President Trump celebrates the House's passage of Obamacare repeal in May 2017.Carlos Barria / Reuters

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.”

Few Republicans have talked much about repealing the ACA since Democrats rode to sweeping gains in last November’s election; the Democrats did so in large part behind their promises to defend the law, particularly its provisions protecting patients with preexisting health conditions. Many Republicans have seemed anxious to put the debate over the ACA behind them.

But over the past several days, Trump has repeatedly reaffirmed his desire to uproot the law. In a succession of tweets and public comments, the president has condemned the late Republican Senator John McCain of Arizona for his 2017 votes that blocked repeal. And in the administration’s budget for the 2020 fiscal year, Trump endorsed a specific plan to replace the law.

In the fall of 2017, Senate Republican leaders had embraced that very plan, put forward by Senators Lindsey Graham of South Carolina and Bill Cassidy of Louisiana, as their last chance to replace former President Barack Obama’s signature health-care law. But it died amid opposition from the same three GOP senators who had blocked earlier efforts to undo the ACA: Susan Collins of Maine, Lisa Murkowski of Alaska, and McCain.

The Graham-Cassidy plan that Trump is now reviving would have deeply retrenched the federal government’s role in health care. It would have repealed both the subsidies the ACA provides to help the uninsured purchase private insurance and the law’s expansion of Medicaid coverage to more of the working poor. It proposed instead to replace those funding streams with a single block grant given to states for covering the uninsured. The bill would also have ended Medicaid’s status as an entitlement, available to anyone who met the eligibility criteria, and instead reconfigured it into a program that would provide states with only a fixed annual sum to cover health care for the needy. It would have allowed states to free insurers from the ACA’s requirements to provide coverage at no extra cost to consumers with preexisting health problems, as well as the law’s mandates to guarantee a wide array of essential health benefits, including maternity care. In a final twist, it would have reallocated money from the mostly blue states that have expanded Medicaid under the ACA to the red states that have not, by basing the future block-grant allocation on a state’s total number of low-income people, not its level of health-care expenditures.

The version of Graham-Cassidy proposed by the president would impose even larger spending cuts than the original. Compared with projected spending over the next decade under existing law for the ACA and Medicaid, Trump’s new plan would cut federal dollars by a resounding $774 billion.

“The administration’s proposal would provide meaningfully less funding than Graham-Cassidy would have,” says Matthew Fiedler, a fellow at the Schaeffer Initiative on Health Policy at the Brookings Institution. “They have taken Graham-Cassidy as the starting point and reduced the block grants that are provided to the states, and [proposed] even deeper Medicaid cuts.”

No one has yet produced a comprehensive analysis of how many Americans would lose insurance coverage under the president’s new budget. In 2017, when the Senate first considered Graham-Cassidy, Fiedler and a colleague estimated that it would eliminate coverage for about 20 million people. Part of that loss has already occurred because it was tied to Graham-Cassidy’s provision eliminating the ACA’s individual mandate, which Republicans repealed in their tax plan. On the one hand, that means there would be fewer net additional losses if Trump’s plan were to pass. But on the other hand, the president’s plan envisions even greater funding cutbacks than the original proposal, which would mean greater coverage declines. Fielder says that at this point, the safest assessment is that “millions” more would lose health insurance under the president’s proposal.

Exactly what Democrats will offer as their alternative health-care plan in 2020 remains, to put it mildly, very much up for debate. On the left, support has intensified for a single-payer system that would eliminate private insurance and enroll all Americans into a single government-funded plan. To varying degrees, several Democratic presidential contenders, led by Senators Bernie Sanders of Vermont and Kamala Harris of California, have endorsed that idea.

But while backing for single payer has deepened in the party, there’s much less evidence that it has broadened. For all the attention to the single-payer bill introduced late last month by House liberals, it has drawn fewer co-sponsors than similar legislation last year. Among the 105 voting House sponsors, supporters have attracted just two Democrats who hold seats that Trump carried in 2016, and only seven who won seats in 2018 that were previously held by the GOP. Until sponsors show that single payer can appeal to Democrats in swing seats such as these, and not just in districts that are reliably Democratic terrain, it will remain far below the 218 votes needed for passage.

Single payer will also soon have competition on the Democratic side. Representatives Rosa DeLauro of Connecticut and Jan Schakowsky of Illinois are expected to reintroduce their December 2018 bill that would automatically enroll the uninsured into Medicare and would allow all Americans to buy into the program, but would not require anyone with private insurance to leave it. It might be a sign of the Democratic debate’s direction that former Texas Representative Beto O’Rourke praised that approach during his initial presidential campaign swing last week; most expect former Vice President Joe Biden to embrace something like it as well.

One theory about the tumultuous history of American health-care debates since World War II is that whichever side appears to be proposing the most disruption to people’s existing arrangements usually loses the argument. Trump and the GOP are certain to contend that whatever ideas Democrats coalesce around will trigger massive change, especially if the Democratic Party’s presidential nominee embraces hard-line versions of the single-payer plan that would eliminate private insurance.

But Trump’s reaffirmed commitment to repealing the ACA will vastly complicate his ability to make that case. Whatever doubts voters might hold about the eventual Democratic plans to build on the ACA will inevitably be weighed with their concerns about Trump’s undiminished fervor to dismantle it. More Americans have expressed positive than negative views about the ACA since the height of the repeal debate in the spring of 2017, according to polls by the nonpartisan Kaiser Family Foundation. And the law now receives solidly favorable ratings from all the groups that powered the big Democratic gains last November: young people, minorities, independents, and college-educated white voters.

“The threat of taking away health care for millions of Americans and allowing insurance companies to charge other Americans a lot more for their coverage is a lot bigger of a problem for voters than Democrats wanting to make sure everybody has affordable health care,” Garin insists.

Trump’s doubling down on repealing the ACA is an extension of his steadfast refusal to acknowledge any warning signs from the 2018 election, which saw Democrats add their most seats in the House since Watergate.

Strategists in both parties agree that no issue contributed more to the Democratic gains last fall than their commitment to defending the ACA, particularly its provisions preventing insurance companies from charging more or denying coverage to patients with preexisting health conditions.

Just over two-fifths of voters in the Election Day exit poll conducted by Edison Research cited health care as the most important issue to their vote—far more than the number of voters who picked any other issue—and fully three-fourths of them backed Democrats in House elections. On another question, nearly three-fifths of voters picked Democrats when asked which party would do a better job at protecting patients with preexisting conditions. Those same respondents voted Democratic in House races by a crushing margin of 89 percent to 4 percent.

Health care, most strategists agree, was especially important in helping Democrats claw back some support from the working-class white voters who stampeded to Trump in 2016. In previously unpublished results provided to me by Edison, non-college-educated white women, usually a solidly Republican-leaning group, split nearly evenly when asked which party would do a better job at protecting patients with preexisting conditions. Fully 90 percent of the blue-collar white women who picked Democrats on that question also voted Democratic for the House. Blue-collar men still leaned more toward the GOP, but even 40 percent of them said that Democrats would better protect people with preexisting conditions, and almost four-fifths who felt that way voted Democratic for the House.

Most of the key dynamics about the 2020 general election, of course, remain unknown this far from the vote. But after Trump’s budget, two things appear more certain. One is that repeal of the ACA will be on the ballot. The other is that Democrats are much more eager to take on that fight than they were in 2012 or even in 2016, when Mitt Romney and Trump each ran on the law’s repeal. “It’s the best contrast we have on health care,” says Brad Woodhouse, the executive director of Protect Our Care, a liberal advocacy group that supports the law. “The president still wants to repeal the Affordable Care Act. It’s in his budget. He’s still slamming the dead-man war hero for his vote on it,” he says, referring to Trump’s attacks on McCain. Trump this month hasn’t talked much about his budget’s plans to unravel the ACA, but it’s a good bet that whoever the Democrats nominate won’t hesitate to remind the country about his prescription in 2020.

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