Sometimes seeing an entirely new situation clarifies something you have been looking at for years. That is what is happening to me as I got a glance of South Africa and India. All these countries share conditions that make implementing universal health coverage very challenging. (Brazil has these same factors so may face the same problems.)
• They are all federal systems in which individual States/provinces have real political power and significant control over health care delivery.
• They all have parallel public systems for the poor and better funded, private systems delivering care to people who can use private insurance or pay out of pocket.
• They have relatively unequal distributions of wealth.
• People and groups with political influence have easy access to the private delivery system and lack confidence in the public delivery system, especially at the primary care and routine hospital levels.
• People and groups using the private sector have the political clout to prevent efforts to redistribute resources to serve poor or other ethnic groups.

Obamacare will stay in place in the US, at least for a while but I think these factors may limit the country from reaching its goal of universal health coverage and may explain why some of the opposition has been so intense

India and South Africa recently announced major health reforms they hope will lead to universal health coverage over the next few years. Both intend to use an insurance mechanism, controlled at the national level to leverage significant changes in their primary care and regional hospital systems, especially around access, breadth of service and quality. The national governments have limited control over the delivery systems now. They hope the purchasing power they get by controlling insurance payments to the providers will give them more control. Obamacare includes major provisions that try to leverage change in the delivery system both directly and indirectly through its insurance reforms. Obamacare certainly tried to force big changes in State Medicaid programs until the Supremes said no. India and South Africa (and China as well) are trying to layer an insurance system on top of existing publicly owned and budgeted provider organizations. Neither country has yet developed an implementation plan to achieve the systems reform goal and neither has gone far enough down to path to know what kind or form of opposition from local forces will emerge. While insurance reforms have certainly affected provider behavior in the US, it is not clear—to me at least—that they have been particularly effective in improving quality or containing cost. In recent years employer based insurance has actually limited choice and braod access and shifted cost to employees. Private insurance has had very little impact on price or quality around the country.. The public insurance programs like Medicare and Medicaid have had marginally more impact on changing behavior. It is a constant cat and mouse game but the providers have beaten the insurers repeatedly. I wonder what will happen in other countries that rely on insurance mechanisms to change their delivery systems.