By Ashley Fuoco Antonelli, Senior Editor

Health care was a big focus for policymakers, political candidates, and voters in 2019, and 2020 will be no different. Here are 3 key things to watch for as Congress returns from recess and the presidential race heats up.

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1. A court ruling threatening the ACA could shake up the presidential race

2019 ended on a note of ambiguity for the Affordable Care Act (ACA). Late last month, a three-judge panel of the U.S. Court of Appeals for the Fifth Circuit in a 2-1 ruling struck down the ACA's individual mandate as unconstitutional, but left the fate of the rest of the law up to a lower court.

As the Washington Post's Amy Goldstein writes, leaving the ACA "in limbo … catapult[s] questions of insurance coverage and consumer health-care protections to the forefront of the 2020 presidential and congressional campaigns."

Several Democratic presidential candidates seeking the 2020 nomination already have released health care reform plans. While some call for completely replacing the ACA with so-called "Medicare-for-All" proposals, others hinge on bolstering the ACA by creating a "public option" health plan—and it's unclear how those proposals would account for a court ruling striking down the ACA.

On the Republican side, Trump has yet to release a plan to address a ruling striking down the ACA, despite saying his administration would do so. But other members of the Trump administration have indicated a plan may not be coming soon. HHS Secretary Alex Azar at an event last October said the administration would not release a plan to replace the ACA until Congress was willing to act on one or a final court ruling is issued in the case challenging the ACA.

2. The long-rumored ban on (most) flavored e-cigarettes is officially here

Concerns about growing e-cigarette use in the United States, particularly among youth, reached a boiling point in 2019. Among the reasons: Research revealed that youth use of e-cigarettes in the country has spiked drastically over the past few years, and a new vaping-linked lung illness struck more than 2,000 by the end of the year.

As concerns mounted, the Trump administration in September 2019 announced that FDA planned to finalize a policy to clear the market of unauthorized, non-tobacco-flavored e-cigarettes. But FDA ultimately held off on finalizing the rule in 2019.

Some observers speculated that the administration was worried about political ramifications heading into the 2020 election, while others said Trump wanted to review the issue before moving forward. Trump indicated, in particular, that he was concerned about how banning flavored e-cigarettes would affect adults trying to quit smoking traditional cigarettes.

However, news outlets early this week reported that it looked like a ban on flavored e-cigarettes would be coming soon—and they were right. FDA on Thursday released new guidance stating that the agency will take enforcement actions against companies that do not stop manufacturing and distributing "unauthorized flavored cartridge-based e-cigarettes … within 30 days."

But the new policy does not go as far as FDA had proposed in September. Instead of banning all flavored e-cigarettes, the new policy applies only to unauthorized dessert-, fruit-, candy- and mint-flavored e-cigarettes that are cartridge based, meaning they use refillable pods. The policy doesn't apply to tank vaping systems that are commonly sold at vape shops or refill pods that are tobacco- or menthol-flavored.

HHS Secretary Alex Azar on Thursday touted the new policy as a "smart, targeted policy that protects our kids without creating unnecessary disruption."

But public health groups and some Democratic lawmakers were quick to criticize the policy for not going far enough to address the youth vaping crisis.

The new policy likely will continue to be a focus of debate over the next few months, as companies respond and potentially move to comply with the new policy, and as public health groups assess the policy's potential effects.

3. After kicking the can down the road in 2019, Congress may take on 'surprise' medical bills and Rx drug costs

Toward the end of 2019, Congress appeared on track to address two of voters' biggest health care concerns: rising prescription drug costs and so-called "surprise" medical bills. Lawmakers had introduced a range of proposals to tackle the problems, some of which even had drawn bipartisan support.

But as 2019 drew to a close, it became clear Congress wouldn't tackle those issues by the year's end. Disagreements between lawmakers, pushback from industry groups and private equity firms, and the House's efforts to impeach President Trump all played a part in derailing Congress' proposals.

Congress is now expected to return to those issues when lawmakers come back from recess. But it's not clear whether lawmakers will have better luck in 2020 than they did in 2019. For instance, Vox's Dylan Scott writes that, when it comes to surprise medical bills, "Democratic and Republican leaders are going to have to decide whether to push through a plan that will surely leave one or both sides of the industry dispute angry or not pass anything at all."

And when it comes to prescription drug costs, Joel White, a policy expert who chairs a coalition of health industry groups and is a registered lobbyist for Pharmaceutical Research and Manufacturers of America, argued to STAT News' Lev Facher and Nicholas Florko, "The fact that you've not seen a deal come through speaks to some of the dysfunction of the current Congress, but also the fact that they're trying to bite off more than they can chew."

Still, House Speaker Nancy Pelosi (D-Calif.) plans to continue to pursue the issues. Pelosi in a letter sent this week to House Democrats wrote, "When we return to Washington, our priority will be to continue a drumbeat across America to press [Trump] and the GOP Senate to pass the Lower Drug Costs Now Act into law," adding, "And we also look forward to ending the financial unfairness of surprise billing, which has bipartisan support in the Congress and among the American people."