The 5 top health care stories of 2018—and what to expect in 2019

Topics: Care Delivery, Clinical Quality, Finance, Costs and Prices, Medical Bills and Debt, Payments and Reimbursement, Payment Reform, Health Care Reform, Industry, Prescription Drugs, Insurance, Exchanges, Health Plans/Insurance Companies, Individual Mandate, Medicaid, Medicare, Legal Issues, Politics and Policy, Federal Government, Regulatory, Health Care Legislation, State Government, Providers, Emergency Department, Hospitals, Physicians, Public Health, Substance Use, Illicit Drugs, Prescription Drug Misuse

By Heather Bell, managing editor

As 2018 comes to a close, we're taking a look back at the biggest stories in health care. From major changes to state Medicaid programs to a state-led lawsuit that might yet succeed in toppling the Affordable Care Act (ACA) where Republican lawmakers failed, American Health Line's coverage in 2018 focused on topics that most affect the health care industry.

What were the biggest stories of the year? In no particular order, here are five picks from American Health Line's editorial team.

1. In some states, Medicaid got more restrictive (and it could be a sign of things to come)

CMS kicked off 2018 by issuing controversial guidance that for the first time allowed states to seek waivers to make work requirements a condition of Medicaid eligibility. Kentucky on Jan. 12 became the first state to receive approval, but until recently the state's waiver remained tied up in court. Proponents of work requirements say they can help people achieve greater well-being and self-sufficiency, while critics have argued that they can have a disproportionate effect on individuals with disabilities and can cause beneficiaries who comply with the spirit of the rule to unnecessarily lose coverage for failing to fulfill documentation requirements.

What to expect in 2019: As of Dec. 7, Kaiser Family Foundation data show five states have received federal approval to impose work requirements on beneficiaries, and 10 states have waiver requests pending—with more likely to follow. In 2019, we'll also begin to see the real-world effects of the waivers. Arkansas so far is the only state that has implemented the requirements, and the latest state data show nearly 17,000 Arkansas residents have lost Medicaid coverage as a result.

2. The Affordable Care Act faced new legal (and regulatory) threats

While a congressional repeal appeared to pose the biggest threat to the ACA in 2017, this year the law faced a different set of legal and regulatory threats. The Trump administration in November released guidance on how states can use State Relief and Empowerment Waivers, formerly known as state innovation waivers, to reform their health insurance markets and avoid certain ACA rules. For example, the new guidance would allow states to change how they distribute and structure ACA premium subsidies.

But the biggest threat to the ACA came in the form of lawsuit filed in February by a group of Republican led-states. The states argued that the ACA's individual mandate is no longer a constitutional exercise of the government's taxation authority because Congress set the mandate's tax penalty to $0, and that without the penalty, the individual mandate—and by extension the entire law—must be invalidated. To the shock of health policy wonks from both sides of the aisle, a federal judge this month ruled in favor of the states and struck down the ACA.

What to expect in 2019: Federal officials were quick to note that the judge's ruling had no immediate effect and that as of now, the ACA and all of its programs will continue to operate in 2019. As for the lawsuit, legal experts largely expect the ruling will not survive appeal, although it could eventually make its way to Supreme Court.

3. Eye-popping health care prices continued to draw criticism from consumers—and policymakers

Whether it was a 1,468% price increase for skin cream, surprise $27,000 in medical bills, rising air ambulance charges, or costly medical devices U.S. health care prices are now under the microscope. Vox's Sarah Kliff spent 2018 combing through readers' emergency department bills to analyze hospital pricing trends; the Trump administration has made increasing access to affordable prescription drugs a key policy platform; and Amazon, Berkshire Hathaway, and JP Morgan Chase teamed up to launch a new company that aims to provide "simplified, high-quality, and transparent health care at a reasonable cost" for their employees.

What to expect in 2019: Many eyes will be on the Amazon-Berkshire-JPMorgan venture to see whether the companies can create a scalable way to rein in health care costs without sacrificing quality. Meanwhile, policymakers will likely continue to apply pressure to drugmakers with above-average price increases.  

4. Value-based care moves forward, and it might go mandatory (again)

Health care providers in 2018 continued to shift toward value-based payment models. A report from the Health Care Payment Learning and Action Network showed about one-third of health care payments made in 2017 were associated with value-based models. And in 2018, CMS and HHS unveiled new proposals to continue the shift away from the traditional fee-for-service payments. CMS announced a new way providers could participate in MACRA's Advanced Alternative Payment Model track, as well as changes to the Medicare Shared Savings Program that would require participating accountable care organizations to take on two-sided risk sooner.

What to expect in 2019: HHS Secretary Alex Azar several times this year has suggested we could see mandatory value-based payment models make a comeback in 2019. Azar most recently said CMMI plans to test a mandatory Medicare payment model for radiation oncology, as well as "new and improved" versions of previously canceled payment models for cardiac care.

5. The United States' opioid misuse epidemic rages on, but there are glimmers of hope

Public health officials, providers, and law enforcement continued to grapple with the United States' opioid misuse epidemic. Opioid-related overdose deaths have continued to rise, with CDC's projected 2017 fatality total exceeding 70,000 people.

But in 2018, policymakers and industry stakeholders took significant steps to curb the epidemic. In March, President Trump unveiled a three-pronged plan to combat the U.S. opioid epidemic featuring a new advertising campaign to discourage drug misuse, increasing access to substance use disorder treatment, and a controversial proposal for certain drug dealers to face the death penalty. Congress followed up in October by passing a bipartisan, bicameral legislative package to address the opioid epidemic through a variety of public health initiatives. And hospitals and health systems have implemented programs to educate physicians on opioid prescribing habits and expand access to medication-assisted treatment and alternative treatments for pain.

What to expect in 2019: Azar in October said early data suggest the United States is "beginning to turn the tide" on the opioid epidemic. But that doesn't mean public health officials and providers don't have their work cut out for them. Providers continue to face obstacles to carrying the opioid reversal drug naloxone, FDA will need to continue to seek out non-opioid alternatives to pain management, and communities and local hospitals will need to increase access to substance use disorder treatment to quell the epidemic.