If 2025 delivered shock waves to public health and federal health programs, this year promises more chaos as providers, payers, consumers and policymakers deal with the repercussions.

Why it matters: The sweeping changes to Medicaid and the Affordable Care Act, the upending of the vaccine system, and new ways people purchase drugs foreshadow the most significant changes to health markets since the passage of Obamacare.

Here are some of the top storylines we'll be watching:

Health care costs: Health insurance premiums are surging in ACA markets, thanks to the expiration of enhanced subsidies, and for workplace coverage. Drugmakers are raising prices for hundreds of medicines, despite President Trump's strong-arming.

• The question is whether Republicans can even agree on what to do about an issue that's ratcheting up voter anxiety.
• Their first chance will come this month in the run-up to the government funding cliff, when there's the opportunity to use a spending deal to retroactively extend the Obamacare subsidies for about 20 million patients, many of whom live in red states.
• The other option would be for the GOP to go it alone with another megabill filled with conservative ideas aimed at lowering health care costs. While that could help endangered incumbents, it would mean another draining health care debate without a clear path for passage.

Medicaid: This is the year when states will have to implement the changes that congressional Republicans passed in last summer's tax-and-spending law — and it's not clear that they'll be ready.

• Among other things, they have just one year to build and test systems to make sure able-bodied recipients are working at least 80 hours a month and gather supporting data for people who are exempt.
• The millions more uninsured Americans arising from all of the changes are expected to drive up unreimbursed care costs for hospitals and threaten those with shaky finances.

Vaccine restrictions: More regional outbreaks of measles, whooping cough and other vaccine-preventable diseases could test the Trump administration's resolve to adopt a new childhood vaccine schedule, especially without going through an established rulemaking process.

• The FDA has also signaled it may impose tougher requirements on new vaccines and the annual flu shot, which medical professionals say would make it impossible to test and manufacture a vaccine in time for each year's flu season.
• And Health Secretary Robert F. Kennedy Jr. wants to revamp the federal liability protections that shield drug manufacturers from being sued for vaccine-related injuries.

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States no longer will be required to report how many children and pregnant women covered by Medicaid are immunized, the Trump administration wrote in a letter to state officials.

Why it matters: The move could significantly decrease visibility into nationwide vaccination rates, since Medicaid and the Children's Health Insurance Program cover almost half of U.S. kids and 41% of births.

State of play: Federal Medicaid administrators starting this year will retire four quality measures on pediatric and prenatal vaccination status of enrollees.

• States can still voluntarily report vaccination levels to CMS.

Zoom in: States have only been required to report a core set of quality measures for kids enrolled in Medicaid — including vaccination status — since 2024.

• Federal Medicaid payments to the states aren't tied to the vaccination reporting measures.

Between the lines: CMS says the HHS secretary has the discretion to change the reporting requirements.

• Childhood vaccination rates are dropping in many parts of the U.S. Some 5.2 million kindergarten-age children live in counties where vaccination rates are below herd immunity, according to data analyzed by the Washington Post.

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Pandemic-era telemedicine flexibilities around the prescribing of controlled substances have been extended yet again, HHS announced Friday.

Why it matters: The extension — the fourth of its kind — will allow patients to receive prescriptions for medicines like attention-deficit/hyperactivity disorder and opioid use disorder treatments via telehealth without a prior in-person visit through the end of 2026.

• In 2024, more than 7 million prescriptions for controlled medications were issued without a prior in-person visit, HHS said, suggesting that an abrupt expiration of the federal flexibilities could have an enormous patient impact.

What we're watching: This extension gives the Drug Enforcement Administration "additional time to finalize permanent regulations," per the announcement.

The big picture: If there was any clear winner during the pandemic, it was telehealth, which emerged with strong bipartisan support.

• But permanent regulation surrounding controlled substances is aiming to balance patient access with preventing misuse of such medications.
• Some patients have grappled with shortages of Adderall and other amphetamines like Vyvanse used for ADHD. Behavioral health providers say access would be further disrupted if old limits on telehealth prescribing were restored.

The Trump administration paused a contentious drug purchasing pilot program that was due to take effect on Jan. 1, after a federal judge ruled that officials didn't sufficiently consider the impact on safety net hospitals.

Why it matters: It's a blow to some large drugmakers, who want to make providers pay full price for medicines they currently get at a steep discount and reimburse them later if they're found to qualify under the federal 340B program.

Driving the news: The payment experiment covering 10 outpatient drugs was paused after U.S. District Court Judge Lance Walker found on Dec. 29 that it likely violated the Administrative Procedure Act.

• The American Hospital Association and individual facilities had challenged the program, saying individual facilities would have to make millions in upfront payments that would otherwise be spent on low-income and rural patients.
• Critics of the pilot have said up-front savings from 340B discounts allow hospitals to invest billions of dollars annually into free clinics, charity care and community-based programs.

What's next: The administration has said it's appealing the ruling. For now, manufacturers who were approved for the pilot have to continue to offer all covered drugs with an up-front discount.

🥼 Trump's recent comments on his aspirin use have revived a medical debate on how it's been used to help prevent heart attacks and blood clots. (Axios)

🤧 Flu season is heating up, but the pattern isn't unusual, and cases may not peak until February. (WaPo)

💊 Trump's drug pricing deals won't benefit many Americans today. They might over time. (Politico)