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The Trump administration inherited some unfinished health business on Inauguration Day. And the nature of federal rules means it can't start from scratch on issues like surprise billing, coverage of GLP-1s and prescribing controlled substances.

The big picture: All eyes will be on Trump health appointees as they sort through policy changes that were launched during the Biden years.

The most pressing include:

Covering anti-obesity drugs: The Biden administration in November proposed requiring Medicare and Medicaid to cover GLP-1s for weight loss. Medicare law prohibits that, but there's room for a "reinterpretation" that would extend coverage.

• The new policy would cost Medicare about $25 billion and Medicaid $11 billion over a decade. But it would likely be popular with seniors and could spare the administration's allies in Congress a difficult vote on coverage expansions down the road.

Lowering nicotine in cigarettes: Just last week, the FDA proposed limiting the nicotine in cigarettes to make them less addictive. The goal is to force more than 28 million cigarette smokers to switch to less harmful products or quit.

• The FDA in Trump's first term proposed a nicotine rule, but the effort was never finalized. The question for Trump 2.0 is how much finishing the job now syncs with the Make America Healthy movement's goals.

Settling billing disputes: The Biden administration left office without finalizing changes to the complex process that governs how insurers and doctors settle disagreements over the cost of patients' out-of-network care.

• Neither insurers nor providers are happy with the current arbitration system that was established by the surprise billing law. Biden administration efforts to find a solution were stymied by litigation, leaving a significant backlog of unsettled disputes.

Telehealth and controlled substances: The Biden Drug Enforcement Administration proposed an 11th-hour registration system for the virtual prescribing of Adderall and other amphetamines like Vyvanse used for ADHD.

• Current flexibilities on teleprescribing expire at the end of this year. Without them, providers have to do an in-person evaluation before prescribing — a situation behavioral health experts say will limit access to increasingly scarce treatments.

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The wave of executive orders Trump is issuing, along with other administration guidance, will offer early clues about how disruptive his second term will be in the health world, Adriel Bettelheim and Peter Sullivan wrote first on Pro.

The big picture: Trump's early health agenda will emerge through rulemaking, appointments and executive orders that allow him to bypass Congress.

Trump moved on Monday to fulfill a campaign pledge with an order that would pull the U.S. out of the World Health Organization — a process he started during his first term but that former President Biden reversed on his first day in office.

• The U.S. is the WHO's top donor, contributing about $130 million a year to help cover its global health preparedness and response, as well as efforts to address HIV, tuberculosis, and childhood vaccination, per Devex.
• Trump's administration is also expected to cut U.S. funding to the UN Population Fund, repeating a move he made during his first term, when he accused it of supporting population control programs in China.

On reproductive health, he's expected to quickly order the reinstatement of the so-called Mexico City policy that blocks non-governmental organizations abroad from receiving U.S. global health funding if they provide or promote abortion.

• He could also undo executive orders and memorandums Biden issued, including dissolving the Interagency Task Force on Reproductive Healthcare Access and the White House Gender Policy Council, according to the Guttmacher Institute, a pro-abortion rights research organization.
• Another target could be nondiscrimination provisions of the Affordable Care Act, including protections on the basis of gender identity and sexual orientation.

On vaccines, Trump repeatedly pledged on the campaign trail to withhold federal funds from public school districts that have vaccine mandates, such as those for MMR, chickenpox and polio.

• While states typically set vaccine requirements, Trump's use of the bully pulpit could stoke further vaccine skepticism, with vax critic Robert F. Kennedy Jr. in line to become the nation's top health official.

During his first term, Trump sent shockwaves by proposing to tie Medicare drug prices to those paid in other countries. His campaign backed off that idea last year, but it's possible Trump could revive the proposal in some form.

• There is also the question of how he handles the next round of Medicare drug price negotiations under the IRA, and if he seeks to make changes to how the program operates.

If you need smart, quick intel on health care policy for your job, get Axios Pro Policy.

Related: Trump promises to reinstate service members expelled over COVID vaccine

For most of the Biden administration, Chiquita Brooks-LaSure presided over Medicare, Medicaid, CHIP and the Affordable Care Act, keeping a relatively low profile while rolling out policies that brought the uninsured rate to historic lows and implemented the first government drug price negotiations.

She spoke to Axios on her last full day on the job. The remarks have been edited for brevity and clarity.

On her legacy at CMS: We have the lowest uninsured rate that we've ever had, and that's what I'm incredibly proud of: that that coverage is really meaningful.

On messaging around Medicare drug price negotiations: We're limited in our resources to talk about and educate people about the changes. And so, yes, I do wish that there was more awareness of the really monumental changes that have occurred and are currently occurring.

On what else she wanted to do: We left everything on the field. [But] I would love more time to continue to work on prior authorization. That's something that we have been tackling, and I think we need to continue to make sure that people can access the care that they need.

• The last thing is not something I can do, but it's the [Medicaid] coverage gap. ... [I wish] that Congress would fill the coverage gap, or the states would expand. I think that is just such a travesty in our country, that some of the poorest people do not have access to health care.

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A study of more than 2 million Veterans Health Administration patient records found GLP-1 drugs lowered the likelihood of dozens of health conditions including Alzheimer's disease but also had some unexpected risks.

Why it matters: The review in Nature Medicine provides some of the most compelling evidence yet that the blockbuster drugs for weight loss have widespread health benefits.

• Researchers compared 175 health outcomes between veterans who took GLP-1s to treat their diabetes from October 2017 through the end of 2023 and those who took more traditional medications.

What they found: Patients using the drugs were found to have reduced risk of neurological issues — including Alzheimer's, substance abuse, psychotic disorders and seizures — compared with patients not on GLP-1s.

• They also appeared to have lower risk for blood clotting disorders, cardiometabolic conditions, infections, and respiratory issues.

Yes, but: The drugs were associated with increased risk for GI disorders, low blood pressure, kidney stones and pancreatitis.

• And GLP-1s were associated with a higher risk for arthritis.
• "We actually expected that ... joints would be happier or feeling less pain and less stress on them because there was less weight to bear," said co-author Ziyad Al-Aly, chief of the research and education service at the VA Saint Louis Health Care System.

The researchers are planning deeper dives to better understand the apparent GLP-1 connection with Alzheimer's, seizures, blood clotting or infection compared with other diabetes drugs.

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