There’s plenty of blame to go around for the poor US performance during the Covid-19 pandemic, from the highly contagious virus itself to the Trump administration’s slow response to deep fissures in US politics and culture. But a new study from a group of scholars at Yale and UMass-Amherst says the US had more deaths per capita than most economic peers due to something more specific: the lack of universal health care.

According to that paper, published this month in PNAS, at least 212,000 fewer Americans would have died of Covid-19 in 2020 alone if the US had a single-payer health care system similar to the Medicare-for-all plan proposed by Sen. Bernie Sanders (I-VT). The country would have also saved $105 billion in pandemic-related health care costs.

The researchers ticked through different factors that would have reduced the number of Covid-19 fatalities under a system in which the government insures everyone and pays almost all of their health care costs:

• Nobody would have lost health insurance as a result of job loss from the pandemic’s shock to the economy. (The study estimates about 14.5 million Americans lost employer-based coverage in March and April of 2020, though some of those people would end up being covered by Medicaid.) Research has repeatedly shown being uninsured leads to patients delaying health care and worse health outcomes. More insured people would have meant more cases being diagnosed and getting treated sooner, reducing the likelihood of severe disease or death.
• Vaccination rates would likely have been higher — and therefore there would have been fewer severe cases and deaths — if more Americans had a relationship with a primary care doctor, which one in four people in the US don’t.
• And by reducing the number of Covid-19 hospitalizations through more vaccinations and earlier diagnoses, US hospitals would have come under less strain. That would have made it easier for them to manage all of their patients, rather than the situation last summer — after vaccines were widely available — when people showed up at hospitals with no room or staff to treat them. Some of those people died.

The logic of the paper’s conclusions makes sense. I wrote in the thick of the spring 2020 surge that all of the fractured American health system’s problems were being fully exposed by a failure to adequately respond to Covid-19. And if you take a look at countries that have universal health care systems — the UK, Taiwan, Australia, and the Netherlands, countries we covered in our Everybody Covered series on universal health care, plus France and Germany — they have experienced fewer deaths per capita than the US has.

Our World In Data

All of these countries do have universal health care, but they do not all have a single-payer system in the vein of Sanders’s Medicare-for-all proposal. Taiwan does. But Australia utilizes a hybrid program where some people depend on public health insurance and other people use private plans. The Netherlands and Germany rely on private health insurance, heavily regulated and subsidized by the government. The UK’s National Health Service goes beyond single-payer and is fully socialized: The government not only pays for care for everyone but also runs hospitals and employs doctors directly.

Countries with universal health care did outperform the US during the pandemic — that part of the paper’s conclusion appears beyond dispute. But they have deployed different programs to achieve that goal. It’s not clear to me that Medicare-for-all would necessarily lead to better outcomes than, say, a system modeled on the Australian or Dutch approach.

Other factors might be in play beyond the specific type of health care system. As Damien Cave wrote for the New York Times in Australia, social trust seems to have been a decisive difference between the American and Australian experiences during the pandemic. The two nations share a lot of sociocultural DNA, but Aussies have much deeper trust in people in general, and their health care system specifically, than Americans do, Cave wrote. When I was reporting on South Korea’s successful Covid-19 response, Korean sources pointed in part to people there having a generally high level of trust in the government.

This also makes some intuitive sense. It follows that people in societies with more trust would be more likely to wear masks or stay home or get vaccinated not only for their own benefit but for the health of the people around them and society at large.

In a way, social trust and universal health care come down to the same thing: a society’s willingness to come together and take care of one another. The US does not have the same culture of collective responsibility that these other wealthy nations do. That lack of social cohesion is reflected both in failures to adhere to public health measures and the failure to build a health care system that takes care of everyone.

Universal health care is a choice, a reflection of a country’s values. When reporting the Everybody Covered series, I found this quote from Princeton health care economist Uwe Reinhardt. It was in his most recent book Priced Out, which was published after he died in 2017:

Canada and virtually all European and Asian developed nations have reached, decades ago, a political consensus to treat health care as a social good.

By contrast, we in the United States have never reached a politically dominant consensus on the issue.

While traveling in Taiwan or the Netherlands, people would ask me about US health care and I would have to tell them that millions of Americans were uninsured and that people could be charged thousands of dollars for medical care. That was unfathomable to the people I met. They lived in a country where people agreed such things should never be allowed to happen.

America has never made that collective commitment to providing everyone with health care. The country paid the price for that shortsightedness during the pandemic, as this new study helps demonstrate. Whatever form it took, a universal health system would have likely prevented tens of thousands of deaths from the novel coronavirus.

Now it’s too late.