Health systems are often discussed as problems of design: the optimal benefit package, the efficient payment mechanism, and the well-calibrated means test. Yet comparative health policy points to a more demanding conclusion. Health systems are not simply designed; they are contested. They are shaped through conflict among governments, industries, professions, investors, and citizens whose interests often diverge, and whose relative power determines what reform can be imagined, enacted, and sustained (Friebel and Wallenburg, Reference Friebel and Wallenburg2024). The six articles in this issue of Health Economics, Policy and Law span tobacco regulation in Europe, fraud enforcement and HIV prevention in the United States, hospital reform in China, and long-term care in England and the Netherlands. Taken together, they show that health systems and their reforms are politised and form political economies that are continuously negotiated. They ask: when health systems are reformed, whose system is being remade, and whose interests does reform ultimately serve?
1. Law and the boundaries of regulatory space
The first contest concerns the boundaries of legitimate state action. Delhomme et al. (Reference Delhomme, De Ruijter, Hervey, McKee and Veraldi2026) examine objections raised by European Union (EU) member states to the application of the United Kingdom's smoke-free generation policy in Northern Ireland under the Windsor Framework. Their analysis challenges the claim that generational tobacco sales bans are inherently incompatible with EU internal market law. They argue instead that such claims rely on selective readings that recast free movement law as a deregulatory free-trade project, rather than as part of the legal architecture of a health-protective market. The constraints imposed by EU law, they conclude, are narrower, and the opportunities for ambitious public health regulation broader, than is often assumed.
The argument matters because it treats legal interpretation as a political resource (Friebel and Wallenburg, Reference Friebel and Wallenburg2026). The authors warn that treating objections submitted through the Technical Regulations Information System as evidence of unlawfulness risks chilling public health ambition, especially in legally hybrid jurisdictions where rule-takers may default to conservative readings. The contested space, in this example, is neither parliament nor market, but the interpretative structure of EU internal market law. Whether that law is framed as a constraint on public health ambition or as the legal architecture of a health-protective market determines the scope of feasible reform. Law does not stand outside the political economy of health; it is one of the principal means through which that political economy is put to work.
2. Politics within enforcement and access
If Delhomme and colleagues show politics shaping the outer boundary of reform, Han et al. (Reference Han, Janousek and Noh2025) show it inside the administrative machinery of the health system. Their study asks why investigations into Medicaid fraud and abuse vary so markedly across United States states. Using fixed-effects panel data from forty-nine states between 2014 and 2021, they find that state operation of an all-payer claims database is associated with higher rates of Medicaid fraud and abuse investigations, while states with Democratic governors tend to record fewer investigations. Enforcement is therefore not simply a technical function of detection capacity. It also reflects the institutional resources, transparency infrastructures, and political priorities through which programme integrity is pursued. The same federal programme can produce different enforcement realities depending on state-level administrative capacity and political context.
Kane (Reference Kane2026) develops a parallel argument about access rather than enforcement. Mapping “PrEP deserts” (i.e., areas without spatial access to providers of HIV pre-exposure prophylaxis) across all fifty states in 2020 and 2023, Kane documents substantial gains in geographic access, with the population living in PrEP deserts declining markedly over the study period. The gains, however, were uneven. Five states saw the total population living in PrEP deserts increase, and the distributional consequences differed across communities. In Kentucky, newly expanded PrEP deserts disproportionately affected communities of colour; in Alabama, the modest increase was driven largely by predominantly white communities losing access. Because HIV prevention in the United States depends on provider location, local healthcare infrastructure, and state and local implementation capacity, national prevention goals translate into equitable access unevenly. Read alongside Han, Janousek and Noh, Kane's article reinforces that federal programmes and national policy ambitions are refracted through subnational institutional and geographic structures, where the distribution of benefit is often decided.
3. Stewardship and the political work of reform
If politics can fragment reform, it can also be organised to make reform possible. Jiang and Ramesh (Reference Jiang and Ramesh2025) develop this argument through the case of Sanming, China – a fiscally constrained city with an ageing population and a medical insurance fund under severe pressure that became a national reference point for comprehensive health system reform. Their framework identifies six stewardship functions (i.e., strategic visioning, institutional alignment, instrument design, partnership management, accountability reinforcement, and learning facilitation) through which active government stewardship helped set direction, coordinate institutions, redesign incentives, and adapt implementation over time. Sanming's reforms were sequenced rather than launched as a single intervention. Drug pricing and procurement reforms generated savings and reduced waste, creating fiscal and political space for later changes to hospital payment, provider incentives, primary care integration, and population-health management. The result was a reorientation of the local health system toward financial sustainability, improved service delivery, and measurable health gains.
The case matters because it treats the political conditions of reform as constructed, not inherited. Sanming's reform leading group concentrated authority, reduced bureaucratic fragmentation, and built the institutional alignment that ambitious reform requires. Similarly, Jiang and Ramesh are equally attentive to fragility. Uneven agency capacity, shifting external policy environments, and weak feedback loops all threaten durability, while nationwide diffusion has remained uneven. Stewardship, on this account, is not a substitute for political economy, but the work of navigating interests, incentives, and institutions.
4. Who pays, who profits: long-term care and distributional conflict
The two long-term care studies move the focus to money, assets, and the boundary between public obligation and private gain. Hu et al. (Reference Hu, Hancock, Wittenberg, King and Morciano2025) examine planned reforms to England's long-term care means test, including a lifetime cap on care-cost contributions and more generous capital limits. They project that public spending on older people's long-term care would be about fourteen per cent higher by 2038. The cap would mainly benefit better-off people currently receiving no state help, while the capital-limit changes would also assist those with more modest income and wealth. Without an agreed framework for fairness in social care funding, who gains, and on what terms, remains contested.
Krabbe-Alkemade et al. (Reference Krabbe-Alkemade, Makai, Canoy, Kemp and Portrait2025) turn to the supply side of marketised care. Studying Dutch institutional long-term dementia care, they examine for-profit and private-equity providers offering round-the-clock care in home-like settings. They find no strong evidence that these providers engage in greater risk selection, upgrading of care entitlements, or lower-quality care than non-profit providers. The findings complicate simple ownership-based assumptions, suggesting that adverse incentives in the Netherlands may depend less on ownership type than on how care is delivered and financed. Read alongside Hu and colleagues, the two studies ask who pays, who profits, and how financing architecture shapes both questions.
5. Towards a political economy of health reform
Taken together, the six articles outline a research agenda for the political economy of health reform. Three propositions follow. First, the instruments of health policy are never neutral. A directive, a claims database, a catchment measure, a means test, and an ownership structure each encode assumptions about whose interests count and who carries risk. Second, the distance between reform as announced and reform as experienced is shaped by institutions and actors operating below the level at which policy is most visible: local authorities, municipal leading groups, or individual providers. Implementation is often subnational, discretionary, and uneven. Third, evidence is itself a contested resource. The same legal text, or body of international literature can be used to enable or obstruct reform, placing a particular responsibility on scholarship to make its framing choices explicit.
For Health Economics, Policy and Law, whose disciplinary mandate sits at precisely this intersection, the implication is clear. Economic estimation and legal analysis are essential, but their significance depends on the political economy that determines which findings are acted upon. The cap that benefits the better-off, the enforcement pattern shaped by state politics, the prevention desert that persists despite national prevention ambition, and the stewardship that must be assembled before it can steer are reminders that health reform is always political. To ask whose system it is, anyway, is not an exercise in scepticism. It is the starting point for understanding why reforms succeed and fail, and what political economies they pursue. That is, who gets what, when, how (Lasswell, Reference Lasswell1936) – and who won't.
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