Universal coverage in the United States: lessons from experience of the 20th century

Both the rising numbers of uninsured Americans and the recent presidential election have put the issue of universal health insurance coverage back on the national agenda. Lack of health insurance is a major barrier to care for 44 million Americans, and lack of high-quality, comprehensive insurance is a barrier to millions more. Universal coverage is one of the best ways to ensure that all Americans have equitable access to quality care, and it also contributes to the financial stability of health care providers, especially those in the urban safety net. A wide variety of ideas to expand health care coverage were proposed, and in some cases enacted, during the last century. At the beginning of the 21st century, the American health care system is made up of varied elements, ranging from employer-sponsored health insurance for the majority of working-age adults to the public Medicare program for the elderly. While this patchwork system leaves many Americans without health insurance, it also creates many different ways to expand coverage, including various options in both the private and public sectors. By understanding how the current health care system developed, how the various proposals for universal health coverage gained and lost political and public support, and the pros and cons of the various alternatives available to expand coverage, we create a solid base from which to solve the problem of the uninsured in the 21st century.