Illustration: Rebecca Zisser/Axios

As Democratic presidential candidates debate their ideal health care system, blue states are making incremental — yet significant — changes to the existing one.

Why it matters: In the states where they have power, Democrats are creating a blueprint for how the ACA could evolve under Democratic control in Washington.

Where it stands: California recently passed the most ambitious expansions of the ACA to date.

  • It made the ACA's premium subsidies available to middle-class people, and made undocumented children and young adult immigrants eligible for the state Medicaid program.
  • "This isn’t just the ACA warmed over. This is actually taking steps beyond it to make it better," said Peter Lee, executive director of Covered California, the state ACA exchange.

Other states have also made significant changes.

What's next: If a future Democratic president wanted something less ambitious than "Medicare for All," these reforms will provide a starting point.

The other side: Republican-led states are surging ahead on their own reforms, like adding work requirements to Medicaid.

The bottom line: "Red states and blue states are moving in very different directions on health care, taking advantage of new flexibility on the one hand and combating efforts by the Trump administration on the other," said Larry Levitt of the Kaiser Family Foundation.

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Photo: Mark Wilson/Getty Images

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