Among wealthy, developed nations, the United States is the only one that does not guarantee health coverage to all its residents. But it’s not the only country in the world without universal healthcare. Most low- and middle-income countries also lack comprehensive coverage systems, relying instead on out-of-pocket payments from patients. What makes the U.S. unusual is that it has the resources to fund universal coverage and still chooses not to.
How the U.S. Compares to Other Wealthy Nations
A Commonwealth Fund analysis comparing the U.S. to Australia, Canada, France, Germany, Japan, the Netherlands, New Zealand, Norway, South Korea, Sweden, Switzerland, and the United Kingdom found that every one of those countries guarantees public health coverage to all residents. The U.S. is the sole outlier, and it’s also the only high-income country where a substantial portion of the population has no health insurance at all.
As of 2024, roughly 26.7 million Americans under age 65 lacked any form of health coverage, an uninsured rate of 9.8%. That number actually increased by more than 1.3 million people from the prior year. No comparable nation has anything close to this gap.
What “Free Healthcare” Actually Means
No country’s healthcare is truly free. Every universal system is funded through some combination of taxes, payroll deductions, or mandatory insurance contributions. When people say “free healthcare,” they typically mean care that’s free at the point of service: you walk into a hospital, get treated, and don’t receive a bill. The money comes from somewhere, but it’s collected through the tax system rather than charged to individual patients.
Wealthy nations use a few different models to make this work. The UK, New Zealand, and Spain use a government-run system where healthcare is both funded and provided by the state, paid for through general taxation. Germany, France, Japan, the Netherlands, and Switzerland rely on nonprofit insurance funds, financed mostly through payroll deductions from employers and employees. Canada and South Korea use a single-payer model where the government runs one insurance program that pays private and public providers. Each approach has trade-offs in wait times, choice of provider, and tax burden, but all of them cover the entire population.
Why the U.S. Never Adopted Universal Coverage
The U.S. came close to universal healthcare multiple times over the past century, and each attempt collapsed for different reasons. In 1915, a draft bill for compulsory health insurance gained initial support from the American Medical Association, but the AMA reversed its position by 1920, and the effort died as the country entered World War I. President Roosevelt considered including national health insurance in the Social Security Act during the 1930s but ultimately decided the political risk would jeopardize the entire bill.
President Truman made national health insurance a centerpiece of his agenda after winning the 1948 election, but opponents deployed fears of socialism to block it. Southern Democrats, who worried that a federal healthcare role might force desegregation, joined the opposition. In the 1970s, Senator Kennedy’s national health insurance proposal competed with President Nixon’s own plan, and the two camps splintered support so thoroughly that neither passed. Watergate consumed the rest of Nixon’s political capital.
The pattern repeated in the 1990s when the Clinton administration’s reform effort fractured under opposition from the health insurance industry and small business groups. Congressional Democrats themselves couldn’t agree on a single approach, and competing alternative proposals blocked progress on any one plan. By the time the Affordable Care Act passed in 2010, the goal had shifted from universal coverage to expanding access within the existing private insurance framework.
What the U.S. Does Cover
The U.S. isn’t entirely without public healthcare programs. Medicare covers about 68 million people, primarily adults 65 and older, for hospital stays, doctor visits, and preventive services. Medicaid and the Children’s Health Insurance Program (CHIP) cover more than 82 million Americans, including low-income adults, pregnant women, children, and people with disabilities. Roughly 38 million children, about half of all kids in the country, receive coverage through Medicaid or CHIP. Three out of every five nursing home residents rely on Medicaid for their care.
The Veterans Health Administration operates its own government-run system for military veterans, functioning essentially like a miniature version of the UK’s model. And Medicare itself is structured like a single-payer system. So the U.S. already runs versions of every major universal healthcare model for specific populations. It just doesn’t extend any of them to everyone.
The Cost of the Current System
The U.S. spends far more on healthcare than any other country, not less. In 2024, healthcare consumed 17.2% of the nation’s GDP. The OECD average was 9.3%, and even Germany, the next highest spender, allocated only 12.3%. Americans pay more per person for healthcare than citizens of any other nation, yet tens of millions remain uninsured and health outcomes lag behind peer countries on key measures like life expectancy and infant mortality.
That spending gap translates directly into personal financial burden. About 20 million adults owe medical debt, and Americans collectively owe at least $220 billion. Roughly 14 million people owe more than $1,000 in medical debt, and about 3 million owe more than $10,000. The problem hits hardest in certain states: South Dakota (17.7%), Mississippi (15.2%), and North Carolina (13.4%) have the highest rates of adults carrying medical debt. People living with disabilities are about twice as likely to carry medical debt as those without.
Even having insurance doesn’t fully protect against medical debt. Among adults insured for the full year, 8% still reported owing medical debt. The 41% of adults who carry some form of healthcare-related debt, including amounts put on credit cards or borrowed from family, illustrates how deeply the cost of care penetrates household finances in ways that simply don’t exist in countries with universal systems.