likely than residents of the other ten countries to forego health care because of cost and to have difficult paying for care even when they were insured.
There is some objective data comparing the causes of our higher prices. A 2012 study by the Institute of Medicine, a division of the National Academy of Sciences, estimated that the U. S. health care system wastes $750 billion a year, roughly 30% of the money spent. The report identified six major areas of waste: unnecessary services ($210 billion annually), inefficient delivery of care ($130 billion), excess administrative costs ($190 billion), inflated prices ($105 billion), prevention failures ($55 billion), and fraud ($75 billion). Our doctors are more highly compensated than doctors in the rest of the world. Our hospitals attempt to maximize their profits, regardless of whether they are legally registered as for-profit or nonprofit corporations. Part of the problem is political corruption. For example, when Congress expanded Medicare to include prescription drug coverage, Medicare was forbidden to use its purchasing power to negotiate for lower drug prices.
More importantly, the authors don't even question why it is necessary for so many Americans to choose between financial ruin and illness or death when they suffer from common medical conditions. They fail to mention that the rest of the world's developed countries have largely solved this dilemma by establishing government run single payer health care systems. If this were merely a matter of money, we could talk about the vast sums this country wastes on overseas military misadventures, or the way our billionaires grow increasingly rich while paying lower tax rates than their secretaries. But these outrages are irrelevant, since a single payer system will save money. All the countries with single payer spend less per capita on health care than we do.
To be fair, Ubel does say, “No one should have to suffer unnecessarily from the cost of medical care.” But he fails to pursue any of the implications of this remark. The authors never make the point that single payer would almost certainly solve many of the financial problems they agonize over in these articles. I suppose it's possible Ubel and his colleagues are secretly hoping to build momentum for single payer by encouraging doctors to empathize more with their patients, but there's nothing in the article to support this speculation.
To paraphrase a point frequently made by Noam Chomsky, no one becomes a tenured professor at an elite university, or is invited to write an editorial for The New York Times, unless he or she has completely internalized the world view of the ruling class, and in the process learned to ignore all the really important issues facing our society.
The antics of the Affordable Care Act rollout are spoofed in this cartoon by Tom Tomorrow.
There is an alternative to what Democrats and Republicans are proposing. On Tuesday, Nov. 19 Dr. Gerald Friedman will present his economic impact study (EIS) on how a single payer system would be more efficient in providing care and controlling costs for Pennsylvania. An executive summary of his study can be read here and the full can be read here. Below is a video of him discussing his study for the state of Maryland.
Mike Konczal has written an important article in which he asks: (1) What parts the Affordable Care Act (ACA) are not working well, and why?, and (2) What does this imply about future developments in health care policy? Will government abandon the effort to provide health care for all, or will we move toward a single-payer system?
The process of signing up for health insurance in the federal exchange (HealthCare.gov) is complicated because everyone must be means tested. The government must be able to confirm virtually every datum the applicants enter: their identity, their citizenship, their income, their eligibility for coverage through other federal or state programs, etc. All this is necessary to determine whether each applicant is entitled to a subsidy, and if so, the amount.
A further complication is that each applicant must be matched to a private insurer. The government must check that all of the thousands of insurance plans meet their minimum standards. They must clearly communicate the important characteristics of each policy to consumers, even though the insurance companies deliberately try to confuse them. They must contend with insurance company sabotage such as canceling plans abruptly and arbitrarily raising rates.
The ACA faces the threat of adverse selection—the possibility that the oldest and sickest among us will patiently navigate the exchange and eventually purchase a policy, while the youngest and healthiest will ignore the law and hope the penalty for not buying insurance is unenforceable. If Americans in poor health are more likely to buy insurance, the costs go up and there is a very real possibility that the system will collapse.
Finally, the federal government has to deal with attempted sabotage by states controlled by Republican governors and legislatures, exemplified by their refusal to set up state exchanges and to participate in Medicaid expansion, which is denying coverage to over 5 million low income Americans.
Konczal describes Category A as the “neoliberal” approach to public policy. Neoliberalism has, in recent years, become a synonym for conservatism. It refers to policies that reduce the role of government in public life through strategies such as privatization and deregulation. Category A social insurance sees the government as “an enabler to market activities, with perhaps some coordinated charity to individuals most in need.”
Category B, on the other hand, encompasses progressive programs such as the New Deal and the Great Society. It sees certain goods and services, such as food, shelter and health care, as basic human rights, and attempts to remove them from the marketplace by providing them to everyone.
There are very few pure examples of Categories A and B; most policies fall somewhere along a continuum between these extremes. However, the ACA falls clearly into Category A. This is not surprising because it is a plan devised by a conservative think tank which was promoted for decades by the Republican party. Social Security and Medicare, on the other hand, fall into Category B. Medicaid is a hybrid, since it is means tested and administered (and regularly sabotaged) by the states.
In the last three decades, we have seen a gradual rollback of Category B programs. This is not surprising, given the extent to which the political system is controlled by corporations and wealthy individuals. In the old days, the Republicans favored Category A and the Democrats Category B. As both parties have shifted to the right, the Democrats have shifted their allegiance to the Category A policies favored by their corporate donors, while many Republicans advocate eliminating social insurance entirely.
Whenever a public service is privatized, it moves from Category B to A. This is what happens, for example, when you turn over tax dollars to charter schools, so that corporations can make profits by educating children as cheaply as possible. Of course, the ultimate disaster for the country would be the Republican plan to privatize Social Security, since another Great Recession—a virtual certainty in the absence of financial reregulation—would have the potential to impoverish our elderly population.
PA Governor Tom Corbett's proposal to expand Medicaid would move this program further toward Category A through a combination of stricter means testing and turning the program over to private insurance companies. Our President, Dave Steil, has written an op-ed critizing the Corbett plan. He rightly notes the waste of money that would result from turning Medicaid over to private insurance companies. However, he overlooks the hardship that increased means testing, premiums and copayments will impose on working class Pennsylvanians.
Advocates of single payer health insurance—obviously a Category B program—are going to be urinating into a stiff wind for the foreseeable future. However, there is some hope. It is the four Category A characteristics noted above that are turning the ACA into a “kludge.” While Republicans will argue for repeal, pragmatists are likely to notice that if you drop some of these characteristics, you can improve health outcomes while saving money. And if you drop all four, you have single payer.
The Economic “Cents” Behind Single-Payer Health Care Reform
An evening with Dr. Gerald Friedman
Tuesday, November 19th from 7-9 PM
First Unitarian Church of Pittsburgh
605 Morewood Ave.
Pittsburgh, PA 15213
This event is brought to you by Health Care 4 All Pa, The University of
Pittsburgh School of Social Work and the First Unitarian Church of Pittsburgh.
Dr. Friedman earned a PhD in Economics from Harvard University. He is a
Professor of Economics at the University of Massachusetts - Amherst, and the author of “The Pennsylvania Health Care Plan: Impact and Implementation”
Come learn more about:
Key features of the Pennsylvania Health Care Plan
(Established by SB 400, introduced to State Senate by primary sponsor Jim Ferlo)
The findings of Dr. Friedman’s Economic Impact Study
& current developments in health care reform
Please bring your questions!
For more information contact Bob Mason:
bmasona@gmail.com
Or visit healthcare4allpa.org
Stewart bravely brings up single payer. She dodges the question. It's good he brings this up now but he, and the rest of the lamestream media he makes fun of, said little about it while the law was being written.
Here's a 8-minute video by author John Green that repeats some arguments that are familiar to single-payer advocates, but in a very clear and concise way.
The war of words over the Affordable Care Act (aka Obamacare) is heating up once again as the date for implementation approaches in Jan 1, 2014. Some in Congress such as Sen. Ted Cruz R-Tx are openly talking of shutting down the federal government to defund the act. A new inspirational talk on the advagntages of a single payer system has been posted by the Healthy Artists Project by State Sen Jim Ferlo D and can be seen above.
More media coverage to come as a Kaiser Family Foundation poll shows that confusion still reigns among the American Public over the Affordable Care Act on the third anniversary of its passage and Governor Corbett continues to refuse to expand Medicaid of which 78% of the public continues to be unaware. Nationally 52% of the public favors expanding Medicaid which is about the same percentage which favors a stronger health care law. The numbers do differ across party lines.
