Advocates hope lawmakers can beat the odds and move major health care legislation in the new year.

2019 opened with bipartisan talk of cracking down on drug prices and surprise medical bills. But it ended without major legislation signed into law on either front, and a host of other health care battles, including a lawsuit threatening the entire Affordable Care Act, looming over the coming election year.

Here are five health care fights to watch in 2020.

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Drug pricing

Lowering drug prices was supposed to be an area for potential bipartisan action in 2019, but the effort ran into a brick wall of industry lobbying and partisan divisions.

There is a push to finally get legislation over the finish line in 2020, though.

Speaker Nancy Pelosi Nancy PelosiMcConnell focuses on confirming judicial nominees with COVID-19 talks stalled Overnight Defense: Top admiral says 'no condition' where US should conduct nuclear test 'at this time' | Intelligence chief says Congress will get some in-person election security briefings Pelosi must go — the House is in dire need of new leadership MORE (D-Calif.) is calling for attaching drug pricing legislation to a package of expiring health care programs, like community health center funding, that must be renewed by May 22. She hopes the pressure from that deadline helps carry a larger package, but that is far from certain, especially as the election gets closer.

Democrats point to President Trump Donald John TrumpHR McMaster says president's policy to withdraw troops from Afghanistan is 'unwise' Cast of 'Parks and Rec' reunite for virtual town hall to address Wisconsin voters Biden says Trump should step down over coronavirus response MORE’s vow to support allowing the government to negotiate drug prices during his 2016 campaign. While Trump backed off that pledge this year, they hold out hope he might come back around. Senate Majority Leader Mitch McConnell Addison (Mitch) Mitchell McConnellMcConnell focuses on confirming judicial nominees with COVID-19 talks stalled McConnell accuses Democrats of sowing division by 'downplaying progress' on election security Warren, Schumer introduce plan for next president to cancel ,000 in student debt MORE (R-Ky.) is also strongly opposed to the idea, and has concerns about a more modest bill from Sens. Chuck Grassley Charles (Chuck) Ernest GrassleySenate Republicans signal openness to working with Biden Senators offer disaster tax relief bill Trump spikes political football with return of Big Ten season MORE (R-Iowa) and Ron Wyden Ronald (Ron) Lee WydenGOP senator blocks Schumer resolution aimed at Biden probe as tensions run high Republican Senators raise concerns over Oracle-TikTok deal Hillicon Valley: TikTok, Oracle seek Trump's approval as clock winds down | Hackers arrested for allegedly defacing U.S. websites after death of Iranian general | 400K people register to vote on Snapchat MORE (D-Ore.) that could provide a more realistic bipartisan path.

“The president said when he ran and until relatively recently that he would support negotiated prices and I expect at some point he will go back to that, and we're just going to keep pushing the Senate to try to achieve that,” said House Energy and Commerce Committee Chairman Frank Pallone Jr. (D-N.J.).

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Surprise billing

The other major health care initiative that Pelosi says she wants in the May package is protecting patients from surprise medical bills.

That effort has also fallen prey to intense industry lobbying and congressional infighting.

Backers of a bipartisan bill from the House Energy and Commerce Committee and Senate Health Committee on the issue pushed for including the measure in a year-end spending and were deeply frustrated when it was left out.

A key factor was House Ways and Means Committee Chairman Richard Neal Richard Edmund NealRep. Cedric Richmond set to join House Ways and Means Committee Coons beats back progressive Senate primary challenger in Delaware Pelosi: House will stay in session until agreement is reached on coronavirus relief MORE (D-Mass.) putting forward the outline of a rival plan days before this month’s funding deadline, showing a split on the way forward.

“It’s certainly going to be harder [next year],” said Shawn Gremminger, senior director of federal relations at Families USA, a liberal health care advocacy group.

“You are now under six months out from the general election,” he said about moving legislation in May 2020.

Backers have a tough road ahead. They will have to bridge the divide between the competing plans and overcome lobbying from powerful doctor and hospital groups, who worry the legislation could lead to damaging cuts to their payments.

ObamaCare

Outside of Capitol Hill negotiating rooms, the GOP lawsuit to overturn the Affordable Care Act is looming large.

A federal appeals court last week issued a long-awaited ruling on the fate of the law, though it did little to settle the issue. The 5th U.S. Circuit Court of Appeals ruled that the law’s mandate to have health insurance is unconstitutional, but punted on the question of whether any of the rest of the law should also be struck down, instead sending it back to the lower court.

The most tangible effect of the move could be to push a final Supreme Court decision on the fate of the law past the 2020 elections, though it’s possible the justices could still choose to take the case sooner.

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Democrats intend to hammer Republicans over the lawsuit during next year’s campaign, though, a strategy that paid off for the party during the 2018 midterms when they focused on health care.

The Democratic group Protect Our Care launched a national TV ad on Friday, saying “President Trump and Republicans just won a major decision in their lawsuit to repeal health care from millions of American families,” and warning of the loss of pre-existing condition protections.

Medicare for All

In the Democratic presidential race, "Medicare for All" is a central dividing line.

How the issue plays out in 2020 will depend in large part on who wins the Democratic nomination. If progressives like Sens. Bernie Sanders Bernie SandersMcConnell accuses Democrats of sowing division by 'downplaying progress' on election security The Hill's Campaign Report: Arizona shifts towards Biden | Biden prepares for drive-in town hall | New Biden ad targets Latino voters Why Democrats must confront extreme left wing incitement to violence MORE (I-Vt.) or Elizabeth Warren Elizabeth WarrenWarren, Schumer introduce plan for next president to cancel ,000 in student debt The Hill's 12:30 Report - Presented by Facebook - Don't expect a government check anytime soon No new taxes for the ultra rich — fix bad tax policy instead MORE (D-Mass.) win the nomination, Republicans will be able to go full bore on their attacks that private health insurance would be eliminated under the proposal.

Even more moderate candidates like former Vice President Joe Biden Joe BidenCast of 'Parks and Rec' reunite for virtual town hall to address Wisconsin voters Biden says Trump should step down over coronavirus response Biden tells CNN town hall that he has benefited from white privilege MORE and South Bend, Ind., Mayor Pete Buttigieg Pete ButtigiegBogeymen of the far left deserve a place in any Biden administration Overnight Defense: Woodward book causes new firestorm | Book says Trump lashed out at generals, told Woodward about secret weapons system | US withdrawing thousands of troops from Iraq A socially and environmentally just way to fight climate change MORE would face attacks that their public option plans are a step down the road toward eventually implementing full-scale single payer.

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The internal debate on the issue has faded somewhat from its peak. Health care has not featured as prominently in the last two debates, and some of the fighting has shifted to other areas, like candidates' fundraising practices.

But the issue is still simmering and could burst back to open warfare among Democrats at any point.

Vaping

The battle over e-cigarette flavors will likely resume in 2020 as the Trump administration and Congress try to cut rising youth vaping rates.

Public health advocates are pushing the administration to clear the market of flavors like mint and fruit that they argue are fueling a youth vaping epidemic.

Trump said he would eliminate those flavors in September, but has appeared to back down after backlash from vaping advocates and the e-cigarette industry.

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Now he says he would like to find a compromise that preserves such flavors for adults while keeping them away from kids.

Advocates like the Campaign for Tobacco-Free Kids plan to pressure Trump to follow through on his word, though it’s looking unlikely.

However, the e-cigarette market could also look vastly different after May 2020, when companies must apply to the Food and Drug Administration to stay on the market

The industry must prove its products benefit public health, a big ask for companies like Juul, whose products are favored by kids who vape.

House Democrats also plan to vote on a bill that would ban flavored e-cigarette and tobacco products, but it’s not clear if it will get a vote in the Senate.