How your health care will be reshaped in 2018

1. Politically induced chaos

The most consistent theme in the politics of health care last year was uncertainty, and that seems highly unlikely to change in 2018.

• The Affordable Care Act's exchanges are a mess of competing priorities that no longer reflect any cohesive policy vision.
• The individual mandate is about to disappear; Congress still has to make a decision about cost-sharing payments and reinsurance. And we'll see new regulations from the Trump administration that will make the landscape even harder for insurers to predict.
• That will push a lot of the action to the states, where insurers will lobby for reinsurance funding, regulatory waivers (on which the Trump administration would have to agree) and state-level coverage requirements. The inevitably mixed results mean an increasingly uneven playing field from one state to the next — and from one county to the next.

And that's just the individual market. Open gubernatorial races in this year's midterms will have an enormous effect on health policy for years to come. Medicaid expansion will be explicitly on the ballot in a handful of states. House Speaker Paul Ryan wants to take another crack at Medicare and Medicaid cuts.

Buckle up. These are just the battles we already know about, barely 24 hours into the year.

2. Industry consolidation

The health care industry is consolidating rapidly — hospitals are merging with each other and with insurers; pharmacies are buying insurance companies; and drug companies are snapping up other drug companies.

The big question: Are these deals good for consumers?

• What happens to networks of hospitals, doctors and pharmacies? Those options will likely narrow as different types of health care businesses end up under the same roof.
• Regulators ultimately will have to consider whether merged companies are gaining too much negotiating power, and whether these deals will lead to lower health care costs.

What's next: Regulatory reviews of all these mega-mergers will fall to the Federal Trade Commission — which already has limited resources — and the Department of Justice.

• Many current deals, including CVS-Aetna, don't present the same antitrust issues that sunk previous health care mergers.
• The end of 2017 was among the busiest seasons of mega-mergers in a long time. Expect the trend to continue, while the deals announced last year move closer to reality.

Don't forget: Many people have overlooked the part of President Trump's health care executive order that said his administration will "focus on promoting competition in health care markets and limiting excessive consolidation."

3. A pipeline full of expensive drugs

This year will see crucial clinical trials — and potentially FDA approval — for a host of drugs, including highly watched therapies in oncology and immunology.

Retail drug spending growth has actually been mild over the past two years, but the pending arrival of expensive new treatments, including CAR-T therapies, will add new fuel to the drug-pricing fire, much like expensive new hepatitis treatments helped blow the issue open in 2014 and 2015.

The impact: This isn't just a political debate: These products can place a real strain on insurance premiums, and could cripple taxpayer-funded health care programs.

• Two academic doctors who study drug economics, Walid Gellad and Aaron Kesselheim, offered in May 2017 some policy ideas to keep spending in check.
• Value-based drug contracts — in which drug companies are only paid if their drugs are effective — are the policy du jour. But we still don't know a lot about how they are designed or whether they work.
• Drugmakers often point out that some of these new products are more expensive but also far more effective than their predecessors. But there still is nothing stopping drug companies from buying old, inexpensive drugs and jacking up their prices — the type of behavior that made Martin Shkreli infamous. And that only gives the industry's critics more ammunition.

What to watch: Policymakers, including HHS secretary nominee Alex Azar, have supported some proposals to crack down on price-inflating tactics, including drugmakers' patent strategies and the secretive rebate system used by pharmacy benefit managers.

4. A new era in Medicaid

The Trump administration has barely gotten started on what might end up being one of its biggest health care legacies — a new, more conservative vision for Medicaid. But those changes are just around the corner.

• Seema Verma, who leads the Centers for Medicare & Medicaid Services, has already said CMS will begin allowing states to impose some form of work requirements on Medicaid recipients.
• Using Medicaid "as a vehicle to serve working age, able-bodied adults does not make sense," Verma said in November.
• Most states already rely on private managed-care organizations — that is, insurance companies — to administer their Medicaid programs. This has quietly become a big line of business for the insurance industry, giving insurers a growing stake in the kinds of regulatory flexibility states are seeking from CMS.

5. The opioid crisis goes on

The opioid crisis is so bad, nationwide, that Americans' life expectancy is going down, despite myriad advances in medical technology.

• There are pieces of a response in place — FDA Commissioner Scott Gottlieb has taken an aggressive stance on promoting medication-assisted therapy, and some states have developed comprehensive plans.

Yes, but: There's no coordinated national strategy to try to get this crisis under control, much less reverse the rising tide of addiction, overdoses and death.

• Neither Congress nor the Trump administration has put much federal money behind an opioid response.
• The White House has declared it an emergency and released a long, detailed set of policy recommendations that cut across a broad swath of federal, state and local agencies. But no one is in charge of putting those ideas into practice.