When we launched Vitals early in 2017, Republicans were attacking the Affordable Care Act, insiders were fretting over the opaque nature of drug pricing, and people were peddling discredited theories about vaccines and autism.

• What's past is prologue. Still, nothing could have prepared us for some of the things that followed.

The big picture: A global pandemic, technological changes and the arrival of new blockbuster drugs marked seismic shifts for a health care system undergoing rapid consolidation.

• Policy debates swung from costs to coverage and back again, and biomedical research became more of a national security concern.
• And patients more than ever are worried about how to navigate the medical system and the cost of care.

As we move to a new chapter for this newsletter, it's time to reflect on some of the biggest changes since Vitals debuted early in the first Trump administration.

Trust in the health system has plummeted. The pandemic experience and backlash to the government's response politicized public health and eroded the public's trust in hospitals, doctors and government agencies. Vaccines and the CDC are now political lightning rods, unlike before COVID.

• That's dovetailing with affordability concerns. Recall the social media-fueled rage against health insurers following the shocking murder of UnitedHealthcare CEO Brian Thompson.
• And the distrust is manifesting itself in other ways, like declining childhood vaccination rates.

Care escaped the doctor's office. As the ranks of independent doctors dwindled, the pandemic ushered in a new era where telehealth and pharmacy-based care became commonplace.

• That's helped narrow some geographic disparities. But uncertainty over insurer reimbursements, added technological costs and privacy issues continue to hang over the new care models.

Health coverage rose, then fell. More people gained health insurance than ever before through the ACA. But those gains are being reversed through steep cuts in federal Medicaid spending and the expiration of enhanced ACA marketplace subsidies.

• The changes are projected to save the government hundreds of billions but already are raising the uninsured rate and stoking concern about people delaying care. Most of the ripple effect won't be seen until after the midterm elections.
• Even employer insurance has entered the political chat: It's gotten so much more expensive that politicians can no longer ignore it.

Consolidation is blurring lines. While policymakers have cranked up scrutiny of certain segments like pharmacy benefit managers, health care giants are protecting their profits by vertically integrating and essentially owning the entire health journey.

• Insurance companies, pharmacies and PBMs have only all existed under the same roof for less than a decade. (UnitedHealth being the exception, though it's also gotten bigger.)
• The consolidation trend is intersecting with affordability concerns, with Republicans and Democrats both questioning whether huge health systems and insurance companies are eliminating market competition and driving up prices.
• It's noteworthy that hospitals are no longer untouchable: Only wonks used to point out that facilities are the biggest contributor to overall health spending.

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Obesity became a pharma focus. Once written off as a vanity issue, obesity has become a major target of drug development, evidenced by the explosion of GLP-1 weight-loss drugs with a widening span of secondary health applications.

• This is another big health cost driver, with public and commercial payers wary about covering the pricey drugs and more trade-offs ahead as new pills drive increased demand.

Medicare's transformation. Some of the biggest changes in the last decade have pivoted around Medicare, starting with the government taking on the role of directly negotiating prices of selected high-cost drugs with manufacturers.

• Medicare Advantage enrollment has also steadily increased to the point where private plans have become ingrained in the system — although there are signs that the market wave has crested.
• Value-based care also is proliferating within the program and throughout the health care system, though fee for service remains the dominant payment system.

And there's more. There have been other huge changes, the effects of which are still playing out. The federal right to abortion no longer exists. Americans are now protected from surprise medical bills. And health care jobs are propping up the economy in ways they weren't a decade ago.

Some things haven't changed. "Medicare for All" still is dividing Democrats and is no closer to becoming reality.

Caitlin Owens contributed.

This was the lead story of the first issue of Vitals on Jan. 9, 2017. Whatever else you want to say about it, we think it held up pretty well.

• That should give you confidence that as we shift our focus to the future of health care, everything we write will be correct.