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, Claire Pernat, Laura Jacobson, and Laura Yudo here.
At this year’s AcademyHealth Annual Research Meeting in Seattle, Washington, I attended a day of invitational International Health Policy Programming, supported by a scholarship from AcademyHealth and The Commonwealth Fund. Going in, I expected the big themes to be how different countries finance health care, structure payment models, and control costs. Instead, I was surprised by a round-table conversation about how equity is measured, or perhaps more accurately, how it often isn’t.
I left realizing that equity is not an inevitable outcome of a well-functioning health system. By “health system,” I mean the way a country organizes, finances, governs, and delivers health care. Equity has to be intentionally built into its design. In much of American health care, we tend to hope equity emerges from expanding coverage and improving quality. Several of the international discussions challenged that assumption, asking instead what it would look like to build equity into the system from the start.
Coverage Is Not Equity
One theme kept resurfacing throughout the international sessions: having insurance does not necessarily mean having access, and having access does not necessarily lead to equitable outcomes. There is a difference between equality and equity. Equality distributes the same resources to everyone, whereas equity distributes them according to need. An insurance card alone guarantees neither. There was also a useful point about sequencing: equity of access (e.g., availability, timeliness, and quality of care) has to come before equity of outcomes.
The United Kingdom was discussed as an example of a system that considers not only access to care but also broader measures such as life expectancy, disease burden, and the social conditions that influence health. Similarly, Thailand’s Universal Coverage Scheme illustrates how equity can be built into health system design by pairing universal coverage with investments in primary care, expanded healthcare infrastructure, and financing reforms that improved access for previously underserved populations.
The discussion also felt particularly timely. As premiums and deductibles continue to rise in the United States (U.S.), enhanced marketplace subsidies expire, and Medicaid eligibility policies continue to evolve across states, maintaining insurance coverage remains an ongoing policy challenge. The conversations reminded me that if coverage alone has never been sufficient to achieve equity, losing coverage only makes that goal more difficult.
Following the money
If equity is more than coverage, the next question is how we measure and pay for it. Payment systems reward what they measure, so equity absent from performance metrics rarely becomes a funding priority. Participants also noted that much of nonprofit hospital community benefit spending may not reach the communities it is intended to serve, in part because our financing system is not designed to direct resources according to need.
Community health workers (CHWs) offered a practical example of investing differently. They build trust and connect underserved populations to care. In my own work on a multi-site NIH-funded trial serving rural communities, CHWs have been indispensable precisely because they are embedded in the communities they serve, yet their work is often undervalued by payment systems.
Healthcare systems alone cannot solve public health challenges. Many countries invest more heavily in prevention, primary care, and social supports such as housing and food security. While no country’s approach can directly be applied to the U.S., international comparisons help identify policies worth adapting.
Designing for Equity: Three Places to Start
Three ideas from the international programming struck me as particularly relevant.
First, fund need, not simply utilization. Directing resources toward communities with greater need is a policy choice that value-based payment is better positioned to support than fee-for-service. Measuring disadvantage is genuinely difficult, but that is ultimately a measurement challenge rather than a reason for inaction.
Second, make equity an explicit, rewarded outcome, and build it in from the beginning. Centers for Medicare & Medicaid Services (CMS) has begun incorporating equity-focused measures into some payment initiatives, though many have since been scaled back. However, international examples suggest that advancing equity does not necessarily require increasingly complex payment systems. Standardized approaches and simpler administration may actually make equity-focused payment more feasible.
Third, hold health systems accountable for where investments ultimately flow. If health systems were expected to demonstrate not only how much community benefit spending leaves the institution, but also which communities ultimately benefit and how, the relationship between institutional spending and community investment would become much more transparent. Ultimately, the goal isn’t to spend more, but to invest more intentionally.
Final Reflections
Perhaps the biggest takeaway from international health policy programming wasn’t learning how other countries organize their health systems but seeing my own work questions through a different lens. The challenges I study such as fragmented healthcare access, unmet social needs, and underinvestment in community infrastructure, are not uniquely American. Our approach to financing solutions to those problems often is. Rather than simply asking how policy can expand access, reduce disparities, and improve quality, these conversations challenged me to instead ask a more fundamental question: What outcome is our health system designed to produce? No country has “solved” health equity, but the international health policy programming reminded me that looking beyond our own borders expands the range of solutions we consider, and every thoughtful step forward brings us closer to a more equitable health system.
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.