The health-care proposal likely to loom largest over the 2020 presidential election was released last week—and it didn’t come from a Democrat.
In the 2020 federal budget that President Donald Trump unveiled, he renewed his commitment to repealing the Affordable Care Act and replacing it with a block-grant system that would likely strip coverage from millions of Americans, especially those in the primarily blue states that have most effectively implemented the law. And he once again promoted sweeping cuts to the Medicaid program that could eliminate coverage for millions more.
These proposals have received remarkably little notice, especially compared with the attention that’s been focused on the differences among Democrats, in the House and in the burgeoning 2020 presidential field, about how to expand coverage to the remaining Americans without insurance. The president’s plan faded from view so fast in part because it has no legislative prospects while Democrats are in control of the House. But his ideas could still cast a long political shadow in 2020 as a marker of the agenda he’ll pursue if reelected—especially if Republicans regain unified control of the federal government.
In other words, no matter what plan Democrats settle on, the president’s ongoing determination to undo the ACA is what’s likely to define the central fault line in next year’s health-care debate: whether the federal government should do more or less to ensure access to health insurance. “The prism for voters is whether more or fewer Americans will have access to affordable health care,” says Geoff Garin, a Democratic pollster who has extensively studied public attitudes on the health-care system. “That’s the real dividing line.”