To say it’s been a big year in health care is a bit of an understatement.
From the back and forth of Congressional Republicans' attempts to repeal and replace the Affordable Care Act (ACA) and President Trump's executive orders on health care to the resignation of U.S. Health and Human Services Secretary Tom Price and the declaration of the opioid epidemic as a public health emergency, 2017 was unpredictable.
But beyond those headlines that appeared in every news outlet -- big or small, conservative or liberal, online or on TV -- there was plenty more policymaking going on beneath the surface, particularly on the state and local level.
Here's some of the biggest health news you may have missed while paying attention to the drama on Capitol Hill.
Changes to Medicaid, one waiver at a time
Federal waivers allow states to operate their Medicaid programs in certain ways not explicitly allowed under federal law. Perhaps the biggest news surrounding Medicaid waivers came toward the end of the year.
In November, Centers for Medicare and Medicaid Administrator (CMS) Seema Verma said in a speech that she is ready to usher in a “new day for Medicaid,” one focused on personal responsibility and decreased regulations for states. The Obama administration largely rejected states' Medicaid waivers out of concern that they would reduce insurance coverage for low-income people.
Six states have pending waivers to impose work requirements on Medicaid recipients, and Wisconsin wants to implement drug testing for all applicants. Most conservative of all, Maine wants to impose asset testing, which screens eligibility based on property and savings -- something strictly prohibited by the ACA.
It’s unclear if CMS would approve something that far-reaching, but Verma does support work requirements. Many thought 2017 would be the year these states would get their wish, but Matt Salo, director of the National Association of Medicaid Directors, isn’t surprised that CMS has taken so long. He thinks it’s probably preparing a legal defense.
“When you know you’re going into new territory, you have to make sure you have your ducks in a row. We know the minute one of those waivers gets approved, there are going to be lawsuits. That’s been part of the hold up,” he says.
In some respects, like battling the nation's opioid epidemic, the Trump administration is continuing the health care traditions of the Obama era.
A decades-old law bans Medicaid from paying for substance abuse treatment in facilities with more than 16 beds. It was enacted as part of a larger push away from large mental institutions, but many see it as a hindrance to getting people into affordable care.
This year, the Trump administration approved waivers to let Virginia and West Virginia ignore that law. Four other states -- California, Maryland, Massachusetts and New Hampshire -- received approval during the Obama administration. Salo expects more states to file for those waivers next year.
When it comes to the opioid epidemic, he says, “there’s no silver bullet, but those waivers are arrows in a quiver."
Drug pricing laws
Responding to public outcry over the price of prescription drugs, there was some movement toward making them cheaper this year -- but it didn't come from the voters.
When given the chance to pass a ballot measure that supporters say could have reduced the price of prescription drugs for Ohio, voters overwhelmingly rejected it. A similar measure failed in California last year, exemplifying the power of pharmaceutical companies, which spent millions of campaign dollars to defeat both measures.
California, however, was one of the few states this year that passed drug pricing regulations. It now requires drug companies to notify insurers within 60 days if the price of a drug will increase by 16 percent or more.
Similarly, Maryland passed a law requiring drug companies to notify the state if the price of a generic drug would increase by 50 percent or more. And New York approved new regulations that will, among other things, threaten drug companies with scrutiny of their profit margins if they don’t agree to voluntarily rebate or pass money back to the state when Medicaid drug spending rises fast.
But considering this issue has bipartisan support, it’s surprising that more states didn't pass similar regulations, says Sabrina Corlette, research professor at the Center on Health Insurance Reforms at Georgetown University.
Corlette co-authored a study with the Urban Institute this year that examined the eight states -- California, Colorado, Delaware, Louisiana, Maryland, Montana, New York and Vermont -- that have enacted some kind of regulation to keep out-of-pocket costs down on specialty drugs. They found that the regulations' impact on drug prices is unclear, but in some instances, the prices for other areas of a health care plan -- such as copayments -- went up.
You probably heard about the Texas bill signed into law in August requiring women to buy supplemental insurance if they want coverage for an abortion. It was dubbed as "rape insurance" and quickly made headlines across the country.
When Texas passes an abortion restriction, other conservative states usually follow, says Elizabeth Nash, a state policy expert for the Guttmacher Institute, an organization that tracks reproductive rights around the world.
However, it was hardly the only state this year to pass abortion restrictions.
Missouri passed arguably the most sweeping anti-abortion law this year during a second special session in the summer. The bill, S.B. 5, includes several never-before-seen provisions.
The regulations, which went into effect in October, require a doctor (not a nurse or social worker) to counsel women 72 hours before a procedure. Critics say it could burden the few doctors in the state who perform abortions. The legislation also allows landlords and employers to rent to or hire people based on their reproductive rights beliefs and gives expanded powers to the state’s attorney general to enforce the abortion laws.
In Kentucky, an intervention by Republican Gov. Matt Bevin could make the state the only one without an abortion clinic.
Kentucky law requires that all abortion clinics have an agreement with a local hospital and ambulance service that they’ll transfer and admit patients in the event of an emergency. The EMW Women’s Surgical Center -- the only clinic in the state -- has an agreement with the University of Louisville’s medical school and a private ambulance company. But the Bevin administration ruled this year that those agreements are “deficient.”
The clinic sued and is still operating until a judge rules. If the court rules in favor of the state, then Kentucky could find itself in a unique position in 2018.
Roll out of marijuana laws
Eight states legalized medical or recreational marijuana last year, but getting those markets up and running is no easy task.
In California, the first state to legalize marijuana for medical use back in 1996, residents are supposed to be able to buy the drug for recreational use starting Jan. 1. But, it's unclear whether that will actually happen everywhere.
Retailers and growers need approval from the state’s Bureau of Cannabis Control -- along with city and county permits -- which didn’t start accepting applications until this month. And according to The Sacramento Bee, most counties have been silent on the issue.
“The roll-out from people’s expectations was that it would be quick, but that’s not what’s happening. The state already had this large medical marijuana structure in place, but it’s just not translating,” says Karmen Hanson, health policy analyst for the National Conference of State Legislatures.
In Maine, it’s been an uphill battle. The state legislature passed a bill detailing how the sale of recreational marijuana would work, but it was vetoed by GOP Gov. Paul LePage.
"Until I clearly understand how the federal government intends to treat states that seek to legalize marijuana, I cannot in good conscience support any scheme in state law to implement expansion of legal marijuana in Maine,” he wrote in his veto letter.
In late November, U.S. Attorney General Jeff Sessions signaled that his department would soon crack down on state marijuana laws.
"We are working our way through to a rational policy, but I don't want to suggest in any way that this department believes that marijuana is harmless and people should not avoid it," he said.
Among the states that legalized medical marijuana last year, Florida and North Dakota’s measures went into effect this year.
Perhaps the biggest change in marijuana policy this year, though, is the fact that statehouses are starting to initiate the discussion.
Typically, it's an issue left up to the voters. But since the 2016 elections, state legislatures have been forming legalization committees and drawing up bills for the next legislative session. According to Hanson, legislatures in Connecticut, Delaware, Illinois, Maryland, New Hampshire, Rhode Island, Texas and Vermont have all started exploring recreational use.
Failure of soda taxes
It looked like the tide was turning on soda taxes in 2016. Berkeley, Calif. -- the first locality to pass an initiative to tax sugary drinks -- revealed promising results from its first year, with consumption of sugary drinks down 20 percent. This was followed by news that the Philadelphia City Council approved a soda tax and Cook County, Ill., approved one last November.
Fast forward one year later, and the viability of the soda tax doesn’t look as bright.
In August, a report revealed that Philadelphia’s soda tax wasn’t producing the windfall that was expected. The soda tax was projected to bring in $46 million in the first six months but only produced close to $40 million. The report also found that people were still buying soda and sugary drinks; they were just traveling outside the city to stock up.
And in a stinging reversal, Cook County repealed its soda tax altogether after just two months. A cocktail of miscommunication, glitches and legal challenges spurred the Cook County Board of Commissioners' decision in October.
*Correction: A previous version of this mistakenly stated that the soda tax in Cook County, Ill., was approved by voters. It was actually approved by the county's Board of Commissioners.