Navigating health systems in times of inequality and uncertainty… <i>And how we go from here</i>

The end of the year offers an opportunity to reflect on all that has happened over the past year.The year 2024, to be sure, brought many societal challenges and insecurities that also impact health systems.Climate change, workforce shortages, technological transition, and growing geopolitical tensions have significantand largely still unknownconsequences for how we organise and provide health care at the national level, and how it impacts our thinking about (access to) care.These challenges are not only important to study and discuss as they impact health care access and quality of care, but they also mirror contemporary issues and challenges.As such, health care can act as a source or 'site of investigation' to study these broader societal phenomena.For this last issue of Health Economics, Policy and Law of the yearwhich is published a bit later than usualwe selected articles that investigate and discuss the consequences for health and health care inequality.The papers address both broader trends, and more specific or 'local' challenges and uncertainties.Both are relevant to better understand our evolving health systems and concerns now, and in the future.One of those bigger challenges is the United Nations' Sustainable Development Goals, among others to provide universal health coverage by 2030.Watson and Amin (2024) study the availability of care in Canadian regions, monitoring the number of physicians ('labour capacity') and beds ('capital').They demonstrate the regional differences in both labour and capital that account for one-third of the efficiency cap between city regions and rural areas.They argue for more specific policies to overcome regional disparities and enhance universal access.The United Nations sustainability goals are also addressed by Singh (2024), who examines the impact of publicly funded health insurance on health care demand.Based on a quasi-experimental study addressing hysterectomy (removal of the uterus) among women in India, they find that public-funded health insurance coverage increases the change of this surgical intervention instead of ensuing preventative or primary care.These findings signal an urgent need to study the (perverse) effects of the aim of universal health coverage, and how this goal gets institutionally embedded in evolving health systems.In the third paper, Dixon et al. (2024) discuss the impact of genomics and genetic information on risk-based insurance and related regulatory models in the UK.Evolving technologies and knowledge related to genetic information provides challenges to risk-based insurance as risks can be better predicted yet remain 'risks' and hence do not tame uncertainty.However, they also increase insecurity by bringing in new types of uncertainty, prompting new regulatory issues.Authors suggest a deliberative approach to establish when and how genetic information can be used in risk-rated insurance.The role of health insurance is further elaborated on by McFarland and Miller (2024), who 'test' Bedford's law to study how health care finance impact clinical decision making and influence health care costs.Although Bedford's law points to a logarithmic distribution of clinical encounters and treatment, the authors show that