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Universal health coverage is within reach of even the poorest countries if these countries are helped to expand their systems of primary healthcare (PHC). The overriding theme is that PHC (with a strong community outreach component) is the best bargain on the planet—alongside spending on primary and secondary education. Investing in PHC, both from domestic revenues and international grants and loans as necessary, can save millions of lives per year at a remarkably low cost. Many low- and middle-income countries (LMICs) direct too many resources to tertiary care rather than PHC. Community outreach programs, notably those that include community health workers, are chronically underfunded, even disproportionately relative to overall funding government for healthcare. In many or most LMICs, the political pressure on national policymakers is, strangely enough, to expand investments in higher level health facilities and specialized care—especially for hospitals. As a result, the underfunding of PHC leads to a vicious cycle. Because PHC services are underfunded, the quality of these services is weak, and patients bypass these facilities to obtain urgent PHC services they need at hospitals. Underutilization of PHC services at PHC facilities and provision of PHC services at hospitals leads to increased funding for hospitals, at leading to progressively lower levels of funding for PHC facilities and for strong community outreach. There is an immediate need to recognize community-level health programs as a permanent feature of effective health systems (even in high-income countries). Additional funding is needed to enable the concerted strengthening and expansion of PHC services in low- and lower-middle-income countries. This would enable, among other things, community health workers to reach their full potential and provide a broad range of life-saving and life-improving services by allocating the skills, supplies, supervision, salaries, and career opportunities that are needed.

Latin American and Caribbean (LAC) countries have experienced a long-term process of improvement in populational health conditions, shifting their health priorities from child–mother care and transmissible diseases to non-communicable diseases (NCDs). However, persistent socioeconomic inequalities create barriers to achieve universal health coverage (UHC). Despite a high level of governmental commitment to UHC, and rising coverage, approximately 25% of the population does not have access to healthcare, particularly in rural and outlying areas. Health system quality issues have been largely ignored, and inefficiency, from health financing to health delivery, is not on the policy agenda. The use of incentives to improve performance are rare in LAC health systems and there are political barriers to introduce reforms in payment systems in the public sector, though the private sector has opportunity to adapt change. Fragmentation in the financing of healthcare is a common theme in the region. Most systems retain social health insurance (SHI) schemes, mostly for the formal sector, and in some cases have more than one; and parallel National Health System (NHS)-type arrangements for the poor and those in the informal labor market. The cost and inefficiency in delivery and financing is considerable. Regional health economics literature stresses inadequate funding—despite the fact that the region has the highest inequality in access and spends the most on healthcare across the regions—and analyzes multiple aspects of health equity. The agenda needs to move from these debates to designing and leveraging delivery and payment systems that target performance and efficiency. The absence of research on payment arrangements and performance is a symptom of a health management culture based on processes rather than results. Indeed, health services in the region remain rooted in a culture of fee-for-service and supply-driven models, where expenditures are independent of outcomes. Health policy reforms in LAC need to address efficiency rather than equity, integrate healthcare delivery, and tackle provider payment reforms. The integration of medical records, adherence to protocols and clinical pathways, establishment of health networks built around primary healthcare, along with harmonized incentives and payment systems, offer a direction for reforms that allow adapting to existing circumstances and institutions. This offers the best path for sustainable UHC in the region.

National health care reform in the United States, from its introduction into the public policy agenda at the turn of the 20th century through policy debates and legislative proposals more than a century later, has achieved limited success with universal coverage for health and mental health services. Opposition to government-sponsored health care has always been present. The extent of the opposition has depended on the type of reform proposed and the era in which it occurred. Medicare and Medicaid reform in the 1960s greatly expanded access and coverage for older adults and low income individuals and families. But, the first true effort to reach universal coverage occurred with the passage of the Affordable Care Act in 2010.