Balancing sustainability with equitable access to new technologies is a challenge for all health systems. For instance, potentially life-extending but expensive medicines, particularly in oncology, may offer only modest benefit near the end of life. The costs of these drugs are placing pressure on public and private payers, individual patients, and their families. The United Kingdom and Australia have established programs that require evidence of comparative clinical and cost-effectiveness to inform decisions. This brief analyzes British, Australian, and German policies on coverage of such medicines. For Europe and Australia, the challenge is to manage the continuing pressure to pay for expensive medicines through tax- or social security-funded systems, without undermining core principles of equity and efficiency. For the United States, the challenge is to ensure fiscal sustainability of Medicare, Medicaid, and the private insurance market without restricting choice, especially as health reform extends access to more Americans.