Coverage Without Capability: Understanding the Disparity Between Urban and Rural Low-Income Populations in Universal Healthcare Reform

Despite the coverage of Universal Healthcare (UHC) reforms being globally expanded and out-of-pocket costs substantively lowered, disparities between urban and rural populations persist, particularly for those with low income. This paper examines the mechanisms through which UHC reforms have failed to close this gap. Drawing on Amartya Sen's Capability Approach and Jennifer Ruger's Health Capability Paradigm, it evaluates equity as the substantive capability to achieve health outcomes, not formal entitlement. The 3A Framework and Marmot's Social Determinants of Health specify the conversion factors that determine whether coverage becomes actual capability to access medical resources and services. Cross-country evidence shows financial protection improves access to medical resources but not treatment outcomes. The binding constraint diverges by setting: social infrastructure in cities, physical infrastructure in rural areas. A comparative study between two contrasting cases of the hyper-dense, public transit-dependent, metropolitan Shenzhen and the mountainous, formerly impoverished rural Chishui County, Guizhou confirms that instead of financial coverage, spatial accessibility is the decisive conversion factor that produces proximity without access in Shenzhen and nominal equity without substantive medical abundance in Chishui.