According to a recent study in JAMA, U.S. life expectancy declined in 2017 for the third year in a row, a trend reversing, as yet incrementally, decades of increasing life expectancy. As chronic health conditions like Alzheimer's disease, type 2 diabetes, and heart disease multiply among an aging population with historically high rates of obesity, "diseases of despair" like drug abuse, alcoholism, and suicide continue to kill thousands across the age span. Against this backdrop, the outlook for the U.S. health care system as we head into an election year remains uncertain on several fronts. Particularly worrisome are setbacks to access to care for children, the poor and middle class, the elderly, immigrants, and other vulnerable populations.

More Americans uninsured. According to data collected in the Gallup National Health and Well-Being Index, the uninsured rate in the United States went up to 13.8% in 2018, still well below the 18% rate before key provisions of the Affordable Care Act (ACA) went into effect in 2014, but up from the 10.9% low seen in 2016. While candidates and parties debate visions for health care plans to improve upon or replace the ACA (see Policy and Politics in next month's issue), evidence is mounting that the Trump administration's efforts over the past three years to roll back or modify provisions affecting access to health care coverage are beginning to hit home in measurable ways.

Damping down marketplace enrollments. Several Republican policies have slowed ACA health care marketplace enrollment: cuts to advertising and outreach; the removal in 2017 of a penalty for not purchasing health insurance; continuing uncertainty for both consumers and insurers from a lawsuit (Texas v. U.S.; decision still pending as we go to press), supported by the Trump administration, that seeks to void the entire ACA, including the protections for people with preexisting conditions; and the Trump administration's support of brokers selling an alternative class of "skinny" health care plans that don't meet ACA insurance standards, often with prohibitively high deductibles and fewer protections for those with preexisting conditions.

Against this headwind, health care marketplace sign-ups as of late November were reported by PBS News to be down to 932,000 from 1.1 million the previous year at the same time.

Fear of a public charge rule. Another factor believed to be slowing marketplace enrollments (and enrollments in public plans like Medicaid) is the Trump administration's public charge rule, in which an immigrant accepting any publicly funded benefits could be denied a green card and risk deportation. The rule, set to go into effect last October, has been temporarily blocked by federal judges in several states (http://www.uscis.gov/greencard/public-charge), but the threat remains.

Medicaid expansion: a matter of life and death? To date, 37 states (and the District of Columbia) have opted to expand Medicaid eligibility under the ACA to individuals making below 138% of the federal poverty level. Data on the benefits of the Medicaid expansion are becoming more convincing with every year; a November 6 analysis by the nonpartisan Center on Budget and Policy Priorities estimated that the expansion saved the lives of up to 19,000 adults ages 55 to 64 in its first four years, from 2014 to 2017, in states that adopted it, and cost 15,600 lives in states that did not.

Work requirements. Despite evidence of the Medicaid expansion's benefits, the Kaiser Family Foundation reported a combined loss of 1.6 million Medicaid and Children's Health Insurance Program enrollments in 2018. One factor contributing to the drop is Medicaid waivers granted by the Centers for Medicare and Medicaid Services to states, allowing them to require Medicaid recipients to verify hours of work or volunteer work. We are starting to see results of these reporting rules for a population that moves frequently, has poor literacy skills, and often lacks reliable Internet access. According to the Center on Budget and Policy Priorities, in Arkansas over 18,000 of those subject to the work requirement were disenrolled from Medicaid in the first seven months, without any significant increase in employment; New Hampshire saw similar results, with many beneficiaries in both states reporting "that they didn't know about the work requirement or whether it applied to them."

Despite continued Trump administration support for work requirements, a number of states are putting on hold plans to implement them after federal judges in 2018 halted the Arkansas program and blocked the one in Kentucky from starting because they conflicted with a central goal of the Medicaid program-to increase access to health care coverage for those who can't afford it.

Children lose coverage. According to an October 22 analysis by the New York Times, "More than a million children disappeared from the rolls of the two main state-federal health programs for lower-income children, Medicaid and the Children's Health Insurance Program, between December 2017 and June [2019]." The Times noted that states that saw the steepest declines, like Texas and Tennessee, had initiated more frequent and rigorous online or mail-based paperwork requirements, again posing a critical obstacle to many in the eligible population.

Here again the continued threat of a public charge rule appears to have played a role. Many immigrants are believed to have avoided enrollment in programs offering insurance to children because of fear of deportation.

Drug costs. Rising health care costs are a subtext of every discussion about health care policy and are likely to play a central role in debates about the future of the ACA or its replacement in the coming year. One particularly high-profile issue has been the cost of drugs, with stories about deaths from the rationing of medications like insulin and high rates of drug cost-related financial hardship among seniors. Politicians have seized on the issue because it allows them to set forth forceful but limited proposals without bogging down in the complexity of the larger debate. House Speaker Nancy Pelosi's current plan would allow Medicare to negotiate with drugmakers about prices. The White House, initially open to discussions with Pelosi, has recently signaled its lack of support for the plan, and has offered several initiatives of its own related to use of rebates in Medicare Part D or tying Medicare drug prices to those in other countries.

Barring a surprise early in 2020, comprehensive bipartisan action on drug costs may be increasingly unlikely as the election year progresses.-Jacob Molyneux, senior editor