Thirteen years ago, as a student in New York City, I marched across the Brooklyn Bridge to implore my colleagues to fight for universal health care. That day, I enunciated what has become my personal mission by saying, “We need universal coverage that is portable. We need universal coverage that is comprehensive. We need universal coverage that ensures equal access to care. Most importantly, we need you — to lead the fight, to force the issue, to bring to America a universal health care system where everybody is in, and nobody is left out.” For America to achieve universal health care physicians must lead the charge.

Our fragmented health care system — a mixture of socialized medicine, social insurance, managed competition, and pure capitalism — sees almost half the country covered by employers, about 15 percent Medicare, and approximately 17 percent Medicaid. Despite the overwhelming amount of attention received, the ACA only directly covers seven to ten Americans (in a combination of the Medicaid expansion and the individual marketplaces). Meanwhile, another 10 percent of the population remains uninsured.

How we tackle that last 10 percent to achieve universal health coverage is the essential question of our generation. Whenever thinking about moving our health care system from where we are to where we want to be, i.e., universal coverage, we must consider these critical questions.

• What does it mean to be “universal?”
• Who would be eligible?
• How comprehensive do we want the coverage to be?
• How will we pay for it?

First, when asked what percentage of the U.S. population would have to be covered to count as “universal,” Americans really want it to be 100 percent. Personally, I’m a bit less idealistic. Even if a laudable goal, 100 percent seems impractical to achieve. Perhaps you agree with my assessment, 84 percent of poll respondents said that at least 98 percent coverage would be good enough. Interestingly, uninsured, undocumented immigrants represent just under two percent of the U.S. population.

Second, defining the percentage of the population that must be covered to be considered “universal” dovetails into who becomes eligible for coverage. What if we chose to exclude undocumented immigrants from universal coverage? It would likely relegate many undocumented immigrants to care in public hospital systems, but would meeting that 98 percent coverage goal become easier?

Third, comprehensiveness of care directly impacts how much taxpayers and households have to pay for coverage. John Graves illustrates this issue of comprehensiveness well. Many people and politicians are now clamoring for “Medicare for All.” Do they know what they are advocating for? Specifically, how comprehensive do they want Medicare for All to be?

Medicare, as it currently exists, pays for about 76 percent of a patient’s anticipated health care costs. That is roughly equivalent to a high deductible employer plan. On the contrary, the “Expanded & Improved Medicare for All” would cover nearly 100 percent of a patient’s anticipated expenses which is essentially equivalent to today’s Medicaid plans for children. Do advocates, when talking about Medicare for All, instead mean a health care plan equivalent to employer coverage? If so, the comprehensiveness — in terms of actuarial value — is closer to 80-84 percent. Since comprehensiveness is something that digs deep into our moral values while simultaneously extracting a price from our collective wallets, it becomes yet one more thing our society must consider carefully.

Is it feasible to expect someone making the average American income or, worse yet, someone below the poverty line to pay for 25 percent of their health care tab? Is it fair that someone who makes over six figures pay nothing for their health care other than the taxes used to fund the system? In my view, if an American universal health care plan is going to have an actuarial value less than 100 percent — similar to the current Medicare or something close to an employer insurance plan — we must have protections for both the poor and the sick to prevent them from skipping necessary health care due to cost.

Lastly, the finances are where the rubber hits the road of creating a universal health care system. Mercatus recently released an analysis of Medicare for All. The headlines screamed that it would cost $33 trillion over a decade. That seems like a large sum of money until you consider that all that money is already inside the current health care system. Americans are just paying for that care in a thousand different ways. With a single payer system, we could cover 30 million more people with less money than we currently spend. The math is easy, but the politics are hard.

I suspect, however, we won’t find a universal health coverage solution for America where both the math and the politics are easy. We’re a nation of people who, in general, hate paying taxes and we lack the social solidarity seen by European democracies. I used to think a Swiss-style system would be the easiest to adapt to American culture because it is so similar to the ACA Marketplaces. Unfortunately, the current GOP is stuck on denying that Obamacare was even their (and the Heritage Foundation’s) idea so, I wouldn’t expect any cooperation from them. As for Democrats, until there is a House of Representatives controlled by them, 60 Senate Democrats, and a willing President, I doubt single payer will come to fruition.

My suggestion: Do not disrupt the employer-sponsored insurance system upon which half our country relies and is comfortable. Instead, provide Medicare for everyone else. We could fold all those other federal and state health programs into Medicare, add in the currently uninsured, and create a system that leaves no one out, except those who opt to keep employer coverage.

Ultimately, the American workforce will have to carry everyone else’s burden so that others — children, the poor, the elderly, the sick — can afford to see a doctor. But, until Americans demonstrate they are explicitly willing to do that, I will continue to sit back and ruminate on this: “The arc of the health care universe is long, but it bends toward universal health coverage.”

Cedric Dark is founder and executive editor, Policy Prescriptions.

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