This year, AcademyHealth and the Commonwealth Fund invited a group of early-career scholars to join a day of international health policy programming at the 2026 Annual Research Meeting (ARM), with scholarship support to help cover their attendance. This post is one in a series of their reflections on what they learned from researchers and health systems around the world, and what it might mean for improving health care here in the U.S. See the other posts by Natalia Pattriti Cram and Claire Pernat.
I attended this year's AcademyHealth Annual Research Meeting with scholarship support from the Commonwealth Fund for a day of invitational international health policy programming, and one word recurred across the sessions: trust. Who does the public believe, why do they stop believing, and how does a health system earn belief back?
The United States faces a deep institutional trust deficit across health care and public health. Cross-national learning, the focus of an invitational Commonwealth Fund program at ARM, has just been named a priority area for health policy research. So I kept returning to one question: what can other countries teach us about trust?
I take up that question through a topic nearly as neglected on the AcademyHealth agenda as it is elsewhere: menopause. How a health system treats menopause, or fails to, illustrates the institutional trustworthiness that ran through the meeting, and several countries are well ahead of the United States.
The treatment gap is well documented. Roughly one in three American women over 40 experiences severe menopausal symptoms; only about one in four receives treatment. Melinda French Gates has taken up the problem, writing a recent New York Times essay about her own menopause and pledging $215 million to reproductive and midlife health. But the gap stems from a trust problem with a traceable origin. When the 2002 Women's Health Initiative findings were reported in ways that overstated the risks of hormone therapy, prescribing collapsed and a generation of clinicians was trained to avoid hormones. The evidence was later corrected, but the caution and the training gap persisted. Lucinda Hiam, whose work on public trust was highlighted at the meeting, argues that mistrust takes root precisely where an institution has failed people, and that responding with louder assertions of authority only deepens it. Menopause is a case in point. Medicine got the science wrong and then went quiet, so women turned to influencers and subscription apps, whose advice is not always evidence-based and whose care is available only to those who can pay.
That vacuum is felt most acutely by women with the strongest reasons for mistrust. Toluwani Adekunle, also presenting at the meeting, characterizes medical mistrust among Black women as rational and earned, the accumulated response to generations of documented harm. The menopause data reflect this history: Black women reach menopause earlier, experience more severe symptoms, and are less likely to be offered hormone therapy. Adekunle’s framing places the burden is on institutions to prove themselves trustworthy, not on individuals to extend trust. Taken together, Hiam and Adekunle suggest that trust is less a feature of national culture than a product of institutional behavior.
Several countries have treated menopause as a system responsibility and begun to recover trust as a result. Australia offers the fullest example. Following a 2024 Senate inquiry that took public testimony on the failures of menopause care, the government committed more than $573 million to women's health, including the first new menopausal hormone therapies added to its subsidy list in over two decades, a Medicare rebate for menopause health assessments, first-ever national clinical guidelines, and clinician training. In this example, the Australian government heard the public, admitted failure, and responded with concrete changes.
England and Ireland have made similar investments in affordability. An HRT prepayment certificate in England caps a year of treatment at about £19.80, removing cost as a determinant of who accesses therapy. Ireland went further and made menopausal hormone replacement therapy free at pharmacies in 2025.
None of these policies mention trust. They change coverage, price, and standards and let the system speak for itself. The United States has largely left that work to the market, though that is beginning to change: nineteen states have introduced menopause bills, and a handful, including Illinois and New Jersey, now mandate insurance coverage for menopause treatment
None of these policies mention trust. They change coverage, price, and standards and let the system speak for itself. The United States has mostly left that work to the market, though this is beginning to change: nineteen states have introduced menopause bills, and a handful, including Illinois and New Jersey, now mandate insurance coverage for treatment. What the countries ahead of us share is not a particular drug or benefit design but a willingness to acknowledge where care fell short and repair it publicly. If health services research wants to take trust seriously, menopause is a good place to start: fund the research, build it into the evidence base and the training pipeline, and hopefully take up more space on the AcademyHealth program.
Supported by the Commonwealth Fund, a national, private foundation based in New York City that supports independent research on health care issues and makes grants to improve health care practice and policy. The views presented here are those of the author and not necessarily those of the Commonwealth Fund, its directors, officers, or staff.