The United States has just passed a grim milestone of 800,000 official deaths from Covid-19, more than in any other country, with the actual death toll likely much higher. As the nation has faced over 100 days in which more than 1,000 people have died and now faces the prospect of a more infectious variant that may weaken vaccine efficacy, it must be asked: How exactly did the richest country in the world get here? There are a number of reasons, but the primary one is that the United States does not have a free, universal health care system. The lack of a national health insurance program affects everything from vaccine hesitancy to the ability to get a test to how we manage the virus going forward.

In the US, we are so accustomed to paying out of pocket for essential health care that when it is provided for free, it is a foreign concept. A significant barrier to vaccination is that some people think they will be charged for it. That could be one of the reasons uninsured people are among those with the lowest rates of vaccination, with 56 percent reporting having received one dose in the latest survey conducted by Kaiser Health News, a lower percentage than Republicans and white evangelicals. The fear of having to pay for a service that is being offered for free isn’t irrational; thanks to loopholes in federal regulations, some people have ended up being mistakenly charged for the vaccine. This has also been the case with testing. While many cities offer free PCR testing, it is not universally free. A number of people have received massive bills after being tested at privately run labs. Pre-pandemic, a study found that 22 percent of Americans delay health care needs because of costs; they might avoid testing and vaccines for the same reason.

Cost and lack of access erode trust. In the US, while trust in the medical establishment is low, the trust individuals have in their primary care physicians is high. A CDC survey of unvaccinated adults from the summer showed that those who were unsure or were never going to get the vaccine reported that their primary care providers were their most trusted source of information. But the share of Americans with primary care physicians has been declining in recent years, and the US spends a lot less on primary care than other countries. Indeed, a significant number of Americans get their health care from the emergency room; one study found that nearly 50 percent of medical care sought at hospitals was emergency-room care.

All of this matters not just for vaccine uptake but for how we manage Covid in the future. There has been a lot of progress in the development of antiviral therapeutics that reduce the risk of hospitalization after infection; Pfizer and Merck have put out promising drugs. But for these drugs to be effective, treatment must begin soon after a person is infected, which means patients need early access to testing and a doctor who can prescribe them. For immunocompromised patients, the FDA has approved a routine antibody treatment from AstraZeneca, but once again cost and access are critical issues. That means that even after Covid has become endemic, we will likely continue to see disparities in disease and death along racial and socioeconomic lines.

The lack of insurance has been deadly for far too many. According to a report by Families USA, a consumer health advocacy organization, nearly one in three Covid deaths is related to gaps in health insurance. But rather than address these gaps, there has been a move to reinforce barriers. Many employers are now charging unvaccinated people an additional fee alongside their insurance. Even the White House’s first attempt to improve access to testing stopped short of making the tests free; instead, people are required to submit their bills to their insurance company for reimbursement. After pressure, the White House announced plans to make 500 million rapid tests available free of charge.

This measure and the recent call to distribute free masks in addition to vaccines would be a good start, but free health care cannot be a temporary measure. The pandemic has demonstrated that a privatized health care system cannot ensure the health of the population. We have barely survived this pandemic, and without universal health care, we won’t survive the next one.