Single payer creates effective response and fallback measures to pandemics.

First, the prevalence of those underlying conditions which exacerbate COVID-19 severity would be reduced via equitable access to care. For example, uninsured adults are significantly more likely than insured adults to be unaware of their hypertension (33, 34), much less likely to be receiving treatment (35), and much less likely to have their hypertension under control (36). Hypertension specifically increases the risk of COVID-19 mortality by 188% (37). Additionally, uninsured women were found to have a higher prevalence of obesity (35), which is another risk factor for severe COVID-19. Diabetes has similarly been associated with significantly increased COVID-19 severity and mortality (38). Uninsured adults with diabetes were half as likely to be aware of their condition as their insured counterparts (39).

Early diagnosis and access to life-saving medical care.

Financial barriers reduce and delay care for COVID-19. Due to apprehension about their ability to pay, 14% of US adults reported that even if they experienced the two most common symptoms of COVID-19, fever and dry cough, they would still avoid seeking care (40). These financial concerns are justified as 18% of the US population had medical debt even prior to the COVID-19 pandemic, collectively totaling $140 billion (41). Medical debt ballooned further during the pandemic as the confluence of lost insurance and lost income makes it more challenging to pay medical bills (42, 43). Removing financial obstacles to care can accelerate diagnosis. More timely medical attention increases the probability of recovery from COVID-19 infection (10, 44). For example, treatment with monoclonal antibodies early during the infection reduced the risk of severe outcomes (hospitalization or death) by 85% (45). Reducing the time to diagnosis also ensures more prompt isolation, which in turn reduces transmission to others.

The Coronavirus Aid, Relief, and Economic Security (CARES) Act subsidizes all testing and medical bills for the uninsured with COVID-19. However, hurdles still exist that may prevent individuals from seeking care. Since this program does not directly offer insurance to patients, uninsured individuals may be unaware that their COVID-19–related medical expenses can be reimbursed, which may prevent them from seeking treatment (46, 47). Furthermore, CARES Act provides financial assistance for only one disease. It is a possibility that people without insurance and seeking medical care for COVID-19 symptoms might be billed for a different diagnosis or other services associated with testing (48).

Geographic inequities in healthcare access have exacerbated case fatality rates in the United States (49). Specific provisions in the Medicare for All 2021 bill to iteratively monitor and address geographic and racial inequity (12) would have particular importance during a pandemic. Rural hospitals are disproportionately reimbursed at the relatively low rates paid by Medicaid (50) and have heavy burdens of uncompensated care (51), which has challenged the survival of rural facilities (52). Although hospital fees nationwide would be reduced by Medicare for All, applying Medicare rates across the board would actually increase support to those rural hospitals which currently serve substantial populations of Medicaid and uninsured patients (53). Furthermore, clinical outcomes such as mortality have been elevated among rural communities during the COVID-19 pandemic (49). Rural hospitals were more prone to shortages of ventilators, personal protective equipment, ICU capacity, and healthcare workers (54). These factors would be rectified by investment to expand healthcare facilities and hospital capacity in rural areas (12).

Facilitation of COVID-19 preventative measures.

COVID-19 mortality rates have been higher and vaccination rates lower among Black and Hispanic individuals relative to White individuals (55, 56). A key driver of these disparities is inequitable access to primary care (57, 58). For example, recommendation of COVID-19 vaccination to patients by their trusted primary care providers is effective in overcoming vaccine hesitancy (59, 60). Consequently, it is unsurprising that individuals without access to a primary care provider have lower rates of vaccine uptake despite it being free to the public. Universal healthcare would ameliorate such inequities, particularly given the provisions for investment to address racial and other disparities.

Alleviating pressure on hospitals during a pandemic.

Beyond COVID-19 outcomes, high hospital caseloads impact non-COVID care and also lead to premature death from non-COVID causes during a pandemic. Removal of cost barriers and alleviation of comorbidities would have reduced not only the risk of COVID-19 death but also hospitalizations, with positive externalities specific to the pandemic context. Particularly during outbreak surges, high demand for COVID-19 hospital services often delayed procedures related to other health conditions. Reduced hospitalization rates facilitated by Medicare for All would have blunted these COVID-19 peaks and thereby freed capacity for non-COVID care.

Fully addressing health disparities requires a multifactorial strategy.

Not all disparities in COVID-19 mortality could have been alleviated by adoption of a single-payer universal healthcare system. Even in countries with single-payer healthcare systems, there can be a steep income gradient associated with COVID-19 outcomes (61). While single-payer healthcare is paramount to addressing health disparities in the United States, the challenge is multifactorial. Pervasive inequities regarding income, education, and housing impact nutrition, mental health, exposure to pollution, and feasibility of accessing healthcare services. Paid sick leave, nutrition programs and affordable housing are among initiatives that are necessary to alleviate disease burdens overall and mitigate systemic gaps in health.

Economic Savings That Could Have Been Realized by Single-Payer Universal Healthcare during the COVID-19 Pandemic.

We calculated the economic savings of a single-payer universal healthcare system in 2020, relative to status quo, by examining two sets of costs: medical costs unrelated to COVID-19 and those attributable to the treatment of COVID-19.

National healthcare costs unrelated to COVID-19.

Per capita healthcare spending in the United States increased from US$10,682 in 2017 to $11,582 in 2019 (62). We previously calculated that a single-payer universal healthcare system would have saved $458 billion in 2017 (3). There are several factors driving these savings. Streamlined administration, negotiated pharmaceutical prices, and application of the Medicare fee schedule throughout the healthcare system are major reforms that would achieve substantial reductions in national medical costs (SI Appendix). Combined, the savings from these mechanisms more than compensate for the expanded utilization when coverage is extended to the entire population (SI Appendix).

Taking into account shifts in demography, healthcare utilization, and coverage composition, we updated our previous analysis and found that single-payer universal healthcare would have saved $438 billion in 2019. A key factor driving the slight reduction in savings compared to 2017 is the increase in the number of Americans who are underinsured from 41 million (63) to 45 million (13). In our analysis, we take into account that these individuals would likely have expanded utilization once provided with full healthcare coverage (64). Given the small difference in savings between 2017 and 2019, we anticipate that 2020 savings would have been similar in the absence of the COVID-19 pandemic.

National healthcare costs related to COVID-19.

Hospitalization and healthcare fees attributable to cases of COVID-19 are much higher under the current system than would have been incurred under Medicare for All. In general, Medicare charges are 22% lower than those charged by private insurance for the same services (65). However, the discrepancy is even greater for COVID-19 in particular. Private insurers paid more than double the Medicare rate for a hospitalized COVID-19 case (66, 67).

To calculate the national expense associated with COVID-19 hospitalizations, we used the estimated cost of COVID-19 hospitalization with or without a ventilator stratified by whether the patient was insured and, if so, their type of insurance (67). While the average Medicare and Medicaid costs for a COVID-19 hospitalization that requires mechanical ventilation were $57,822 and $47,396, respectively, the average charge to private insurance was $114,842. Charges for hospitalizations that did not require ventilation were lower but showed a similar pattern across insurance types (SI Appendix, Table S5). We combined the age distribution of 11,832,077 [95% uncertainty interval (UI): (10,586,595, 13,077,559)] estimated hospitalizations through 12 March 2022 (68, 69) (SI Appendix), age-specific insurance coverage by type, and age-specific probability of ventilation given hospitalization to estimate the proportion of hospitalizations in each age group that were reimbursed at each different cost level (SI Appendix, Table S5). Since ratification of the CARES Act, the Federal Government has been reimbursing hospitals for the care of uninsured COVID-19 patients at Medicare rates. Therefore, we applied Medicare rates for uninsured individuals who were hospitalized. We calculated that the expense of COVID-19 hospitalization has totaled $365.8 [95% UI: (327.3, 404.3)] billion, of which $141.2 [95% UI: (126.3, 156.1)] billion occurred in 2020. If the Medicare rate had been applied to all hospitalizations, $105.6 [95% UI: (94.5, 116.7)] billion would have been saved during the pandemic thus far and $39.4 [95% UI: (35.2, 43.5)] billion in 2020.

Consolidating the expected general savings from a transition to Medicare for All with savings specific to COVID-19, single-payer universal healthcare could have cost $459 billion less in 2020 than our current system. These savings would alleviate the burden on employers and individuals to cover insurance premiums, copays, and deductibles. Since Medicare for All would achieve savings overall, the tax revenue needed to fund Medicare for All would be significantly lower than the healthcare premiums that are currently paid by employers and households.

The Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 provided a mechanism by which individuals who become unemployed may temporarily retain healthcare insurance for themselves and their families. However, the unemployed individuals must shoulder the entire premium payments, including the proportion that was previously paid by their former employer, which on average is $21,342 annually for family coverage (70). Due to a 2% COBRA administrative fee, the premiums paid by the unemployed worker are actually higher than that paid when they were employed. The American Rescue Plan of 2021 included subsidies to cover COBRA premiums for individuals who lost employment during the pandemic. While essential to relieve household financial strain due to prolonged reliance on COBRA, an estimated $57 billion in subsidies will ultimately flow to insurers (71). In 2020, many of these companies made multibillion-dollar second quarter profits, double the amount for the previous nonpandemic year (72). Under a universal single-payer system, the recently unemployed keep their coverage, and the taxpayer is not subsidizing these profits.

COVID-19 can also have long-term health and economic consequences. Among survivors of COVID-19, there can be substantial and often long-term morbidity (73). The debilitating symptoms of long COVID can include pulmonary and cardiovascular disorders, mental health impairments, neurologic symptoms, and functional mobility impairments (73). The cost of treatment for these symptoms is substantial (74). Uninsured individuals, including many whose unemployment was precipitated by the pandemic, would have to bear the full cost of these treatments. Further, long COVID may affect the ability to work, potentially reducing income or leading to insurance loss (75). As with acute COVID, affordability may be a deterrent to seeking needed care for long COVID, particularly for low-income families (75). By curtailing the spread of COVID-19, Medicare for All would also have reduced the incidence of long COVID. Additionally, medical expenses associated with long COVID would be lower under a more efficient healthcare system and covered for the patient regardless of employment status.

Medicare for All as Pandemic Preparedness.

The COVID-19 outbreak has underscored the societal vulnerabilities that arise from the fragmented healthcare system in the United States. Universal healthcare coverage decoupled from employment and disconnected from profit motivations would have stood the country in better stead against a pandemic. Emergence of virulent pathogens is becoming more frequent, driven by climate change and other global forces (76). Universal single-payer healthcare is fundamental to pandemic preparedness. We determined that such a system could have saved 211,897 lives in 2020 alone. Strikingly, it would have done so at lower cost than the current healthcare system, saving the US $459 billion in 2020 at a time of economic tumult. To facilitate recovery from the ongoing crisis and bolster pandemic preparedness, as well as safeguard well-being and prosperity more broadly, now is the time to transition to a healthcare system that can better serve the American people.