Health policy is inherently political. The allocation of resources, access to care, and decisions about how health care systems are structured and governed reflect deep ideological commitments and contestations. As 2024 unfolds, a pivotal election year for both the United States and various European countries, health care issues are once again taking centre stage. Policy decisions about health care often become battlegrounds for broader debates about the role of government, market forces, and the extent to which health care should be a public good or (increasingly) a commodity. In this issue of Health Economics, Policy and Law, we have brought together a set of papers that explore the political dimensions of health care reform, drawing on research that address the intersections of politics, health care systems, and policymaking in the United States and Europe.

The health care debate in the United States is deeply partisan – an issue examined critically by Gusmano and Thompson (Reference Gusmano and Thompson2023). While the passage of the Affordable Care Act (ACA) in 2010 was a landmark achievement for Democratic legislators to increase health care access, there have been persistent challenges from Republican lawmakers, including attempts to undermine or repeal the ACA. The current Democratic Biden administration has worked to reinvigorate the programme through legislative and executive effort, yet ongoing political and legal battles, especially in states that have resisted Medicaid expansion, continue to shape the future of health coverage in the United States. The political stand-off over health care reform is reflective of deeper ideological conflicts within the political system, and the work underscores how electoral outcomes have significant implications for health policy.

An almost equally dividing topic is the legalisation of marijuana for medical and recreational usage, often due to concerns about health and safety, and its wider societal implications. The increasing acceptance of medical marijuana in the United States provides a stark example of how state-level policy innovations can outpace federal regulatory frameworks. The critical research by Kalbfuss et al. (Reference Kalbfuss, Odermatt and Stutzer2024) shows that legalising medical marijuana is linked to improved mental health outcomes, a finding that has received widespread attention in policy discussions. In the context of the 2024 elections, the future of marijuana policy will likely continue to be debated. As more states legalise both medical and recreational use, the federal government faces increasing pressure to harmonise its policies. The research findings therefore provide important evidence to inform these debates, particularly in how health care systems address mental health treatment and the broader decriminalisation of cannabis.

The National Health Service (NHS) in the United Kingdom is often held up as a model of publicly funded health care, yet the meanings behind its defining terms – ‘national,’ ‘health,’ and ‘service’ – are contested and politically charged. The research by Powell and Williams (Reference Powell and Williams2024) offers a content analysis of these three words, illustrating how they evoke different visions of what the NHS should be. The term ‘national’ implies inclusivity and equity, reflecting the idea that health care should be available to all citizens. However, the terms ‘health’ and ‘service’ introduce tensions between medical professionalism, service provision, and the economic realities of delivering care. The analysis is particularly timely as the United Kingdom has recently voted in a new Labour government tasked with shaping the future of the NHS. Funding shortages, staffing crises, and increasing patient demand have placed the NHS under significant pressure, and the political rhetoric surrounding its future reflects deeper ideological divides. For example, should the NHS be restructured to become more efficient, even if that means introducing more private sector involvement? The research in this issue underscores the political nature of health care and the need for deliberate strategies to reconcile these competing visions. The language of health care policy matters, and in an election year, how political parties frame their visions for the NHS will be critical in shaping public opinion and the future direction of the health care service.

Sweden's publicly funded health care system shares many similarities with the English NHS but differs significantly in its approach to health care governance. The paper by Bergstedt et al. (Reference Bergstedt, Sandman and Nedlund2024) examines how political leadership in health care governance can be enhanced through mediating institutions that focus on priority-setting. Particular attention is given to the role of political advisory committees in regional authorities tasked with making priority-setting more explicit and systematic. This approach is seen to enhance democratic legitimacy and ensure that health care priorities reflect the needs of the population. However, this democratic approach also introduces tensions, which become even more pronounced during election periods, as political actors may cater to public sentiment rather than focusing on the long-term sustainability of the health care system. However, the issue of priority setting in health care is not unique to Sweden and it will grow in importance. Across the world, governments are grappling with how to allocate limited resources in a way that balances equity, efficiency, and quality of care.

In 2020, England implemented a significant policy change, shifting from an opt-in to an opt-out system for organ donation. The paper by Williams et al. (Reference Williams, Bostock, Noyes, McLaughlin, O'Neill, Al-Haboubi, Boadu and Mays2024) explores the political and ethical dimensions of this transition, highlighting how the policy aims to increase the number of organs available for transplantation while navigating concerns about consent and individual autonomy. The move to an opt-out system has sparked broader debates about the role of government in health care decision-making. Critics argue that the policy infringes on personal freedom, while supporters suggest that it is a necessary step to address the chronic shortage of donor organs. The results of this policy could influence future health care reforms, particularly in areas where governments seek to balance individual autonomy with collective health outcomes.

The paper by van Velzen et al. (Reference van Velzen, Janssen and Varkevisser2023) examines the ongoing debate in the Netherlands about centralising emergency care services, linking the issue to broader international discussions about cost, quality, and access to health care. The centralisation of emergency care is often seen to improve efficiency and outcomes by concentrating resources in larger, better-equipped hospitals. However, this approach can also lead to the closure of smaller, rural hospitals, raising concerns about access for disadvantaged populations. The work also highlights the political challenges of centralisation, particularly the tension between improving care quality and maintaining equitable access, which is even becoming more pronounced in the current populist political debate that stresses the importance of rural areas. As health care costs and pressures on important resources such as health care professionals continue to rise, centralisation – and the divide between the city and the rural – will remain a key issue in political debates, both in the Netherlands and across Europe.

Finally, the paper of Attwell et al. (Reference Attwell, Roberts and Rizzi2024) brings us back to another highly politicised topic; the struggle of governments to deal with the COVID-19 pandemic. This paper addresses the political dynamics of vaccination policies during the pandemic in Western Australia, discussing the COVID-19 vaccine mandates for employment and public spaces. Based on an interview study, the authors argue that the public was supportive in policy measures to restricting access to non-vaccinated citizens to reopen the country yet warns for the consequences of such stringent policy measures for future vaccine uptake, bringing in the crucial aspect of temporality to the political and policy debate that is worth exploring further.

The politics of health policy is deeply intertwined with electoral cycles, ideological divisions, and public sentiment. The papers in this issue provide valuable insights into how health care systems are shaped by political decisions, and how these decisions impact access, quality, and equity. As 2024 unfolds, the outcomes of elections in the United States and Europe will have profound implications for the future of health care delivery, both in terms of policy innovation and the pursuit of health equity.