American Journal of Health Education

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Debunking Myths Impeding Health Care Reform

Thomas O’Rourke & Nicholas Iammarino

To cite this article: Thomas O’Rourke & Nicholas Iammarino (2020) Debunking Myths
Impeding Health Care Reform, American Journal of Health Education, 51:3, 135-141, DOI:
10.1080/19325037.2020.1740121

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AMERICAN JOURNAL OF HEALTH EDUCATION
2020, VOL. 51, NO. 3, 135–141
https://doi.org/10.1080/19325037.2020.1740121

COMMENTARY

Debunking Myths Impeding Health Care Reform

Thomas O’Rourkea and Nicholas Iammarinob
a
University of Illinois at Urbana-Champaign; bRice University

ABSTRACT ARTICLE HISTORY

Health care reform tops the list of issues that voters consider important going into the 2020 elections. As Received 22 January 2020
health professionals, it is imperative that we not only become informed about this issue but also help Accepted 14 February 2020
shape our healthcare future. Based on a review of the health service and health policy literature, we
address several myths that add to the confusion regarding the public debate on health care reform. This
Commentary does not advocate for any specific reform proposal but identifies and debunks several
commonly mentioned myths. Public understanding of these myths is essential as the health care reform
debate continues to evolve. We also suggest several ways for health educators and professionals to
engage actively in this dialogue as part of our professional responsibility. Translating health care reform
into health education practice is consistent with the Code of Ethics for the Health Education profession
that provides a framework of shared values within which Health Education is practiced. Including health
care reform into health education practice also is consistent with several areas included in the
Responsibilities and Competencies for Certified Health Education Specialists.
A AJHE Self-Study quiz is online for this article via the SHAPE America Online Institute (SAOI)
http://portal.shapeamerica.org/trn-Webinars

Background largely been obscure, researched, and debated primarily

Who among us would argue that improving health is funda-
mental to human happiness and well-being? Optimal health
also has been linked to important contributions to economic
progress, since healthy populations live longer and are thus
more productive citizens. Countless factors influence health
status and a country’s ability to provide quality health services
for its people. Likewise, major chronic diseases and illnesses
such as cardiovascular disease, cancer, diabetes, cirrhosis,
Alzheimer’s/dementia, etc. are recognized as major public
health challenges today. Chronic diseases are broadly defined
as conditions that last one year or more and require ongoing
medical attention and/or limit activities of daily living or both.1
Chronic diseases such as heart disease, cancer and diabetes are
the leading causes of death and disability in the US. They are
also leading drivers of the nation’s $3.5 trillion in annual
healthcare costs in 2017.2 In 2014, 60 percent of Americans
had at least one chronic condition, and 42 percent had multi-
ple chronic conditions.3 Ninety percent of the nation’s annual
health expenditures are for people with chronic and mental
health conditions.
Brought about by demographic, technological, social,
cultural, economic and political factors, all healthcare
systems are continually confronting issues related to
cost, access and quality. In years past, public discussion
of healthcare and its related system of delivery has
by those in the health arena and has remained outside
the mainstream public debate. However, increasingly
individual citizens find themselves losing their health
coverage, forced to change their providers when their
employers change plans, see annual skyrocketing costs
in their premiums while receiving less in benefits, and
an increasing number of individuals and families hav-
ing to file for medical bankruptcy. Not surprisingly,
a healthcare overhaul or a replacement has become
center stage in both the public and politician’s eyes.
This is further aggravated by a recent decline in U.S life
expectancy. In contrast to most of the past 60 years
where life expectancy rates in the United States have
been increasing, a recent study found that U.S. life
expectancy rates decreased for three years in a row
after 2014. The main cause appears to be higher rates
of death among middle-aged Americans due to drug
overdoses, alcohol abuse, suicides, and organ system
diseases such as diabetes.4 Indeed, our life expectancy
compared to France, Canada, and the United Kingdom
has tapered off and lags behind these countries.5
Suddenly, health care reform has emerged as a major
debate topic among politicians vying for our vote. Among
a growing number of proposals, single-payer and Medicare
for All proposals have achieved center stage and are being

CONTACT Thomas O’Rourke torourke@illinois.edu University of Illinois at Urbana-Champaign, 1206 South Fourth Street, Rm. 129, Huff Hall,
Champaign, IL 61820
© 2020 SHAPE America
136 T. O’ROURKE AND N. IAMMARINO
debated across multiple platforms. While historically
Americans have consistently expressed that the U.S. health
care system needs improvement, they are also fearful of
something new, change, or what they do not know. Not
surprisingly, despite a majority of Americans supporting
universal access, opponents have been quick to suggest
a myriad of reasons why such a plan would not be feasible
and would ultimately fail. These include being too expen-
sive, a cultural aversion to big government (although the
85 year old Social Security and 55 year old Medicare remain
very popular), and an emphasis on individual versus collec-
tive responsibility. Other reasons are viewing health care as
a private privilege rather than a public good, concern that
such a plan would limit patient choice of health care cover-
age and access, as well as the absence of political will and
opposition from the health care industry. As health
professionals, regardless of our particular research interests
and whether we work in business/industry, school/univer-
sity, or community settings, it is imperative that we not only
become informed of these issues, but that we also help shape
our healthcare future. There are a number of misconcep-
tions or “myths” that extend beyond the general public and
are sometimes mentioned even among our own ranks.
Myths, widely held but false beliefs or ideas, are ubiquitous.
Examples abound including lightning never strikes the same
place twice or that a penny dropped from the empire state
building can kill a person on the sidewalk. Based on a careful
review of the health service and health policy research
literature, we have chosen several myths that often appear
in the mainstream media that add to the confusion regard-
ing the public debate on health care reform.
This Commentary does not advocate for any specific
reform proposal but identifies and debunks several
commonly mentioned myths. Public understanding of
these myths is essential as the health care reform debate
continues to evolve. We also suggest several ways and
opportunities for health educators and professionals to
engage actively in this dialogue as we see this as part of
our professional responsibility.
Myth #1 – The U.S. has the best health care
system in the world
A frequently mentioned myth is the U.S. has the best
healthcare system in the world. Closer analysis does not
support this contention. To the contrary, abundant evi-
dence exists that it is far from the best. Based on an analysis
of 72 indicators that measure performance in five domains
important to policymakers, providers, patients, and the
public (Care Process, Access, Administrative Efficiency,
Equity, and Health Care Outcomes), the Commonwealth
Fund found that the U.S. ranked last among 11 similarly
wealthy industrialized countries on performance overall.6 It
ranked last or near last on the Access, Administrative
Efficiency, Equity, and Health Care Outcomes domains.
Based on this broad range of indicators, the
Commonwealth Fund concluded that the U.S. health sys-
tem is an outlier in two important aspects. While the
U.S. spends more than other nations, it falls short of the
performance achieved by other high-income countries. In
terms of health outcomes as infant mortality and longevity,
Bezruchka summed it up perfectly by saying that if the
United States were in the Health Olympics we would be
eliminated in the early heats and not get to the finals in any
event much less to the medal podium.7
Also of concern is that while the U.S. lags behind
most developed countries on most health indices over
the past half century, while most of our health statistics
improved, our relative ranking has worsened.8 Data
from the Organization for Economic Cooperation and
Development (OECD), and international organization
of 36 member countries working with more than 70
nonmember economies to promote economic growth,
prosperity, and sustainable development, show that the
United States ranks poorly on most standard measures
of health status. For example, the U.S. ranks below
OECD member country average in longevity and infant
mortality including (as well below) countries like
Portugal, Greece and Slovenia.9
Additionally, after improving for several decades,
U.S. longevity has worsened in recent years for some
populations, as chronic diseases and mental illness affect
more and more people. Causes are multifaceted. Rising
levels of obesity and diabetes have made it difficult to
maintain previous progress in cutting deaths from heart
disease and stroke. This decreased longevity for whites
was largely accounted for by increasing death rates from
drug and alcohol poisonings, suicide, and chronic liver
diseases and cirrhosis. Furthermore, the opioid crisis has
caused more working-age adults to die from drug-
related accidental poisoning.10 Many of these challenges
where the U.S. falls short could be alleviated by delivery
of timely and accessible health care services.11,12 Among
many factors contributing to this are poor access to
primary care contributing to inadequate prevention
and management of chronic diseases.
These finding are of particular concern given that the
U.S. is an outlier, spending considerably more on health
care than any other country, whether measured per capita
or as a percentage of GDP. In 2018, the OECD reported
U.S per capita spending at $10,586 while the average for
wealthy OECD countries, excluding the United States,
was only $5,300. While the U.S. spent 16.9% of GDP on
healthcare, the average for wealthy OECD countries was
less than 11%.9 A recent 2020 study published in the
Annals of Internal Medicine found U.S. insurers and

providers spent $812 billion on administration, amount-
ing to 2497 USD per capita (34.2% of national health
expenditures) versus $551 per capita (17.0%) in Canada
or more than a fourfold disparity in dollars per capita. The
study estimated that cutting U.S. administrative costs to
Canadian single payer levels would have saved more than
$600 billion in 2017 and amount that could be used to
cover America’s 30 million uninsured and eliminate
copayments and deductibles for everyone.13
There is no evidence to suggest that our higher health
care expenditures are linked to either better outcomes or
health status. These differences become especially note-
worthy when most measures of U.S. utilization such as
physician visits per capita and hospital days per capita
were below the OECD median. This has led to the con-
clusion that spending differences are not due to a greater
quantity of medical services rendered but rather the prices
paid for each unit of care provided.14,15
Interestingly, the Commonwealth Fund study noted
the three countries with the best overall health system
performance scores (United Kingdom, Australia and the
Netherlands) had strikingly different health care systems.
In distinct and different ways all provided universal cov-
erage and access leading the Commonwealth Fund to
suggest that high performance can be achieved through
a variety of payment and organizational approaches.6
In addition, public opinion does not support the myth
that the U.S. has the best health care system. While
surveys clearly show that people like their health care
provider, they are far less enamored with the system. In
response to the question, “Which of the statements do
you think best describes the U.S. health care system
today- it is in a state of crisis, it has major problems, it
has minor problems, (or) it does not have any pro-
blems?”, 70% of Americans describe the current
U.S. healthcare system as being “in a state of crisis” or
having “major problems.” This is consistent with the 65%
to 73% range for this figure in all but one poll since
Gallup first asked the question in 1994.16
Similarly, another Commonwealth Fund Survey found
more than seven of 10 adults believe the U.S. health
system is not serving the public well, with a large majority
of adults saying it needs to be fundamentally changed or
completely rebuilt. Most adults surveyed reported diffi-
culties accessing care, poor care coordination and strug-
gles with the costs and administrative hassles of health
insurance. The survey also found substantial evidence of
inefficient and wasteful delivery of health services.17
Blendon18 reported that a majority of survey respondents
rated the nation’s health care system as “fair” (30%) or
“poor” (39%) while only 4% of respondents rating the
health care system as excellent. In addition, with respect
to the state of the health care system, a majority of
DEBUNKING MYTHS IMPEDING HEALTH CARE REFORM 137
respondents (51%) reported the system as having “major
problems” while only 4% said “no problems.”
Myth #2 – National health insurance, universal
access or “medicare for all” implies or requires
government ownership and operation of the
health care system
Any mention of health care reform including national
health insurance, universal access or “Medicare For All”
is often accompanied by the claim or warning of govern-
ment ownership and operation of the system. Often this
claim is accompanied by the decades old phrase of
“socialized medicine.” This myth is not new. It goes back
more than sixty years when on November 19, 1945,
President Truman, in a Special Message to the Congress
Recommending a Comprehensive Health Program,
brought forth a proposal for national health insurance.
Anticipating strong opposition, he emphasized that his
proposal was only a financing mechanism and the delivery
of health care by physicians, hospitals and other health
professionals would remain in the private sector.
Anticipating opposition, he stressed that, “Socialized med-
icine means that all doctors work as employees of govern-
ment. The American people want no such system. No
such system is here proposed.”19 However, in strong oppo-
sition, the then president of the American Medical
Association, Dr. Morris Fishbein, refuted, “This is the
first step toward the regimentation of utilities, of industry,
of finance, and eventually of labor itself. This is the kind of
regimentation that led to totalitarianism in Germany and
the downfall of that nation … no one will ever convince
the physicians of America that the … bill is not socialized
medicine.”20 Similar scenarios played out before Medicare
was passed in 1965 and with current proposals for uni-
versal access and Medicare for All.
The myth is based on a misunderstanding of terms
such as universal health coverage, national health insur-
ance and “socialized” medicine. The World Health
Organization defines universal health coverage “as
ensuring that all people have access to needed health
services (including prevention, promotion, treatment,
rehabilitation and palliation) of sufficient quality to be
effective while also ensuring that the use of these ser-
vices does not expose the user to financial hardship.”21
Universal health coverage can be achieved in many
ways.22,23 It can be administered by the public or pri-
vate sector or a combination of both. It does not
require government ownership or operation. Similarly,
to accomplish universal access most industrial nations
have a national health insurance (NHI) system that
insures a nation’s population against the costs of health
care. NHI is a financing mechanism for providing care.
138 T. O’ROURKE AND N. IAMMARINO
Provision of services remains largely a private sector
function. Far less common are examples of “socialized”
medicine such as the British National Health Service or
the U.S. Veterans Administration where the govern-
ment owns and operates the health care system and
employs the health care professionals.
While the U.S. is an outlier as the only industrialized
nation without universal access, although having the high-
est costs, most industrial nations incorporate some form
of national health insurance covering the entire popula-
tion while restraining growth in healthcare expenditures
within the parameter of a mixed private/public delivery
system. Examples include Germany, Japan and France. In
each country health care is largely privately delivered. In
terms of similarities with the U.S., most citizens of these
countries receive their healthcare coverage through the
workplace, most physician services are provided by pri-
vate practice practitioners paid on a fee-for service (not
salaried) basis and use private insurers. However, there are
major differences between these countries and the U.S.
While each country has its differences in financing and
organization, each provides universal access, a basic ben-
efit package to all citizens and a uniform payment to
physicians and hospitals. Furthermore, the government,
although neither owning nor operating the system, plays
a significant role in mandating coverage and restraining
the growth of healthcare expenditures by healthcare pro-
viders, by imposing controls on prices for professional
services, drugs, and devices. Similarly, in Canada, which
has a public single-payer national health insurance
financed system, physicians are not government employ-
ees. Rather, like the U.S., most physicians run their own
practices, are not salaried but paid as fee-for-service.
Provinces and territories in Canada have primary respon-
sibility for organizing and delivering health services and
supervising providers. To contain costs, provincial
governments negotiate fees with provincial medical asso-
ciations. Most hospitals are private and the government
uses global (annual) budgeting to contain hospital
expenditures. Thus, the notion that universal access and
cost-control require government ownership and opera-
tion is not supported. These countries demonstrate that
universal access and cost-control can occur in a private/
public delivery system arrangement although the govern-
ment provides a more important and powerful role than
in the U.S. A common denominator is that each country
provides universal access at significantly less cost and
better outcomes.
Importantly, and consistent with this observation, is
that no current health care reform proposal for uni-
versal access or Medicare for All national health insur-
ance includes government ownership and operation.
Rather, they include some form of public financing
within a private delivery system. Besides increasing
access, if reform followed other countries examples,
they could reduce costs by decreasing complexity, con-
solidating administrative tasks and leveraging purchas-
ing power to exert cost controls that currently do not
exist.
Myth 3 – “healthcare reform lacks the broader
public support by most Americans”
In one of his commentaries in The New York Times
back in 2009, columnist Paul Krugman, a recipient of
the Nobel Prize in Economics, recounted the incident
whereby a man stood up at a town hall meeting of his
local congressman and exclaimed, “keep your govern-
ment hands off my Medicare.” The congressman tried
to explain that Medicare is already a government pro-
gram – but the voter wasn’t having any of it.24
To some this may seem amusing but illuminates the
degree to which health reformers must do battle with
the constant barrage of misinformation. Ten years
hence, and with a new Administration in office, this
misinformation and confusion regarding healthcare
reform, universal coverage and now Medicare for All
proposals is perhaps even more perplexing and confus-
ing to many. This problem is not just that many
Americans do not understand what is being proposed
(back then as it is now); many are not adequately
informed of the way our American healthcare works.
Yet, any number of public opinion polls tell a slightly
different story. While Americans may not understand
the complexities of our current system, there is wide-
spread agreement that changing and reforming it is
both necessary and important to them.
For over 20 years, the Kaiser Family Foundation has
been tracking public opinion on the idea of a national
health plan including language referring to Medicare for
All since 2017. Historically, these regular ongoing polls
have shown a steady rising support for the federal gov-
ernment doing more to help provide health insurance
for more Americans. However, until 2016 this support
had not yet reached the level whereby a majority support
a national health plan in which all Americans would get
their insurance from a single government plan.25
A 2019 telephone survey (including cell phones and
landlines) assessing Americans’ values on private health
insurance and beliefs about national health insurance
reform was conducted for the Commonwealth Fund,
the New York Times, and Harvard University.26 Using
a nationally representative, probability-based sample of
2,005 randomly selected adults, ages 18 and older, it
found that, regardless of their preferences for health
insurance reform, a majority (79%) of the public

believed “All Americans have a right to health care
regardless of their ability to pay.” The survey also
found that about three-quarters of adults (73%) who
favor Medicare-for-all and a majority of adults (55%)
who favor improving the existing Affordable Care Act
(ACA) say they prefer a “Health insurance system run
mostly by the government” over a “Health system based
mostly on private health insurance.” In another survey,
Gallup also asked those who favor either keeping the
ACA in place or replacing it with a federally funded
system to choose between these two options. The feder-
ally funded system won among this group by a 2-to-1
ratio.27
Reflecting a gradual but steady shift in thinking over
the years, more and more U.S. physicians support
national health insurance. A 2008 survey of physicians
by Merritt Hawkins, a physician search firm, found that
58 percent opposed a single payer system while 42 percent
supported it.28 In 2017, that same firm again surveyed
physicians and found that 56 percent now strongly or
somewhat supported a single payer system while 35 per-
cent opposed it.28 Indeed support for national health
insurance single payer plan has grown steadily over recent
years with hundreds of labor,29 civic and faith-based
organizations endorsing strong reform measures.30
More recently, on January 2020 the American College of
Physicians (ACP), the largest medical specialty society
and second-largest physician group in the U.S. after the
American Medical Association (AMA), endorsed two
proposals to achieve universal coverage and access to the
care people need, at a cost they and the country can
afford. Characterizing the nation’s existing health care
system as “inefficient, unaffordable, unsustainable, and
inaccessible to many”, the two options supported by the
ACP were a single-payer financing approach, or a publicly
financed coverage option to be offered along with regu-
lated private insurance. Thus, the idea that healthcare
reform lacks public support by most Americans is not
supported.31
Translation to Health Education Practice
Our aim is to provide the rationale and concrete ways
for health educators and professionals to include health
care reform as part of their practice. While there is no
shortage of health care reform proposals, there is no
intent to identify or endorse any specific proposal.
Rather, given the extent of conflicting claims and mis-
information, the intent of this commentary is to
debunk myths impeding health care reform thereby
enabling the public to evaluate health reform proposals
and arrive at an informed decision
DEBUNKING MYTHS IMPEDING HEALTH CARE REFORM 139
Translating health care reform into health education
practice is consistent with the Code of Ethics for the
Health Education profession that provides a framework of
shared values within which Health Education is practiced.32
Article 1 of the Code addresses Responsibility to the Public.
“A Health Educator’s ultimate responsibility is to educate
people for the purpose of promoting, maintaining, and
improving individual, family, and community health.”
More specifically, Section 4 of that article states, “Health
educators accept the responsibility to act on issues that can
adversely affect the health of individuals, families, and
communities.”
Furthermore, including health care reform into health
education practice is consistent with several areas
included in the Responsibilities and Competencies for
Certified Health Education Specialists.33 The seven areas
of Responsibilities along with their Competencies and
Sub-competencies provide a comprehensive description
of the profession. Specifically, involvement of health
educators in efforts at informing and influencing health
care reform is consistent with Area VII: Communicate,
Promote, and Advocate for Health, Health Education/
Promotion, and the Profession. Competencies under this
include engaging in advocacy for health and engaging
stakeholders in advocacy initiatives.
How might the above be integrated into practice?
Several possibilities are provided. These examples are
only suggestive, certainly are not exhaustive and impor-
tantly, need to be adapted and personalized to your
unique locale.
(1) Use your expertise in organizing and commu-
nicating by working with existing community
agencies and organizations already involved
with health care issues.
(2) Work with other civic, labor, faith and profes-
sional organizations to promote awareness, inter-
est and involvement with health care issues and
policies at local, state or national levels.
(3) Inform the public about current health care
reform efforts and encourage their involvement
in efforts at reform. This can be accomplished in
many ways including public speaking, organizing
a public meeting, or participating in events invol-
ving community agencies and organizations.
(4) Use opportunities provided by local media to
inform the public on health care reform issues
including misconceptions and myths. This can
be done either in the role as health educator
and/or as a citizen. This could include Letters
to the Editor or, better yet as the authors have
done, write an Op-Ed or Commentary that
provides an expanded opportunity to educate
140 T. O’ROURKE AND N. IAMMARINO
the public. Other possibilities include appear-
ance on a local radio or TV public affairs news
segment. Given its ubiquitous presence and
importance, initiate a social media presence
using vehicles such as Facebook, Instagram,
Twitter, Tumblr, and Snapchat or participate
in existing blogs dealing with health care issues.
As health educators, many of us are respected leaders in
our local communities. Many likely sit on local boards
that span a broad range of organizations. We encourage
using these opportunities to speak to, and educate, our
“neighbors” about the need for health care reform while
debunking myths impeding change.
Summary and conclusions
Obstacles to healthcare reform are multiple and include
political, economic, institutional and organizational fac-
tors. However, more insidious are the “myths”, often
heard from opponents of reform supportive of the status
quo that are ingrained in the debate over health care
reform. Many of these myths are repeated and perpetu-
ated in the mass media and become generally accepted by
large segments of the public even though unsupported by
empirical data from the health policy community. Issues
of health care availability, access, cost, affordability and
quality affect all of us personally and as a society.
Dispelling these myths should enable and promote
a more cogent discussion by all parties of the myriad of
important health care issues and reform proposals.
Perhaps Winston Churchill was correct when he said,
“You can always count on Americans to do the right
thing – after they have tried everything else.”
Disclosure statement
No potential conflict of interest was reported by the authors.
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