Per the original May 2018 Position Paper, life isn’t fair, and neither is disease. We know this. But health care is a part of our lives that we can control, and we can make it fairer. In the United States, the dominant reason for unfairness in health care is a failure to commit to universality. Universality is not uniformity. Universality is a promise that all patients will be helped according to their clinical need, not who they are or how much they can pay. This promise was built into the healing professions centuries ago, but has never consistently been kept. For many millions of uninsured and underinsured patients, we’ve made it almost impossible to keep. For other Americans — Medicare beneficiaries — we’ve done much better. The Medicare example shows what can be done on a larger scale through public financing. It can include small elements of private financing, but only with robust regulatory reform that includes efficiency and transparency standards much closer to Medicare’s. What’s vital here is not to pick a plan and push it, but to pick a principle and honor it. We shouldn’t work toward universality. We should begin with a commitment to universality and then work towards achieving it, with automatic enrollment in public programs (Medicare, Medicaid, the Children’s Health Insurance Program) for patients not otherwise insured. We believe that the best path to universal coverage is through the expansion of proven public programs such as Medicare or Medicaid. These already have the infrastructure and provider networks to serve our communities, but need improvements that target excessive prices and that reduce the amount of low value services performed. A "Medicare for All" approach has many virtues, one of the strongest being its administrative simplicity. We believe it is futile to expand on a complex, confusing, fragmented, and administratively expensive private insurance structure with inherently misaligned priorities.

The United States is the only wealthy nation in the world that has not yet committed itself to assuring affordable health care for all. Chronologically, we are well behind other developed countries: Germany (1883), United Kingdom (1947), Japan (1961), and Canada (1965).

The Organization for Economic Co-operation and Development, a group of 35 high- and middle-income countries dedicated to economic development, defines universal health coverage as “having access to good quality health services without suffering financial hardship.”

Medicare: a taxpayer funded insurance plan, which covers citizens over the age of 65, as well as people with disabilities. In 2016, 14% of Americans received Medicare. Medicaid/Children’s Health Insurance Program (CHIP): a joint state-federal taxpayer program of public insurance for the needy, children, low income disabled, and the elderly. In 2016, 19% of Americans were covered by Medicaid. Employer-sponsored insurance: private health insurance as a benefit provided by one’s employer, which covers 49% of Americans. Non-group/individual private insurance: 7% of Americans purchase private insurance, with or without a federal subsidy.

In the 28 years between 1988 and 2016: Employer-based insurance coverage fell from 63% to 56% of the population. Medicaid coverage increased from 7% to 19% of the population. The percentage of uninsured Americans fell from around 25% of the population in 1963 to 9% in 2016. It is now going back up and projected to be even higher in future years. High deductible health insurance, often a marker of underinsurance, grew from 25% of private insurance plans in 2010 to 40% in 2016.

The uninsured (currently 9% of the population.) The underinsured (The Commonwealth Fund describes the underinsured as “those who have high deductibles and high out-of-pocket expenses relative to their income.”) Currently 28% of working-age adults are underinsured. For more information, see the Narratives Shared American values and Insecurity in health care. Updated 6/1/2018