Central to the objectives of Canadian national health insurance were the principles that health is a basic right that should be open to all and that all Canadians, regardless of their ability to pay, would be provided with publicly financed comprehensive hospital and medical services. During the two decades that this program has been in place, substantial gains have been realized in making insured services more accessible to all Canadians, in the reduction of regional mortality disparities, and in a leveling out of earlier sharp differences in the supply of health resources across Canada. These changes have not been matched by any significant realignment of the health status of Canadians relative to their economic circumstances, nor as yet by the full removal of economic constraints affecting accessibility to health services. The Canadian experience raises the fundamental concern of whether a reasonable level of equity can be achieved in nations having distinctive regional priorities, a federal structure linking people of different cultural identities, and where a sharp gradient of economic opportunities is entrenched.