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“Medical care is one of the less important determinants of life expectancy,” said Joseph Newhouse, a health economist at Harvard. “Socioeconomic status and other social factors exert larger influences on longevity.”

The United States has relied more on market forces, which have been less effective.

For spending, many experts point to differences in public policy on health care financing. “Other countries have been able to put limits on health care prices and spending” with government policies

One result: Prices for health care goods and services are much higher in the United States.

“The differential between what the U.S. and other industrialized countries pay for prescriptions and for hospital and physician services continues to widen over time,”

The degree of competition, or lack thereof, in the American health system plays a role

periods of rapid growth in U.S. health care spending coincide with rapid growth in markups of health care prices. This is what one would expect in markets with low levels of competition.

Although American health care markets are highly consolidated, which contributes to higher prices, there are also enough players to impose administrative drag. Rising administrative costs — like billing and price negotiations across many insurers — may also explain part of the problem.

The additional costs associated with many insurers, each requiring different billing documentation, adds inefficiency

“We have big pharma vs. big insurance vs. big hospital networks, and the patient and employers and also the government end up paying the bills,”

Though we have some large public health care programs, they are not able to keep a lid on prices. Medicare, for example, is forbidden to negotiate as a whole for drug prices,

once those spending constraints eased, “suppliers of medical inputs marketed very costly technological innovations with gusto,”

, all across the world, one sees constraints on payment, technology, etc., in the 1970s and 1980s,” he said. The United States is not different in kind, only degree; our constraints were weaker.

Mr. Starr suggests that the high inflation of the late 1970s contributed to growth in health care spending, which other countries had more systems in place to control

These are all highly valuable, but they came at very high prices. This willingness to pay more has in turn made the United States an attractive market for innovation in health care.

The last third of the 20th century or so was a fertile time for expensive health care innovation

being an engine for innovation doesn’t necessarily translate into better outcomes.

international differences in rates of smoking, obesity, traffic accidents and homicides cannot explain why Americans tend to die younger.

Some have speculated that slower American life expectancy improvements are a result of a more diverse population

But Ms. Glied and Mr. Muennig found that life expectancy growth has been higher in minority groups in the United States

even accounting for motor vehicle traffic crashes, firearm-related injuries and drug poisonings, the United States has higher mortality rates than comparably wealthy countries.

The lack of universal health coverage and less safety net support for low-income populations could have something to do with it

“The most efficient way to improve population health is to focus on those at the bottom,” she said. “But we don’t do as much for them as other countries.”

The effectiveness of focusing on low-income populations is evident from large expansions of public health insurance for pregnant women and children in the 1980s. There were large reductions in child mortality associated with these expansions.

A report by RAND shows that in 1980 the United States spent 11 percent of its G.D.P. on social programs, excluding health care, while members of the European Union spent an average of about 15 percent. In 2011 the gap had widened to 16 percent versus 22 percent.

“Social underfunding probably has more long-term implications than underinvestment in medical care,” he said. For example, “if the underspending is on early childhood education — one of the key socioeconomic determinants of health — then there are long-term implications.”

Slow income growth could also play a role because poorer health is associated with lower incomes. “It’s notable that, apart from the richest of Americans, income growth stagnated starting in the late 1970s,”

History demonstrates that it is possible for the U.S. health system to perform on par with other wealthy countries

That doesn’t mean it’s a simple matter to return to international parity. A lot has changed in 40 years. What began as small gaps in performance are now yawning chasms

“For starters, we could have a lot more competition in health care. And government programs should often pay less than they do.” He added that if savings could be reaped from these approaches, and others — and reinvested in improving the welfare of lower-income Americans — we might close both the spending and longevity gaps.

“Obviously it’s an improvement, but I think that it is inadequate given the health care crisis that we’re in,” said Representative Ro Khanna, a progressive Democrat from California who favors the single-payer, government-run system called Medicare for All that has been embraced by Senator Bernie Sanders, independent of Vermont, and the Democratic left.

“We’re in a national health care crisis,” Mr. Khanna said. “Fifteen million people just lost private health insurance. This would be the time for the government to say, at the very least, for those 15 million that we ought to put them on Medicare.”

The stimulus bill would make upper-middle-income Americans newly eligible for financial help to buy plans on the federal marketplaces, and the premiums for those plans would cost no more than 8.5 percent of an individual’s modified adjusted gross income. It would also increase subsidies for lower-income enrollees.

Just when Mr. Biden or Democrats would put forth such a plan remains unclear, and passage in an evenly divided Senate would be an uphill struggle. White House officials have said Mr. Biden wants to get past the coronavirus relief bill before laying out a more comprehensive domestic policy agenda.

The Affordable Care Act is near and dear to Mr. Biden, who memorably used an expletive to describe it as a big deal when he was vice president and President Barack Obama signed it into law in 2010. It has expanded coverage to more than 20 million Americans, cutting the uninsured rate to 10.9 percent in 2019 from 17.8 percent in 2010.

Mr. Biden made clear when he was running for the White House that he did not favor Medicare for All, but instead wanted to strengthen and expand the Affordable Care Act. The bill that is expected to reach his desk in time for a prime-time Oval Office address on Thursday night would do that. The changes to the health law would cover 1.3 million more Americans and cost about $34 billion, according to the Congressional Budget Office.

Even so, some 30 million Americans were uninsured between January and June 2020, according to the latest figures available from the National Health Interview Survey. The problem has only grown worse during the coronavirus pandemic, when thousands if not millions of Americans lost insurance because they lost their jobs.

Republicans have always said that their plan was to repeal and replace the health law, but after 10 years they have yet to come up with a replacement. Mr. Ayres said his firm is working on “coming up with some alternative health care message” that does not involve “simply throwing everybody into a government-run health care problem.”

Yet polls show that the idea of a government-run program is gaining traction with voters. In September, the Pew Research Center reported that over the previous year, there had been an increase, especially among Democrats, in the share of Americans who say health insurance should be provided by a single national program run by the government.

“I would argue there is more momentum for Medicare expansion given the pandemic and the experience people are having,” said Mr. Khanna, the California congressman. “They bought time, but I think at some point there will be a debate on a permanent fix.”

But because those provisions last only two years, the relief bill almost guarantees that health care will be front and center in the 2022 midterm elections, when Republicans will attack the measure as a wasteful expansion of a health law they have long hated. Meantime, some liberal Democrats may complain that the changes only prove that a patchwork approach to health care coverage will never work.

Under the changes, the signature domestic achievement of the Obama administration will reach middle-income families who have been discouraged from buying health plans on the federal marketplace because they come with high premiums and little or no help from the government.

“For people that are eligible but not buying insurance it’s a financial issue, and so upping the subsidies is going to make the price point come down,” said Ezekiel Emanuel, a health policy expert and professor at the University of Pennsylvania who advised Mr. Biden during his transition.

WASHINGTON — President Biden’s $1.9 trillion coronavirus relief bill will fulfill one of his central campaign promises, to fill the holes in the Affordable Care Act and make health insurance affordable for more than a million middle-class Americans who could not afford insurance under the original law.

The Affordable Care Act is near and dear to Mr. Biden, who memorably used an expletive to describe it as a big deal when he was vice president and President Barack Obama signed it into law in 2010. It has expanded coverage to more than 20 million Americans, cutting the uninsured rate to 10.9 percent in 2019 from 17.8 percent in 2010.

The poll found that 36 percent of Americans, and 54 percent of Democrats, favored a single national program. When asked if the government had a responsibility to provide health insurance, either through a single national program or a mix of public and private programs, 63 percent of Americans and 88 percent of Democrats said yes.

Just when Mr. Biden or Democrats would put forth such a plan remains unclear, and passage in an evenly divided Senate would be an uphill struggle. White House officials have said Mr. Biden wants to get past the coronavirus relief bill before laying out a more comprehensive domestic policy agenda.

Republicans have always said that their plan was to repeal and replace the health law, but after 10 years they have yet to come up with a replacement. Mr. Ayres said his firm is working on “coming up with some alternative health care message” that does not involve “simply throwing everybody into a government-run health care problem.”

In January, he ordered the Affordable Care Act’s health insurance marketplaces reopened to give people throttled by the pandemic economy a new chance to obtain coverage.

Yet polls show that the idea of a government-run program is gaining traction with voters. In September, the Pew Research Center reported that over the previous year, there had been an increase, especially among Democrats, in the share of Americans who say health insurance should be provided by a single national program run by the government.

With its expanded subsidies for health plans under the Affordable Care Act, the coronavirus relief bill makes insurance more affordable, and puts health care on the ballot in 2022.

cludes rich new incentives to entice the few holdout states — including Texas, Georgia and Florida — to finally expand Medicaid to those with too much money to qualify for the federal health program for the poor, but too little to afford private covera

“Biden promised voters a public option, and it is a promise he has to keep,” said Waleed Shahid, a spokesman for Justice Democrats, the liberal group that helped elect Representative Alexandria Ocasio-Cortez and other progressive Democrats. Of the stimulus bill, he said, “I don’t think anyone thinks this is Biden’s health care plan.”

“I think that argument has been fought and lost,” said Whit Ayres, a Republican pollster, conceding that the repeal efforts are over, at least for now, with Democrats in charge of the White House and both houses of Congress.

That was before more than 68,000 people in the United States tested positive for the coronavirus, grinding the country to a halt, upending lives from coast to coast, and postponing primary elections in many states. The virus has made the stakes, and the differing visions the two parties have for health care in America, that much clearer.

“Sometimes these health care debates can get a bit abstract, but when it’s an immediate threat to the health of you and your family, it becomes a lot more real.”

While the Democrats spent much of their primary fighting about whether to push for “Medicare for all” or build on the Affordable Care Act, the coronavirus crisis may streamline the debate to their advantage: At a time when the issue of health care is as pressing as ever, they can present themselves as the party that wants people to have sufficient coverage while arguing that the Republicans do not.

“A crisis like the coronavirus epidemic highlights the stake that everyone has in the care of the sick,” said Paul Starr, a professor of sociology and public affairs at Princeton who served as a health policy adviser in the Clinton White House. “It really strengthens the Democratic case for expanded health coverage, and that should work, I should think, to Biden’s advantage in a campaign against Trump.”

The virus is also having dire economic consequences, depriving Mr. Trump of a potent re-election argument rooted in stock market gains and low unemployment numbers. It is testing Mr. Trump’s leadership in the face of a national emergency like nothing he has encountered, and if voters give him poor marks, that could inflict lasting damage on his chances in November’s general election.

Four years ago, Mr. Trump ran for president promising to repeal the Affordable Care Act, popularly known as Obamacare. But his campaign pledge quickly turned into a debacle in the first year of his presidency when Republicans struggled and ultimately failed to repeal and replace the health law. In the midterm elections the next year, Democrats emphasized health care, highlighting issues like preserving protections for people with pre-existing conditions, and they won control of the House.

Mr. Trump is particularly vulnerable on the issue of health care. Over the course of his presidency, his administration has repeatedly taken steps to undermine the Affordable Care Act, including by arguing in court that the entire law should be invalidated. The Supreme Court agreed this month to hear an appeal in that case, which is the latest major challenge to the law. The court is not expected to rule until next year, but Democrats point to the Trump administration’s legal position as yet another example of the president’s desire to shred the Affordable Care Act.

In his campaign, Mr. Biden has already put a focus on health care, promising to build on the Affordable Care Act and create a so-called public option, an optional government plan that consumers could purchase. On the campaign trail, he has talked about his own exposure to the health care system

In the Democratic primary race, the health care debate has largely focused on the divide between moderate-leaning Democrats looking to build on the Affordable Care Act and progressives calling for Medicare for all, a government-run health insurance program. Mr. Biden and Mr. Sanders represent the two sides of that argument.

In a poll this month by Morning Consult, four in 10 Americans said the coronavirus outbreak had made them more likely to support universal health care proposals in which everyone would receive their health insurance from the government.

In fact, “public health has actively participated in its own marginalization,” Daniel Goldberg, a historian of medicine at the University of Colorado, told me. As the 20th century progressed, the field moved away from the idea that social reforms were a necessary part of preventing disease and willingly silenced its own political voice. By swimming along with the changing currents of American ideology, it drowned many of the qualities that made it most effective.

Germ theory offered a seductive new vision for defeating disease: Although the old public health “sought the sources of infectious disease in the surroundings of man; the new finds them in man himself,” wrote Hibbert Hill in The New Public Health in 1913

“They didn’t have to think of themselves as activists,” Rosner said. “It was so much easier to identify individual victims of disease and cure them than it was to rebuild a city.”

As public health moved into the laboratory, a narrow set of professionals associated with new academic schools began to dominate the once-broad field. “It was a way of consolidating power: If you don’t have a degree in public health, you’re not public health,”

Mastering the new science of bacteriology “became an ideological marker,” sharply differentiating an old generation of amateurs from a new one of scientifically minded professionals,

Hospitals, meanwhile, were becoming the centerpieces of American health care, and medicine was quickly amassing money and prestige by reorienting toward biomedical research

Public health began to self-identify as a field of objective, outside observers of society instead of agents of social change. It assumed a narrower set of responsibilities that included data collection, diagnostic services for clinicians, disease tracing, and health education.

Assuming that its science could speak for itself, the field pulled away from allies such as labor unions, housing reformers, and social-welfare organizations that had supported city-scale sanitation projects, workplace reforms, and other ambitious public-health projects.

That left public health in a precarious position—still in medicine’s shadow, but without the political base “that had been the source of its power,”

After World War II, biomedicine lived up to its promise, and American ideology turned strongly toward individualism.

Seeing poor health as a matter of personal irresponsibility rather than of societal rot became natural.

Even public health began to treat people as if they lived in a social vacuum. Epidemiologists now searched for “risk factors,” such as inactivity and alcohol consumption, that made individuals more vulnerable to disease and designed health-promotion campaigns that exhorted people to change their behaviors, tying health to willpower in a way that persists today.

Public health is now trapped in an unenviable bind. “If it conceives of itself too narrowly, it will be accused of lacking vision … If it conceives of itself too expansively, it will be accused of overreaching,

“epidemiology isn’t a field of activists saying, ‘God, asbestos is terrible,’ but of scientists calculating the statistical probability of someone’s death being due to this exposure or that one.”

In 1971, Paul Cornely, then the president of the APHA and the first Black American to earn a Ph.D. in public health, said that “if the health organizations of this country have any concern about the quality of life of its citizens, they would come out of their sterile and scientific atmosphere and jump in the polluted waters of the real world where action is the basis for survival.”

a new wave of “social epidemiologists” once again turned their attention to racism, poverty, and other structural problems.

The biomedical view of health still dominates, as evidenced by the Biden administration’s focus on vaccines at the expense of masks, rapid tests, and other “nonpharmaceutical interventions.”

Public health has often been represented by leaders with backgrounds primarily in clinical medicine, who have repeatedly cast the pandemic in individualist terms: “Your health is in your own hands,” said the CDC’s director, Rochelle Walensky, in May

the pandemic has proved what public health’s practitioners understood well in the late 19th and early 20th century: how important the social side of health is. People can’t isolate themselves if they work low-income jobs with no paid sick leave, or if they live in crowded housing or prisons.

This approach appealed, too, to powerful industries with an interest in highlighting individual failings rather than the dangers of their products.

“Public health gains credibility from its adherence to science, and if it strays too far into political advocacy, it may lose the appearance of objectivity,”

In truth, public health is inescapably political, not least because it “has to make decisions in the face of rapidly evolving and contested evidence,” Fairchild told me. That evidence almost never speaks for itself, which means the decisions that arise from it must be grounded in values.

Those values, Fairchild said, should include equity and the prevention of harm to others, “but in our history, we lost the ability to claim these ethical principles.”

“Sick-leave policies, health-insurance coverage, the importance of housing … these things are outside the ability of public health to implement, but we should raise our voices about them,” said Mary Bassett, of Harvard, who was recently appointed as New York’s health commissioner. “I think we can get explicit.”

The future might lie in reviving the past, and reopening the umbrella of public health to encompass people without a formal degree or a job at a health department.

What if, instead, we thought of the Black Lives Matter movement as a public-health movement, the American Rescue Plan as a public-health bill, or decarceration, as the APHA recently stated, as a public-health goal? In this way of thinking, too, employers who institute policies that protect the health of their workers are themselves public-health advocates.

“We need to re-create alliances with others and help them to understand that what they are doing is public health,

Even before the pandemic struck, local public health agencies had lost almost a quarter of their overall workforce since 2008 — a reduction of almost 60,000 workers

The agencies’ main source of federal funding — the Centers for Disease Control and Prevention’s emergency preparedness budget — had been cut 30 percent since 2003. The Trump administration had proposed slicing even deeper.

According to David Himmelstein of the CUNY School of Public Health, global consensus is that, at minimum, 6 percent of a nation’s health spending should be devoted to public health efforts. The United States, he said, has never spent more than half that much.

the problems have been left to fester.

Delaware County, Pa., a heavily populated Philadelphia suburb, did not even have a public health department when the pandemic struck and had to rely on a neighbor to mount a response.

With plunging tax receipts straining local government budgets, public health agencies confront the possibility of further cuts in an economy gutted by the coronavirus. It is happening at a time when health departments are being asked to do more than ever.

While the country spends roughly $3.6 trillion every year on health, less than 3 percent of that spending goes to public health and prevention

“Why an ongoing government function should depend on episodic grants rather than consistent funding, I don’t know,” he added. “That would be like seeing that the military is going to apply for a grant for its regular ongoing activities.”

Compared with Canada, the United Kingdom and northern European countries, the United States — with a less generous social safety net and no universal health care — is investing less in a system that its people rely on more.

Himmelstein said that the United States has never placed much emphasis on public health spending but that the investment began to decline even further in the early 2000s. The Great Recession fueled further cuts.

Plus, the U.S. public health system relies heavily on federal grants.

“That’s the way we run much of our public health activity for local health departments. You apply to the CDC, which is the major conduit for federal funding to state and local health departments,” Himmelstein said. “You apply to them for funding for particular functions, and if you don’t get the grant, you don’t have the funding for that.”

Many public health officials say a lack of a national message and approach to the pandemic has undermined their credibility and opened them up to criticism.

Few places were less prepared for covid-19’s arrival than Delaware County, Pa., where Republican leaders had decided they did not need a public health department at all

At the same time, many countries that invest more in public health infrastructure also provide universal medical coverage that enables them to provide many common public health services as part of their main health-care-delivery system.

Taylor and other elected officials worked out a deal with neighboring Chester County in which Delaware County paid affluent Chester County’s health department to handle coronavirus operations for both counties for now.

One reason health departments are so often neglected is their work focuses on prevention — of outbreaks, sexually transmitted diseases, smoking-related illnesses. Local health departments describe a frustrating cycle: The more successful they are, the less visible problems are and the less funding they receive. Often, that sets the stage for problems to explode again — as infectious diseases often do.

It has taken years for many agencies to rebuild budgets and staffing from deep cuts made during the last recessio

During the past decade, many local health departments have seen annual rounds of cuts, punctuated with one-time infusions of money following crises such as outbreaks of Zika, Ebola, measles and hepatitis. The problem with that cycle of feast or famine funding is that the short-term money quickly dries up and does nothing to address long-term preparedness.

“It’s a silly strategic approach when you think about what’s needed to protect us long term,”

She compared the country’s public health system to a house with deep cracks in the foundation. The emergency surges of funding are superficial repairs that leave those cracks unaddressed.

“We came into this pandemic at a severe deficit and are still without a strategic goal to build back that infrastructure. We need to learn from our mistakes,”

With the economy tanking, the tax bases for cities and counties have shrunken dramatically — payroll taxes, sales taxes, city taxes. Many departments have started cutting staff. Federal grants are no sure thing.

80 percent of counties have reported their budget was affected in the current fiscal year because of the crisis. Prospects are even more dire for future budget periods, when the full impact of reduced tax revenue will become evident.

Christine Hahn, medical director for Idaho’s division of public health and a 25-year public health veteran, has seen the state make progress in coronavirus testing and awareness. But like so many public health officials across the country taking local steps to deal with what has become a national problem, she is limited by how much government leaders say she can do and by what citizens are willing to do.

“I’ve been through SARS, the 2009 pandemic, the anthrax attacks, and of course I’m in rural Idaho, not New York City and California,” Hahn said. “But I will say this is way beyond anything I’ve ever experienced as far as stress, workload, complexity, frustration, media and public interest, individual citizens really feeling very strongly about what we’re doing and not doing.”

“I think the general population didn’t really realize we didn’t have a health department. They just kind of assumed that was one of those government agencies we had,” Taylor said. “Then the pandemic hit, and everyone was like, ‘Wait, hold on — we don’t have a health department? Why don’t we have a health department?’ ”

“People locally are looking to see what’s happening in other states, and we’re constantly having to talk about that and address that,”

“I’m mindful of the credibility of our messaging as people say, ‘What about what they’re doing in this place? Why are we not doing what they’re doing?’ ”

Many health experts worry the challenges will multiply in the fall with the arrival of flu season.

“The unfolding tragedy here is we need people to see local public health officials as heroes in the same way that we laud heart surgeons and emergency room doctors,” Westergaard, the Wisconsin epidemiologist, said. “The work keeps getting higher, and they’re falling behind — and not feeling appreciated by their communities.”

In practice, though, this Republican notion is an awfully peculiar kind of freedom. It requires most Americans to spend not just money, but also time and energy agonizing over the bewildering logistics of coverage and treatment — confusing plans, exorbitant premiums and deductibles, exclusive networks, mysterious tests, outrageous drug prices.

I never had to worry whether I was covered. All Finns are covered for all essential medical care automatically, regardless of employment or income.

If you can’t afford it, not buying it is hardly a choice.

in Finland I never worried about where my medical care came from or whether I could afford it. I paid my income taxes — which, again despite the stereotypes, were about the same as what I pay in federal, state and local income taxes in New York City — and if I needed to see a doctor, I had several options.

And more often than not, individual choices are severely restricted by decisions made by employers, insurers, doctors, pharmaceutical companies and other private players. Those interest groups, not the consumer, decide which plans are available, what those plans cover, which doctors patients can see and how much it will cost.

And when it comes to cervical cancer, American women are at a significant disadvantage: The United States comes in only 22nd

According to the latest report of the O.E.C.D. — an organization of mostly wealthy nations — the United States as a whole does not actually outshine other countries in the quality of care.

In fact, the United States has shorter life expectancy, higher infant mortality and fewer doctors per capita than most other developed countries.

When it comes to outcomes in some illnesses, including cancer, the United States does have some of the best survival rates in the world — but that’s barely ahead of, or even slightly behind, the equivalent survival rates in other developed countries.

the United States are South Korea, Israel, Australia, Sweden and Finland, all with some form of government-managed universal health care.

Meanwhile, life expectancy at age 65 is higher in 24 other developed nations, including Canada, Britain and most European nations.

It’s true that in countries with universal health care the cost of hiring a new employee can be significant, especially for a small employer. Yet these countries still have plenty of thriving businesses, with lower administrative burdens. It can be done.

Americans might still assume that long waits for care are inevitable in a health care system run by the government. But that’s not necessarily the case either.

A report in 2014 by the Commonwealth Fund, a private foundation specializing in health care research, ranked the United States third in the world in access to specialists. That’s a great achievement. But the Netherlands and Switzerland did better

When it comes to nonemergency and elective surgery, patients in several countries, including the Netherlands, Germany and Switzerland, all of which have universal, government-guided health care systems, have faster access than the United States.

in fact Americans who are getting a raw deal. Americans pay much more than people in other countries but do not get significantly better results.

The trouble with a free-market approach is that health care is an immensely complicated and expensive industry, in which the individual rarely has much actual market power

It is not like buying a consumer product, where choosing not to buy will not endanger one’s life. It’s also not like buying some other service tailored to individual demands, because for the most part we can’t predict our future health care needs.

The point of universal coverage is to pool risk, for the maximum benefit of the individual when he or she needs care

And the point of having the government manage this complicated service is not to take freedom away from the individual

The point is the opposite: to give people more freedom. Arranging health care is an overwhelming task, and having a specialized entity do the negotiating, regulating and perhaps even much of the providing is just vastly more efficient than forcing everyone to go it alone

What passes for an American health care system today certainly has not made me feel freer. Having to arrange so many aspects of care myself, while also having to navigate the ever-changing maze of plans, prices and the scarcity of appointments available with good doctors in my network, has thrown me, along with huge numbers of Americans, into a state of constant stress. And I haven’t even been seriously sick or injured yet.

As a United States citizen now, I wish Americans could experience the freedom of knowing that the health care system will always be there for us regardless of our employment status. I wish we were free to assume that our doctors get paid a salary to look after our best interests, not to profit by generating billable tests and procedures. I want the freedom to know that the system will automatically take me and my family in, without my having to battle for care in my moment of weakness and need. That is real freedom.

So is the freedom of knowing that none of it will bankrupt us. That is the freedom I had back in Finland.

According to the Republican orthodoxy, government always takes away not only people’s freedom to choose their doctor, but also their doctor’s ability to choose the correct care for patients. People are at the mercy of bureaucrats. Waiting times are long. Quality of care is dismal.

in a nation that purports to champion freedom, the outdated disaster that is the United States health care system is taking that freedom away.

I spent much of that year as an industry spokesman, my last after 20 years in the business, spreading AHIP’s “information” to journalists and lawmakers to create the impression that our health-care system was far superior to Canada’s, which we wanted people to believe was on the verge of collapse.

The campaign worked. Stories began to appear in the press that cast the Canadian system in a negative light. And when Democrats began writing what would become the Affordable Care Act in early 2009, they gave no serious consideration to a publicly financed system like Canada’s.

Today, the respective responses of Canada and the United States to the coronavirus pandemic prove just how false the ideas I helped spread were.

There are more than three times as many coronavirus infections per capita in the United States, and the mortality rate is twice the rate in Canada.

The most effective myth we perpetuated — the industry trots it out whenever major reform is proposed — is that Canadians and people in other single-payer countries have to endure long waits for needed care.

While it’s true that Canadians sometimes have to wait weeks or months for elective procedures (knee replacements are often cited), the truth is that they do not have to wait at all for the vast majority of medical services.

And, contrary to another myth I used to peddle — that Canadian doctors are flocking to the United States — there are more doctors per 1,000 people in Canada than here. Canadians see their doctors an average of 6.8 times a year, compared with just four times a year in this country.

Most important, no one in Canada is turned away from doctors because of a lack of funds, and Canadians can get tested and treated for the coronavirus without fear of receiving a budget-busting medical bill.

In America, exorbitant bills are a defining feature of our health-care system. Despite the assurances from President Trump and members of Congress that covid-19 patients will not be charged for testing or treatment, they are on the hook for big bills, according to numerous reports.

That is not the case in Canada, where there are no co-pays, deductibles or coinsurance for covered benefits. Care is free at the point of service. And those laid off in Canada don’t face the worry of losing their health insurance. In the United States, by contrast, more than 40 million have lost their jobs during this pandemic, and millions of them — along with their families — also lost their coverage.

Then there’s quality of care. By numerous measures, it is better in Canada. Some examples: Canada has far lower rates than the United States of hospitalizations from preventable causes like diabetes (almost twice as common here) and hypertension (more than eight times as common).

And even though Canada spends less than half what we do per capita on health care, life expectancy there is 82 years, compared with 78.6 years in the United States.

Of the many regrets I have about what I once did for a living, one of the biggest is slandering Canada’s health-care system. If the United States had undertaken a different kind of reform in 2009 (or anytime since), one that didn’t rely on private insurance companies that have every incentive to limit what they pay for, we’d be a healthier country today.

Living without insurance dramatically increases your chances of dying unnecessarily. Over the past 13 years, tens of thousands of Americans have probably died prematurely because, unlike our neighbors to the north, they either had no coverage or were so inadequately insured that they couldn’t afford the care they needed. I live with that horror, and my role in it, every day.

here were more specific reasons to be skeptical of those claims. We didn’t know, for example, who conducted that 2004 survey or anything about the sample size or methodology — or even what criteria were used to determine who qualified as a “business leader.” We didn’t know if the assertion about imaging equipment was based on reliable data or was an opinion. You could easily turn up comparable complaints about outdated equipment at U.S. hospitals.

Another bullet point, from the same book, quoted the CEO of the Canadian Association of Radiologists as saying that “the radiology equipment in Canada is so bad that ‘without immediate action radiologists will no longer be able to guarantee the reliability and quality of examinations.’ ”

Here’s an example from one AHIP brief in the binder: “A May 2004 poll found that 87% of Canada’s business leaders would support seeking health care outside the government system if they had a pressing medical concern.” The source was a 2004 book by Sally Pipes, president of the industry-supported Pacific Research Institute,

We enlisted APCO Worldwide, a giant PR firm. Agents there worked with AHIP to put together a binder of laminated talking points for company flacks like me to use in news releases and statements to reporters.

Clearly my colleagues and I would need a robust defense. On a task force for the industry’s biggest trade association, America’s Health Insurance Plans (AHIP), we talked about how we might make health-care systems in Canada, France, Britain and even Cuba look just as bad as ours.

That summer, Michael Moore was preparing to release his latest documentary, “Sicko,” contrasting American health care with that in other rich countries. (Naturally, we looked terrible.) I spent months meeting secretly with my counterparts at other big insurers to plot our assault on the film, which contained many anecdotes about patients who had been denied coverage for important treatments.

One way or another, everyone pays for health care. It accounts for about 18 percent of G.D.P. — nearly $11,000 per person. Individuals directly pay about a quarter, the federal and state governments pay nearly half, and most of the rest is paid by employers.

Many Americans think their health insurance is a gift from their employers — a “benefit” bestowed on lucky workers by benevolent corporations. It would be more accurate to think of employer-provided health insurance as a tax.

Rising health care costs account for much of the half-century decline in the earnings of men without a college degree, and contribute to the decline in the number of less-skilled jobs.

Employer-based health insurance is a wrecking ball, destroying the labor market for less-educated workers and contributing to the rise in “deaths of despair.”

We face a looming trillion-dollar federal deficit caused almost entirely by the rising costs of Medicaid and Medicare, even without the recent coronavirus relief bill.

Rising costs are an untenable burden on our government, too. States’ payments for Medicaid have risen from 20.5 percent of their spending in 2008 to 28.9 percent in 2019. To meet those rising costs, states have cut their financing for roads, bridges and state universities. Without those crucial investments, the path to success for many Americans is cut off

Every year, the United States spends $1 trillion more than is needed for high quality care.

executives at hospitals, medical device makers and pharmaceutical companies, and some physicians, are very well paid.

American doctors control access to their profession through a system that limits medical school admissions and the entry of doctors trained abroad — an imbalance that was clear even before the pandemic

Hospitals, many of them classified as nonprofits, have consolidated, with monopolies over health care in many cities, and they have used that monopoly power to raise prices

These are all strategies that lawmakers and regulators could put a stop to, if they choose.

The health care industry has armored itself, employing five lobbyists for each elected member of Congress. But public anger has been building — over drug prices, co-payments, surprise medical bills — and now, over the fragility of our health care system, which has been laid bare by the pandemic

A single-payer system is just one possibility. There are many systems in wealthy countries to choose from, with and without insurance companies, with and without government-run hospitals. But all have two key characteristics: universal coverage — ideally from birth — and cost control.

In the United States, public funding is likely to play a significant role in any treatments or vaccines that are eventually developed for Covid-19. Americans should demand that they be available at a reasonable price to everyone — not in the sole interest of drug companies.

We are believers in free-market capitalism, but health care is not something it can deliver in a socially tolerable way.

They choose not to. And so we Americans have too few doctors, too few beds and too few ventilators — but lots of income for providers

America is a rich country that can afford a world-class health care system. We should be spending a lot of money on care and on new drugs. But we need to spend to save lives and reduce sickness, not on expensive, income-generating procedures that do little to improve health. Or worst of all, on enriching pharma companies that feed the opioid epidemic.

Medical device manufacturers have also consolidated, in some cases using a “catch and kill” strategy to swallow up nimbler start-ups and keep the prices of their products high.

Ambulance services and emergency departments that don’t accept insurance have become favorites of private equity investors because of their high profits

Britain, for example, has the National Institute for Health and Care Excellence, which vets drugs, devices and procedures for their benefit relative to cost

At the very least, America must stop financing health care through employer-based insurance, which encourages some people to work but it eliminates jobs for less-skilled workers

Our system takes from the poor and working class to generate wealth for the already wealthy.

passed a coronavirus bill including $3.1 billion to develop and produce drugs and vaccines.

The industry might emerge as a superhero of the war against Covid-19, like the Royal Air Force in the Battle of Britain during World War II.

illions have lost their paychecks and their insurance

lower costs are going to be about finding ways to get people to take more responsibility for their health — for losing weight, for example, or bringing their blood pressure down.

there are other concerns, such as whether an all-encompassing system like Kaiser’s can really be replicated and whether the limits it places on where patients can seek care will be accepted by enough people to make a difference.

Or whether, as the nation’s flirtation with health maintenance organizations, or H.M.O.’s, in the 1990s showed — people will balk at the concept of not being able to go to any doctor or hospital of their choice.

its integrated model is in favor again. Hospitals across the country are buying physician practices or partnering with doctors and health insurers to form accountable care organizations, or A. C.O.’s, as a way of controlling more aspects of patient care. Doctors are also creating so-called medical homes, where patient care is better coordinated.

The days when doctors, hospitals and other providers are paid separately for each procedure will disappear eventually, health experts say. Instead, providers will have financial incentives to encourage them to keep people healthy, including lump sums to care for patients or provide comprehensive care for a specific condition. “All of care is going to move down this path, and it has to,” Mr. Halvorson said. “Medical homes are doing it; the very best A. C.O’s are going to figure out how to do it.”

there are downsides to the creation of large health care systems that may be motivated by the desire to increase their clout in the market, making it easier to fill beds and charge the insurers more for care. “They become these huge local monopolies,”

“We have all the pieces,” said Philip Fasano, Kaiser’s chief information officer. “Anything a patient needs you get in the four walls of our offices,

its plans are typically at least 10 percent less expensive than others, especially where they control all the providers

Kaiser has also been using the information to identify those doctors or clinics that excel in certain areas, as well as those in need of improvement. The organization has also used the records to change how it delivers care, identifying patients at risk for developing bed sores in the hospital and then sending electronic alerts every two hours to remind the nurses to turn the patients. The percentage of patients with serious pressure ulcers, or bed sores, dropped to well under 1 percent from 3.5 percent.

When citizens cannot imagine security, politics becomes the distribution of insecurity, the allocation of fears and anxieties that push us away from an idea of common citizenship and toward authoritarianism. What is lethal for Americans is also lethal for our democracy.

I am an American historian who has seen the pandemic from both sides of the Atlantic, and who has just written a book about health care in the United States. When journalists from other countries ask me why so many Americans have died during the coronavirus pandemic, they phrase the question actively: “What have Americans done to bring about such needless mayhem?” And that is the right way to think about our COVID-19 policy. It is not a blundering, but a bludgeoning.

In other rich nations, it is easier to see a doctor and harder to die than in the United States. As I write these lines, I am sick in Austria. That means that if I call a doctor, I see her the same day, get tests right away, fill out no forms, and pay no fees. Without worries about access to care, I am a freer person. On the scale of a whole society, the gain in liberty is extraordinary. 

Lost to us are the political consequences: If we take for granted radical inequality and repeated emergencies in the realm of health, we are primed for authoritarianism in the realm of life.

Our babies and their mothers die at rates that Europeans find unbelievable. American Millennials will likely pay more for health care yet die younger than their parents and grandparents did. Life expectancy peaked here in 2014, even as it continues to rise elsewhere.

Americans pay twice as much per capita for health care as the citizens of peer countries do, for the privilege of dying years younger.

Many of us, by some calculations nearly half, simply avoid care because it seems unaffordable.

Those of us with insurance think about how good our insurance is, and where it will get us. Those of us who get access believe that we deserve it. It does not occur to us that the less-bad access we have is worse than what everyone has in countries with universal health care.

Too many of us take for granted that health and freedom are somehow in contradiction—and so we exclude our own bodies from our notion of rights. We treat as normal a system of commercial medicine in which decisions about life and death are made on the basis of profit.

ur sense that suffering is normal is also racial

Many white Americans regard their own suffering as virtuous, while maintaining that public health care would only be abused by Black people and immigrants. In other words, suffering is normal so long as others suffer more

In the health-care debate in the United States, proposals to extend coverage to all are decried as government overreach, socialism, even outright tyranny. But the lack of health security is what makes Americans vulnerable to demagogues and authoritarians.

Racial inequality brings unnecessary death. It also brings a sentiment that an authoritarian leader can exploit: Namely, that those who suffer the most are themselves at fault. When racism is a preexisting condition, the disproportionate death rates of Americans of color during a pandemic seem normal.

America’s only hope of stopping the COVID-19 pandemic was to do so at the outset. Such efforts have been mounted before. Under George W. Bush, the number of SARS cases in the U.S. was limited, and no one died. In 2014, the Obama administration took the fight against Ebola to West Africa, a prudent step that was normal then but that seems like science fiction now.

Before the novel coronavirus arrived in the U.S., the Trump administration dismantled the institutions that were responsible for early warning and early action

By telling Americans in February what they wanted to hear about the virus—that it was not serious, that it would disappear, that everyone could get a test—Trump ensured that death would be widespread.

By failing to institute a regime of testing, he made it normal for us to follow our own guesswork and emotions rather than dealing with facts.

The Trump administration announced a kind of new federalism, in which governors would have to show their loyalty to get federal assistance, and in which the Democratic ones would be blamed regardless of what happened

The bluster shrouded the basic decision, which was not to launch a federal response to the pandemic. No nationwide lockdown, no national testing initiative, no national contact-tracing initiative, no nationwide signaling on wearing masks and washing hands. This set the United States apart from every other comparable country.

After first blaming Democrats for not doing enough, Trump switched to blaming them for doing too much.

This is America’s basic problem: Health care is not a promise for all, but rather an expectation of the rich that they will do relatively better than the poor, and of white people that they will do relatively better than Black people

Suffering can seem meaningful if it affirms this basic order, even if that suffering is one’s own

Yet a democracy can become suffused with suffering, to the point where many voters do not even expect that policy might help them or loved ones stay well

An aspiring authoritarian such as Trump knows what to do: provide the emotional jolts of pleasure that distract from the general decline. “Winning” is no longer about gaining something for oneself, such as a healthier or longer life, but about taking pleasure in the suffering of others. This is a sensibility—the strong survive; the weak get what they deserve—that favors authoritarianism over democracy.

In this election, Americans face a choice not between individuals, but between regimes: between tyranny and a republic as forms of government, and between suffering and happiness as its aims. If Trump is defeated, our democracy should be reinforced by universal health care. Health and freedom collapse together, and they can be recovered together. We would be much freer as a people if we accorded ourselves health care as a right.

Largely an office procedure when widespread screening was first recommended, colonoscopies have moved into surgery centers — which were created as a step down from costly hospital care but are now often a lucrative step up from doctors’ examining rooms — where they are billed like a quasi operation.

The high price paid for colonoscopies mostly results not from top-notch patient care, according to interviews with health care experts and economists, but from business plans seeking to maximize revenue; haggling between hospitals and insurers that have no relation to the actual costs of performing the procedure; and lobbying, marketing and turf battles among specialists that increase patient fees.

While several cheaper and less invasive tests to screen for colon cancer are recommended as equally effective by the federal government’s expert panel on preventive care — and are commonly used in other countries — colonoscopy has become the go-to procedure in the United States. “We’ve defaulted to by far the most expensive option, without much if any data to support it,”

Hospitals, drug companies, device makers, physicians and other providers can benefit by charging inflated prices, favoring the most costly treatment options and curbing competition that could give patients more, and cheaper, choices. And almost every interaction can be an opportunity to send multiple, often opaque bills with long lists of charges: $100 for the ice pack applied for 10 minutes after a physical therapy session, or $30,000 for the artificial joint implanted in surgery.

The United States spends about 18 percent of its gross domestic product on health care, nearly twice as much as most other developed countries. The Congressional Budget Office has said that if medical costs continue to grow unabated, “total spending on health care would eventually account for all of the country’s economic output.”

The more than $35,000 annually that Ms. Yapalater and her employer collectively pay in premiums — her share is $15,000 — for her family’s Oxford Freedom Plan would be more than sufficient to cover their medical needs in most other countries. She and her husband, Jeff, 63, a sales and marketing consultant, have three children in their 20s with good jobs. Everyone in the family exercises, and none has had a serious illness.

A major factor behind the high costs is that the United States, unique among industrialized nations, does not generally regulate or intervene in medical pricing, aside from setting payment rates for Medicare and Medicaid, the government programs for older people and the poor. Many other countries deliver health care on a private fee-for-service basis, as does much of the American health care system, but they set rates as if health care were a public utility or negotiate fees with providers and insurers nationwide, for example.

“In the U.S., we like to consider health care a free market,” said Dr. David Blumenthal, president of the Commonwealth Fund and a former adviser to President Obama. ”But it is a very weird market, riddled with market failures.”

Consumers, the patients, do not see prices until after a service is provided, if they see them at all. And there is little quality data on hospitals and doctors to help determine good value, aside from surveys conducted by popular Web sites and magazines. Patients with insurance pay a tiny fraction of the bill, providing scant disincentive for spending.

Even doctors often do not know the costs of the tests and procedures they prescribe. When Dr. Michael Collins, an internist in East Hartford, Conn., called the hospital that he is affiliated with to price lab tests and a colonoscopy, he could not get an answer. “It’s impossible for me to think about cost,” he said

Instead, payments are often determined in countless negotiations between a doctor, hospital or pharmacy, and an insurer, with the result often depending on their relative negotiating power. Insurers have limited incentive to bargain forcefully, since they can raise premiums to cover costs.

“People think it’s like other purchases: that if you pay more you get a better car. But in medicine, it’s not like that.”

To contain such a pathogen, nations must develop a test and use it to identify infected people, isolate them, and trace those they’ve had contact with. That is what South Korea, Singapore, and Hong Kong did to tremendous effect. It is what the United States did not.

That a biomedical powerhouse like the U.S. should so thoroughly fail to create a very simple diagnostic test was, quite literally, unimaginable. “I’m not aware of any simulations that I or others have run where we [considered] a failure of testing,”

The testing fiasco was the original sin of America’s pandemic failure, the single flaw that undermined every other countermeasure. If the country could have accurately tracked the spread of the virus, hospitals could have executed their pandemic plans, girding themselves by allocating treatment rooms, ordering extra supplies, tagging in personnel, or assigning specific facilities to deal with COVID-19 cases.

None of that happened. Instead, a health-care system that already runs close to full capacity, and that was already challenged by a severe flu season, was suddenly faced with a virus that had been left to spread, untracked, through communities around the country.

With little room to surge during a crisis, America’s health-care system operates on the assumption that unaffected states can help beleaguered ones in an emergency.

That ethic works for localized disasters such as hurricanes or wildfires, but not for a pandemic that is now in all 50 states. Cooperation has given way to competition

Partly, that’s because the White House is a ghost town of scientific expertise. A pandemic-preparedness office that was part of the National Security Council was dissolved in 2018. On January 28, Luciana Borio, who was part of that team, urged the government to “act now to prevent an American epidemic,” and specifically to work with the private sector to develop fast, easy diagnostic tests. But with the office shuttered, those warnings were published in The Wall Street Journal, rather than spoken into the president’s ear.

Rudderless, blindsided, lethargic, and uncoordinated, America has mishandled the COVID-19 crisis to a substantially worse degree than what every health expert I’ve spoken with had feared. “Much worse,”

“Beyond any expectations we had,” said Lauren Sauer, who works on disaster preparedness at Johns Hopkins Medicine. “As an American, I’m horrified,” said Seth Berkley, who heads Gavi, the Vaccine Alliance. “The U.S. may end up with the worst outbreak in the industrialized world.”

it will be difficult—but not impossible—for the United States to catch up. To an extent, the near-term future is set because COVID-19 is a slow and long illness. People who were infected several days ago will only start showing symptoms now, even if they isolated themselves in the meantime. Some of those people will enter intensive-care units in early April

A “massive logistics and supply-chain operation [is] now needed across the country,” says Thomas Inglesby of Johns Hopkins Bloomberg School of Public Health. That can’t be managed by small and inexperienced teams scattered throughout the White House. The solution, he says, is to tag in the Defense Logistics Agency—a 26,000-person group that prepares the U.S. military for overseas operations and that has assisted in past public-health crises, including the 2014 Ebola outbreak.

The first and most important is to rapidly produce masks, gloves, and other personal protective equipment

it would also come at a terrible cost: SARS-CoV-2 is more transmissible and fatal than the flu, and it would likely leave behind many millions of corpses and a trail of devastated health systems.

This agency can also coordinate the second pressing need: a massive rollout of COVID-19 tests.

These measures will take time, during which the pandemic will either accelerate beyond the capacity of the health system or slow to containable levels. Its course—and the nation’s fate—now depends on the third need, which is social distancing.

There are now only two groups of Americans. Group A includes everyone involved in the medical response, whether that’s treating patients, running tests, or manufacturing supplies. Group B includes everyone else, and their job is to buy Group A more time. Group B must now “flatten the curve” by physically isolating themselves from other people to cut off chains of transmission.

Given the slow fuse of COVID-19, to forestall the future collapse of the health-care system, these seemingly drastic steps must be taken immediately, before they feel proportionate, and they must continue for several weeks.

Persuading a country to voluntarily stay at home is not easy, and without clear guidelines from the White House, mayors, governors, and business owners have been forced to take their own steps.

when the good of all hinges on the sacrifices of many, clear coordination matters—the fourth urgent need

Pundits and business leaders have used similar rhetoric, arguing that high-risk people, such as the elderly, could be protected while lower-risk people are allowed to go back to work. Such thinking is seductive, but flawed. It overestimates our ability to assess a person’s risk, and to somehow wall off the ‘high-risk’ people from the rest of society. It underestimates how badly the virus can hit ‘low-risk’ groups, and how thoroughly hospitals will be overwhelmed if even just younger demographics are falling sick.

A recent analysis from the University of Pennsylvania estimated that even if social-distancing measures can reduce infection rates by 95 percent, 960,000 Americans will still need intensive care.

There are only about 180,000 ventilators in the U.S. and, more pertinently, only enough respiratory therapists and critical-care staff to safely look after 100,000 ventilated patients. Abandoning social distancing would be foolish. Abandoning it now, when tests and protective equipment are still scarce, would be catastrophic.

If Trump stays the course, if Americans adhere to social distancing, if testing can be rolled out, and if enough masks can be produced, there is a chance that the country can still avert the worst predictions about COVID-19, and at least temporarily bring the pandemic under control. No one knows how long that will take, but it won’t be quick. “It could be anywhere from four to six weeks to up to three months,” Fauci said, “but I don’t have great confidence in that range.”

there are three possible endgames: one that’s very unlikely, one that’s very dangerous, and one that’s very long.

The first is that every nation manages to simultaneously bring the virus to heel, as with the original SARS in 2003. Given how widespread the coronavirus pandemic is, and how badly many countries are faring, the odds of worldwide synchronous control seem vanishingly small.

The second is that the virus does what past flu pandemics have done: It burns through the world and leaves behind enough immune survivors that it eventually struggles to find viable hosts. This “herd immunity” scenario would be quick, and thus tempting

The U.S. has fewer hospital beds per capita than Italy. A study released by a team at Imperial College London concluded that if the pandemic is left unchecked, those beds will all be full by late April. By the end of June, for every available critical-care bed, there will be roughly 15 COVID-19 patients in need of one.  By the end of the summer, the pandemic will have directly killed 2.2 million Americans,

The third scenario is that the world plays a protracted game of whack-a-mole with the virus, stamping out outbreaks here and there until a vaccine can be produced. This is the best option, but also the longest and most complicated.

there are no existing vaccines for coronaviruses—until now, these viruses seemed to cause diseases that were mild or rare—so researchers must start from scratch.

The first steps have been impressively quick. Last Monday, a possible vaccine created by Moderna and the National Institutes of Health went into early clinical testing. That marks a 63-day gap between scientists sequencing the virus’s genes for the first time and doctors injecting a vaccine candidate into a person’s arm. “It’s overwhelmingly the world record,” Fauci said.

The initial trial will simply tell researchers if the vaccine seems safe, and if it can actually mobilize the immune system. Researchers will then need to check that it actually prevents infection from SARS-CoV-2. They’ll need to do animal tests and large-scale trials to ensure that the vaccine doesn’t cause severe side effects. They’ll need to work out what dose is required, how many shots people need, if the vaccine works in elderly people, and if it requires other chemicals to boost its effectiveness.

No matter which strategy is faster, Berkley and others estimate that it will take 12 to 18 months to develop a proven vaccine, and then longer still to make it, ship it, and inject it into people’s arms.

as the status quo returns, so too will the virus. This doesn’t mean that society must be on continuous lockdown until 2022. But “we need to be prepared to do multiple periods of social distancing,” says Stephen Kissler of Harvard.

First: seasonality. Coronaviruses tend to be winter infections that wane or disappear in the summer. That may also be true for SARS-CoV-2, but seasonal variations might not sufficiently slow the virus when it has so many immunologically naive hosts to infect.

Second: duration of immunity. When people are infected by the milder human coronaviruses that cause cold-like symptoms, they remain immune for less than a year. By contrast, the few who were infected by the original SARS virus, which was far more severe, stayed immune for much longer.

scientists will need to develop accurate serological tests, which look for the antibodies that confer immunity. They’ll also need to confirm that such antibodies actually stop people from catching or spreading the virus. If so, immune citizens can return to work, care for the vulnerable, and anchor the economy during bouts of social distancing.

Aspects of America’s identity may need rethinking after COVID-19. Many of the country’s values have seemed to work against it during the pandemic. Its individualism, exceptionalism, and tendency to equate doing whatever you want with an act of resistance meant that when it came time to save lives and stay indoors, some people flocked to bars and clubs.

“We can keep schools and businesses open as much as possible, closing them quickly when suppression fails, then opening them back up again once the infected are identified and isolated. Instead of playing defense, we could play more offense.”

The vaccine may need to be updated as the virus changes, and people may need to get revaccinated on a regular basis, as they currently do for the flu. Models suggest that the virus might simmer around the world, triggering epidemics every few years or so. “But my hope and expectation is that the severity would decline, and there would be less societal upheaval,”

After infections begin ebbing, a secondary pandemic of mental-health problems will follow.

But “there is also the potential for a much better world after we get through this trauma,”

Testing kits can be widely distributed to catch the virus’s return as quickly as possible. There’s no reason that the U.S. should let SARS-CoV-2 catch it unawares again, and thus no reason that social-distancing measures need to be deployed as broadly and heavy-handedly as they now must be.

Pandemics can also catalyze social change. People, businesses, and institutions have been remarkably quick to adopt or call for practices that they might once have dragged their heels on, including working from home, conference-calling to accommodate people with disabilities, proper sick leave, and flexible child-care arrangements.

Perhaps the nation will learn that preparedness isn’t just about masks, vaccines, and tests, but also about fair labor policies and a stable and equal health-care system. Perhaps it will appreciate that health-care workers and public-health specialists compose America’s social immune system, and that this system has been suppressed.

Attitudes to health may also change for the better. The rise of HIV and AIDS “completely changed sexual behavior among young people who were coming into sexual maturity at the height of the epidemic,”

Years of isolationist rhetoric had consequences too.

“People believed the rhetoric that containment would work,” says Wendy Parmet, who studies law and public health at Northeastern University. “We keep them out, and we’ll be okay. When you have a body politic that buys into these ideas of isolationism and ethnonationalism, you’re especially vulnerable when a pandemic hits.”

Pandemics are democratizing experiences. People whose privilege and power would normally shield them from a crisis are facing quarantines, testing positive, and losing loved ones. Senators are falling sick. The consequences of defunding public-health agencies, losing expertise, and stretching hospitals are no longer manifesting as angry opinion pieces, but as faltering lungs.

After COVID-19, attention may shift to public health. Expect to see a spike in funding for virology and vaccinology, a surge in students applying to public-health programs, and more domestic production of medical supplies.

The lessons that America draws from this experience are hard to predict, especially at a time when online algorithms and partisan broadcasters only serve news that aligns with their audience’s preconceptions.

“The transitions after World War II or 9/11 were not about a bunch of new ideas,” he says. “The ideas are out there, but the debates will be more acute over the next few months because of the fluidity of the moment and willingness of the American public to accept big, massive changes.”

One could easily conceive of a world in which most of the nation believes that America defeated COVID-19. Despite his many lapses, Trump’s approval rating has surged. Imagine that he succeeds in diverting blame for the crisis to China, casting it as the villain and America as the resilient hero.

One could also envisage a future in which America learns a different lesson. A communal spirit, ironically born through social distancing, causes people to turn outward, to neighbors both foreign and domestic. The election of November 2020 becomes a repudiation of “America first” politics. The nation pivots, as it did after World War II, from isolationism to international cooperation

The U.S. leads a new global partnership focused on solving challenges like pandemics and climate change.

In 2030, SARS-CoV-3 emerges from nowhere, and is brought to heel within a month.

On the Global Health Security Index, a report card that grades every country on its pandemic preparedness, the United States has a score of 83.5—the world’s highest. Rich, strong, developed, America is supposed to be the readiest of nations. That illusion has been shattered. Despite months of advance warning as the virus spread in other countries, when America was finally tested by COVID-19, it failed.

When I asked about Australia’s rather impressive health outcomes, he said that while “Australia’s mortality that is amenable to, or influenced by, the health care system specifically is good, it’s not fundamentally better than that seen in peer O.E.C.D. countries, the U.S. excepted. Rather, Australia’s public health, social policy and living standards are more responsible for outcomes.”

Addressing these issues in the United States would require significant investment, to the tune of hundreds of billions or even trillions of dollars a year. That seems impossible until you remember that we spent more than $4.4 trillion on health care in 2022. We just don’t think of social policies like housing, food and education as health care.

Other countries, on the other hand, recognize that these issues are just as important, if not more so, than hospitals, drugs and doctors. Our narrow view too often defines health care as what you get when you’re sick, not what you might need to remain well.

When other countries choose to spend less on their health care systems (and it is a choice), they take the money they save and invest it in programs that benefit their citizens by improving social determinants of health

In the United States, conversely, we argue that the much less resourced programs we already have need to be cut further. The recent debt limit compromise reduces discretionary spending and makes it harder for people to access government programs like food stamps.

When I asked experts in each of these countries what might improve the areas where they are deficient (for instance, the N.H.S. has been struggling quite a bit as of late), they all replied the same way: more money. Some of them lack the political will to allocate those funds. Others can’t make major investments without drawing from other priorities.

Singapore will need to spend more, it’s very unlikely to go above the 8 percent to 10 percent of G.D.P. that pretty much all developed countries have historically spent.

That is, all of them except the United States. We currently spend about 18 percent of G.D.P. on health care. That’s almost $12,000 per American. It’s about twice what other countries currently spend.

We cannot seem to do what other countries think is easy, while we’ve happily decided to do what other countries think is impossible.But this is also what gives me hope. We’ve already decided to spend the money; we just need to spend it better.

the story of the golden calf also reminds us that without rules we quickly become slaves to our passions—and there’s nothing freeing about that.

And the story suggests something more: unchaperoned, and left to our own untutored judgment, we are quick to aim low and worship qualities that are beneath us—in this case, an artificial animal that brings out our own animal instincts in a completely unregulated way.

Similarly, in this book Professor Peterson doesn’t just propose his twelve rules, he tells stories, too, bringing to bear his knowledge of many fields as he illustrates and explains why the best rules do not ultimately restrict us but instead facilitate our goals and make for fuller, freer lives.

Peterson wasn’t really an “eccentric”; he had sufficient conventional chops, had been a Harvard professor, was a gentleman (as cowboys can be) though he did say damn and bloody a lot, in a rural 1950s sort of way. But everyone listened, with fascination on their faces, because he was in fact addressing questions of concern to everyone at the table.

unlike many academics who take the floor and hold it, if someone challenged or corrected him he really seemed to like it. He didn’t rear up and neigh. He’d say, in a kind of folksy way, “Yeah,” and bow his head involuntarily, wag it if he had overlooked something, laughing at himself for overgeneralizing. He appreciated being shown another side of an issue, and it became clear that thinking through a problem was, for him, a dialogic process.

for an egghead Peterson was extremely practical. His examples were filled with applications to everyday life: business management, how to make furniture (he made much of his own), designing a simple house, making a room beautiful (now an internet meme) or in another, specific case related to education, creating an online writing project that kept minority students from dropping out of school by getting them to do a kind of psychoanalytic exercise on themselves,

These Westerners were different: self-made, unentitled, hands on, neighbourly and less precious than many of their big-city peers, who increasingly spend their lives indoors, manipulating symbols on computers. This cowboy psychologist seemed to care about a thought only if it might, in some way, be helpful to someone.

I was drawn to him because here was a clinician who also had given himself a great books education, and who not only loved soulful Russian novels, philosophy and ancient mythology, but who also seemed to treat them as his most treasured inheritance. But he also did illuminating statistical research on personality and temperament, and had studied neuroscience. Though trained as a behaviourist, he was powerfully drawn to psychoanalysis with its focus on dreams, archetypes, the persistence of childhood conflicts in the adult, and the role of defences and rationalization in everyday life. He was also an outlier in being the only member of the research-oriented Department of Psychology at the University of Toronto who also kept a clinical practice.

Maps of Meaning, published nearly two decades ago, shows Jordan’s wide-ranging approach to understanding how human beings and the human brain deal with the archetypal situation that arises whenever we, in our daily lives, must face something we do not understand.

The brilliance of the book is in his demonstration of how rooted this situation is in evolution, our DNA, our brains and our most ancient stories. And he shows that these stories have survived because they still provide guidance in dealing with uncertainty, and the unavoidable unknown.

this is why many of the rules in this book, being based on Maps of Meaning, have an element of universality to them.

We are ambivalent about rules, even when we know they are good for us. If we are spirited souls, if we have character, rules seem restrictive, an affront to our sense of agency and our pride in working out our own lives. Why should we be judged according to another’s rule?

And he felt he had to understand the ideologies that drove totalitarian regimes to a variant of that same behaviour: killing their own citizens.

Ideologies are simple ideas, disguised as science or philosophy, that purport to explain the complexity of the world and offer remedies that will perfect it.

Ideologues are people who pretend they know how to “make the world a better place” before they’ve taken care of their own chaos within.

Ideologies are substitutes for true knowledge, and ideologues are always dangerous when they come to power, because a simple-minded I-know-it-all approach is no match for the complexity of existence.

To understand ideology, Jordan read extensively about not only the Soviet gulag, but also the Holocaust and the rise of Nazism. I had never before met a person, born Christian and of my generation, who was so utterly tormented by what happened in Europe to the Jews, and who had worked so hard to understand how it could have occurred.

I saw what now millions have seen online: a brilliant, often dazzling public speaker who was at his best riffing like a jazz artist; at times he resembled an ardent Prairie preacher (not in evangelizing, but in his passion, in his ability to tell stories that convey the life-stakes that go with believing or disbelieving various ideas). Then he’d just as easily switch to do a breathtakingly systematic summary of a series of scientific studies. He was a master at helping students become more reflective, and take themselves and their futures seriously. He taught them to respect many of the greatest books ever written. He gave vivid examples from clinical practice, was (appropriately) self-revealing, even of his own vulnerabilities, and made fascinating links between evolution, the brain and religious stories.

Above all, he alerted his students to topics rarely discussed in university, such as the simple fact that all the ancients, from Buddha to the biblical authors, knew what every slightly worn-out adult knows, that life is suffering.

chances are, if you or someone you love is not suffering now, they will be within five years, unless you are freakishly lucky. Rearing kids is hard, work is hard, aging, sickness and death are hard, and Jordan emphasized that doing all that totally on your own, without the benefit of a loving relationship, or wisdom, or the psychological insights of the greatest psychologists, only makes it harder.

focused on triumphant heroes. In all these triumph stories, the hero has to go into the unknown, into an unexplored territory, and deal with a new great challenge and take great risks. In the process, something of himself has to die, or be given up, so he can be reborn and meet the challenge. This requires courage, something rarely discussed in a psychology class or textbook.

Jordan

views of his first YouTube statements quickly numbered in the hundreds of thousands. But people have kept listening because what he is saying meets a deep and unarticulated need. And that is because alongside our wish to be free of rules, we all search for structure.

the first generation to have been so thoroughly taught two seemingly contradictory ideas about morality, simultaneously—at their schools, colleges and universities, by many in my own generation. This contradiction has left them at times disoriented and uncertain, without guidance and, more tragically, deprived of riches they don’t even know exist.

morality and the rules associated with it are just a matter of personal opinion or happenstance, “relative to” or “related to” a particular framework, such as one’s ethnicity, one’s upbringing, or the culture or historical…

The first idea or teaching is that morality is relative, at best a…

So, the decent thing to do—once it becomes apparent how arbitrary your, and your society’s, “moral values” are—is to show tolerance for people who think differently, and…

for many people one of the worst character flaws a person can have is to be “judgmental.”* And, since we don’t know right from wrong, or what is good, just about the most inappropriate thing an adult can…

That emphasis on tolerance is so paramount that for many people one of the worst character flaws a person can have is to be “judgmental.”* And, since we don’t know right from wrong, or what is good, just about the most inappropriate thing an…

And so a generation has been raised untutored in what was once called, aptly, “practical wisdom,” which guided previous generations. Millennials, often told they have received the finest education available anywhere, have actually…

professors, chose to devalue thousands of years of human knowledge about how to acquire virtue, dismissing it as passé, “…

They were so successful at it that the very word “virtue” sounds out of date, and someone using it appears…

The study of virtue is not quite the same as the study of morals (right and wrong, good and evil). Aristotle defined the virtues simply as the ways of behaving that are most conducive to happiness in life. Vice was…

Cultivating judgment about the difference between virtue and vice is the beginning of wisdom, something…

By contrast, our modern relativism begins by asserting that making judgments about how to live is impossible, because there is no real good, and no…

Thus relativism’s closest approximation to “virtue” is “tolerance.” Only tolerance will provide social cohesion between different groups, and save us from harming each other. On Facebook and other forms of social media, therefore, you signal your so-called…

Intolerance of others’ views (no matter how ignorant or incoherent they may be) is not simply wrong; in a world where there is no right or wrong, it is worse: it is a sign you are…

But it turns out that many people cannot tolerate the vacuum—the chaos—which is inherent in life, but made worse by this moral relativism; they cannot live without a moral compass,…

So, right alongside relativism, we find the spread of nihilism and despair, and also the opposite of moral relativism: the blind certainty offered by ideologies…

Dr. Norman Doidge, MD, is the author of The Brain That Changes Itself

so we arrive at the second teaching that millennials have been bombarded with. They sign up for a humanities course, to study the greatest books ever written. But they’re not assigned the books; instead they are given…

(But the idea that we can easily separate facts and values was and remains naive; to some extent, one’s values determine what one will pay…

For the ancients, the discovery that different people have different ideas about how, practically, to live, did not paralyze them; it deepened their understanding of humanity and led to some of the most satisfying conversations human beings have ever had, about how life might be lived.

Modern moral relativism has many sources. As we in the West learned more history, we understood that different epochs had different moral codes. As we travelled the seas and explored the globe, we learned of far-flung tribes on different continents whose different moral codes made sense relative to, or within the framework of, their societies. Science played a role, too, by attacking the religious view of the world, and thus undermining the religious grounds for ethics and rules. Materialist social science implied that we could divide the world into facts (which all could observe, and were objective and “real”) and values (…

it seems that all human beings are, by some kind of biological endowment, so ineradicably concerned with morality that we create a structure of laws and rules wherever we are. The idea that human life can be free of moral concerns is a fantasy.

given that we are moral animals, what must be the effect of our simplistic modern relativism upon us? It means we are hobbling ourselves by pretending to be something we are not. It is a mask, but a strange one, for it mostly deceives the one who wears it.

Far better to integrate the best of what we are now learning with the books human beings saw fit to preserve over millennia, and with the stories that have survived, against all odds, time’s tendency to obliterate.

these really are rules. And the foremost rule is that you must take responsibility for your own life. Period.

Jordan’s message that each individual has ultimate responsibility to bear; that if one wants to live a full life, one first sets one’s own house in order; and only then can one sensibly aim to take on bigger responsibilities.

if it’s uncertain that our ideals are attainable, why do we bother reaching in the first place? Because if you don’t reach for them, it is certain you will never feel that your life has meaning.

And perhaps because, as unfamiliar and strange as it sounds, in the deepest part of our psyche, we all want to be judged.

Instead of despairing about these differences in moral codes, Aristotle argued that though specific rules, laws and customs differed from place to place, what does not differ is that in all places human beings, by their nature, have a proclivity to make rules, laws and customs.

Freud never argued (as do some who want all culture to become one huge group therapy session) that one can live one’s entire life without ever making judgments, or without morality. In fact, his point in Civilization and Its Discontents is that civilization only arises when some restraining rules and morality are in place.

Aleksandr Solzhenitsyn, the great documenter of the slave-labour-camp horrors of the latter, once wrote that the “pitiful ideology” holding that “human beings are created for happiness” was an ideology “done in by the first blow of the work assigner’s cudgel.”1 In a crisis, the inevitable suffering that life entails can rapidly make a mockery of the idea that happiness is the proper pursuit of the individual. On the radio show, I suggested, instead, that a deeper meaning was required. I noted that the nature of such meaning was constantly re-presented in the great stories of the past, and that it had more to do with developing character in the face of suffering than with happiness.

I proposed in Maps of Meaning that the great myths and religious stories of the past, particularly those derived from an earlier, oral tradition, were moral in their intent, rather than descriptive. Thus, they did not concern themselves with what the world was, as a scientist might have it, but with how a human being should act.

I suggested that our ancestors portrayed the world as a stage—a drama—instead of a place of objects. I described how I had come

to believe that the constituent elements of the world as drama were order and chaos, and not material things.

Order is where the people around you act according to well-understood social norms, and remain predictable and cooperative. It’s the world of social structure, explored territory, and familiarity. The state of Order is typically portrayed, symbolically—imaginatively—as masculine.

Chaos, by contrast, is where—or when—something unexpected happens.

As the antithesis of symbolically masculine order, it’s presented imaginatively as feminine. It’s the new and unpredictable suddenly emerging in the midst of the commonplace familiar. It’s Creation and Destruction,

Order is the white, masculine serpent; Chaos, its black, feminine counterpart. The black dot in the white—and the white in the black—indicate the possibility of transformation: just when things seem secure, the unknown can loom, unexpectedly and large. Conversely, just when everything seems lost, new order can emerge from catastrophe and chaos.

For the Taoists, meaning is to be found on the border between the ever-entwined pair. To walk that border is to stay on the path of life, the divine Way. And that’s much better than happiness.