Challenging Dogma - Fall 2011

Friday, December 23, 2011

A Critique of the United State’s Approach to Single Payer Financing Based on Advertising Theory – Caitlyn Nystedt


We have a problem. A big problem. We spend more money per capita in this country on health care and have subpar health outcomes to show for it. (10) On average, each American spent approximately $8,000 in 2008, which is astronomically high as compared other developed countries like Germany and the United Kingdom who spent $3,737 and $3,129 per person in 2008 respectively. This is a serious issue, especially in this economic crisis. Our ever expanding health care costs not only are 16% of the Gross Domestic Product (GDP), but also continue to be increasing over time. It is expected by 2015 that health care costs will consume 20% of the GDP. (10) That means for every $1,000 Americans spend, $200 is on health care costs. Or another way of looking at it is that for every $10 spent, $2 is spent on health care costs. Unlike other countries, the United States does not have single payer financing for health care costs like our other fellow developed nations.

Single payer financing is when health care is paid for by one large insurance pool. For example, Medicare is finance by single payer through the Medicare tax in which every employee and employer contributes a percentage of income to the large insurance pool which funds medical care for citizens 65 years of age and older. (4) Another example is the United Kingdom where every citizen pays a tax, which is then collected in a large insurance pool which funds their country’s health care costs through the National Health Service. The difference between every developed country and the United States is that the United States has it’s citizens pay for their health care costs primarily through private insurance companies, mostly through benefit plans from employers. It is this policy approach that has caused the exceedingly high costs of health care in this country. If the United States adopted single payer financing to pay for its health care costs, we would see a dramatic decrease in spending from administrative costs alone. For decades, there has been a push for a centralized single payer financing for health care for every citizen, but such campaigns have failed. They have failed because they often fall back on the Health Belief Model to convince citizens, citizens fall victim to the Small Numbers Theory, and that most, if not all campaigns for single payer financing have failed to address the perceived threat of personal freedom of American citizen have towards single payer financing.

Argument 1:

Campaigns for a universal single payer financing have mostly used the Health Belief Model to try to convince Americans that single payer financing is in their best interest. It is important to mention the nucleus of the model, which is that health and health seeking behavior is motivated by four factors. These four factors are (1) Perceived susceptibility, (2) Perceived severity, (3) perceived benefits of an action, and (4) Perceived barriers to taking that action. To other important components of the model include Cues to Action, where an external event motivates a person to act, and Self-Efficacy, which is a person’s belief that they can take action. (2) The Health Belief Model has been shown to have serious flaws. (1,5) In a study conducted by Ogden found that the Health Belief Model is too unspecific to use, but also practitioners should not use the Health Belief model because they cannot be tested. (5) If a theory cannot be tested, it cannot be proven to be true. In the debate for health care reform, many cite the figures I mentioned above. These numbers are useful, but they do not convince people that it is an issue that directly affects them. Campaigns like “Physicians for National Health Program” and information released by the Kaiser Foundation, follows the Health Belief Model by the logic that Americans are unaware of their perceived threat and perceived seriousness of high health care costs. By using informative cues to action, bulletins and mass media campaigns, that use primarily statistics and financial information regarding the nation as a whole, they are only appealing to the rational not the irrational decision making of humans.

Another flaw of the Health Belief Model use in motivating Americans to take action to direct the United States toward single payer financing is its focus on the individual. This model is wholly devoted to the individual not taking into consideration the influence of group level behavior. It is crucial to incorporate group level behavior models, such as Marketing Theory and Advertising Theory, for a campaign at the national level. A campaign at the national level is what is needed to make a serious attempt to alter the United States’ approach on health care financing and to direct it towards single payer.

Argument 2:

Americans understand that the health care costs are high, but do not see it as something they are affected by. This effect of unrealistic optimism about future health care spending is relatable to the study published by Weinstein in the Journal of Personality and Social Psychology. In his study, he was able to show that people have an optimistic bias about many future life events. The subjects were found to believe that they were more likely to experience positive future life events than their peers, and in contrast, they believed that they were less likely to experience negative future life events than their peers. (11) The important aspect to take from this research is that people tend to count themselves out of the population that is susceptible to unfortunate life events. This unrealistic optimism was also seen in a study conducted by Ayanian and Cleary in the Journal of American Medical Association. This their study they found that most smokers do not view themselves as having an increased risk of cancer even though they are aware of the risks of smoking. (1) This unrealistic optimism can be extended to many life events concerning public health, including events such as going bankrupt due to personal high health care spending, being dropped from your private insurance coverage, having too expensive prescriptions to pay for food, etc. It is these life events that campaigns for single payer financing should focus on with stories, music and visual images that appeal to the irrational side. Using these stories, music and visual images will enable the view to try to place themselves in that situation, making the situations (bankruptcy due to high health care bills, uninsurance, etc.) a real possibility.

Argument 3:

The most pertinent flaw in the campaigns that have been directed towards steering the United States towards single payer financing for health care is that they do not address Americans’ perceived threat of their freedom associated with socialized medicine. In the 1970s, organizations like the American Medical Association with the help of Ronald Regan, created advertisements that directly targeted Americans’ values of freedom and autonomy in regards to their health care. (8) These advertisements along with others put a stigma on the term “socialized medicine” where socialized medicine is seen as a threat to the freedom of choice and autonomy within the American population. Americans are not particularly fond of government involvement. For any campaigned aimed at promoting a single payer finance system for health care in the United States, the campaign must address the stigma that is associated with any form of socialized medicine.

Not only do these campaigns not address the stigma around single payer financing in health care as a treat to their freedom, but they also do not create the large promise needed in great advertising. Like Ogilvy mentions in “Confessions of an Advertising Man,” the promise is the soul of an advertisement. (6) Like most public health campaign, the promise is often over looked and/or overshadowed by statics and facts. What use are the statistics and facts if the promise is not of interest to the target population, or worse if the promise is absent? It is absolutely crucial that the promise is relevant and connected to a strong core value that resonates with everyone.

Proposed Intervention:

In attempt to try to attack the stigma surrounding the single payer financing of our health care system, I would propose launching a mass media campaign with the ultimate goal to begin branding a National Health Program that is financed by a single payer system. We would hopefully be able to partner with an organization such as Physicians for a National Health Program. Such partnership would prove extremely useful in having a key player of the health care system and the most trusted player of the health care system, the physicians.

The campaign would include primarily television and web advertising. This proposed intervention would need to have a very large budget and be able to afford the expensive ad time and ad placement for the highest viewership possible. Like the Truth Campaign, a large budget for mass media marketing will be the most significant factor in a successful campaign. (3) How effective is an advertisement if no one sees it? Instead of using statistics and factual information in a Health Belief Model, we would use Advertising Theory to develop our campaign.

The campaign would strive to follow Advertising Theory by adhering to its three main elements of effective ads, which are Promise, Core Values, and Support. The campaign’s primary promises would include you are not alone, together we can fight the system, and we deserve more. The core values would include togetherness, unity, patriotism, freedom and autonomy.

The Support of the campaign is where the message is seen, heard and felt. Through the use of visual stories, actual stories told and accompanying music, the promise of togetherness and unity through a National Health Program would be conveyed. Television advertisements would have music that is marketable by itself (so it could be the iTunes free song of the day or posted free on the campaign’s website). The music would also have to be selected very carefully making sure it has a matching emotion and feeling to the advertisement so the promise and core values are conveyed.

The visuals of the support would have to include the “everyday” American. These would be people who represent all the demographics from across the nation. Some advertisements wouldn’t need much besides the music and the visual of a chain of good deeds being done, whereas some advertisements would include a story from an “everyday” American about their struggle with the current health care system. One story could be how a family became bankrupt because a family member was diagnosed with cancer and wasn’t covered by his or her insurance. Another story could be how a family member died because of an administrative error. These stories would enable the view to see him or her in these scenarios, which would attempt to avert the unrealistic optimism that the view is not at risk for these types of situations. The campaign would also include series of positive, simple advertisements. The more positive advertisements would include a story of caring for one another. This story wouldn’t necessarily need a person talking, but instead a chair on kind acts that ends at the beginning person. This ad would convey the idea of togetherness and unity. At the end of every commercial there would be the logo of National Health Program and a link to the website.

The campaign could also feature another set of advertisements that would give a strong call to action. Assuming it tested well with focus groups, an advertising campaign that asks the question, “Why is our health care system not working?” could potentially reverse the stigma surrounding socialized health care for its advantage. By focusing on the ways that the consumer is being manipulated by the system, (adverse selection, cherry picking, disparate health care costs for same services, etc.), a call to action could really make a difference in the campaign for single payer system. With the current economic crises, we could use the distrust of Wall Street and the large corporations to our advantage. We could market single payer health care system as a transparent, accountable system that the consumer get’s a say in the rules. The advertisements would look like one person writing a check to the health insurance company, then following that check to the health insurance company where it gets placed in a cart which is then rolled into a closed door meeting with a sign, “Corporate America Only.” Another advertisement would highlight the cruel rules of pre-existing conditions and the benefits of not insuring the sick. These advertisements would emphasize that they are playing a game and losing, they are losing because they don’t get a say in the rules. This would evoke a strong emotion that their freedom and autonomy are being infringed.

It is important to note that all these advertisements would need to be thoroughly tested before focus groups before release. As many have said, the most effective advertisements and brands come from extensive research. It is crucial that we don’t just guess at what might work and send it out to the public without any testing. (6, 3) We need to know our audience; otherwise we won’t know what language to use to be effective at spreading our message.

The advertisements would prompt the viewers to visit the website of the campaign, which would clearly show ways to show support for a single payer health care system. These ways would include firm political supporters of single payer financing, petitions to sign, videos to post on Facebook and Twitter, handouts with short quick information about our system compared to others. Information is a key aspect of any campaign. As Oligvy mentions, give the facts, but do not bore people. (6) We cannot campaign with zero facts or statistics, but we can campaign using them with the best strategy. Using facts that would strike a chord on a personal level would be the most beneficial. For instance, the fact that the average American spent $8,000 on health care in 2008 isn’t very personable. If instead say the average American spent $8,000 in 2008, which means I spent $8,000, your mom spent $8,000, your sister spent $8,000, your best friend spent $8,000, etc. Then follow with a simple question, “Did you get your money’s worth? Did they?” Using the facts in a way that follows the message will be most impactful.


We’ve sure got a problem, and we need change now. Hopefully, there will soon be a campaign like the one mentioned above. Striving for a paradigm shift in the American population on how we view single payer financing for our health care system. It would need an incredible amount of support both financially and administratively. Support for serious change in our health care system would need to come from all key players. These key players include physicians, hospitals, government, communities, employers, employees, and consumers. The shift towards single payer health care system is a group level, a national level, behavior that needs to happen together. The old way in the Health Belief Model concerning just the individual is not effective, especially for a campaign of this nature. By adhering to the basic elements of Advertising Theory, we could create a national campaign that could make a real impact on how Americans view a single payer health care system. This change in perspective could then evoke actions that prompt serious changes in our policies and approaches to our devastatingly high health care spending.


1. Ayanian, J.Z., and Cleary, P. D. “Perceived Risks of Heart Disease and Cancer Among Cigarette Smokers,” JAMA, 281(11) March 17, 1999. pp. 1019-1021.

2. Edberg, M., “Chapter 4: Individual Health Behavior Theories,” Essentials of Health Behavior: Social and Behavioral theory in Public Health, Sudbury, MA: Jones and Bartlett Publishers, 2007. pp. 35-49.

3. Hicks, J. H. “The Strategy Behind Florida’s “Truth” Campaign,” Tobacco Control, Vol. 10, 2001. pp. 3-5.

4. " “ the Official U.S. Government Site for Medicare." “ the Official U.S. Government Site for Medicare. N.p., n.d. Web. 10 Dec. 2011. .

5. Ogden, J., “Some Problems with Social Cognition Models: A pragmatic and Conceptual Analysis,” Health Psychology, 22(4) 2003. pp. 424-252.

6. Oligvy, D. “Chapter 5: How to Build Great Campaigns,” Confessions of an Advertising Man, New York: Atheneum, 1964. pp. 89-103.

7. "Physicians for a National Health Program." Physicians for a National Health Program. N.p., n.d. Web. 10 Dec. 2011. .

8. "Ronald Reagan Speaks Out Against Socialized Medicine - YouTube ." YouTube - Broadcast Yourself. . N.p., n.d. Web. 10 Dec. 2011. .

9. Salazar, M. K., “Comparison of Four Behavioral Theories,” AAOHN Journal, 39(3) March 1991. pp. 128-135.

10. "Snapshots: Health Care Spending in the United States & Selected OECD Countries - Kaiser Family Foundation." The Henry J. Kaiser Family Foundation - Health Policy, Media Resources, Public Health Education & South Africa - Kaiser Family Foundation. N.p., n.d. Web. 10 Dec. 2011. .

11. Weinstein, N. D., "Unrealistic Optimism About Future Life Events, " Journal of Personality an Social Psychology, 39(5) 1980. pp. 806-820.

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