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Illustration: Rebecca Zisser/Axios

Forget the Affordable Care Act: The future of our health care system will be shaped by a much bigger and broader fight — one that will likely culminate with a 2020 choice between private markets and an authentic government-run program in the form of a Bernie Sanders-style Medicare for All. 

The bottom line: The cost of health care — both for individuals seeking coverage and the government seeking sustainability — promises to return as the biggest domestic issue once the Trump obsession burns off. 

This is one of America's great unsolved problems: We have the world's best care, talent and innovation. But before it gets to patients, the magic goes through a hodgepodge of inexplicable, expensive and unnecessary hurdles.

What's next: The health care debate is no longer a linear fight over a straight repeal of President Obama's health care law. Instead, it has metastasized into a multi-front war.

One of our most vital national systems is falling apart:

  • Medicare is running out of money faster than expected — a reminder that no one's dealing with that problem, and that there's no way to duck it in 2020. 
  • The opioids crisis continues, with Congress trying to pass a ton of mini-bills to look like it's doing something. A few of them might make a difference. This remains a crisis — and a costly one. 
  • And don't forget prices. The U.S. doesn’t use more health care than other countries — we just pay more for it. Consumers are getting sick of it, and eventually they’ll respond to politicians with plans that seek to bring down prices (as they already have on prescription drugs).
  • Polls show health care is at the top of the list of voters' concerns for the midterms. So look for it to dominate the early rounds of 2020.

The new battlegrounds, as sketched by Axios managing editor David Nather:

  • The ACA repeal fight has moved to the courts, and the Trump administration has picked a fight over preexisting conditions — one of the most popular parts of the law.
  • But Republicans haven't given up on repeal. A group of outside conservatives is about to unveil a new plan and push congressional Republicans to take one more vote before November's midterms — even though there's no sign that any votes have changed.
  • "There's going to be at least one more grassroots effort to convince them to take another run at health care" so base voters don't think Republicans have given up, said Lanhee Chen of Stanford, a former Mitt Romney adviser who's part of the group.
  • Democrats have moved on to Medicare for All. The fight to watch will be between establishment Democrats, who want to make it voluntary and preserve a role for employment-based private insurance, and Democrats from the Sanders wing who are ready to move everyone into a government-run system.
  • "Democrats have always felt that health care should be a right," and they've watched the ACA actually become more popular under attack, said Neera Tanden, a former Hillary Clinton adviser who heads the Center for American Progress.
  • ACA premiums are going up, and for the first time it's Democrats who will try to turn that into a campaign weapon.
  • But health care spending and premiums are rising for everyone else, too.

Go deeper:

Go deeper

House passes government funding, debt ceiling bill

Speaker Nancy Pelosi. Photo by Kevin Dietsch/Getty Images

The House passed a bill on Tuesday to fund the government through early December, along with a measure to raise the debt ceiling through December 2022.

Why it matters: The stopgap measure, which needs to be passed to avoid a government shutdown when funding expires on Sept. 30, faces a difficult journey in the Senate where at least ten Republicans would need to vote in favor.

2 hours ago - Politics & Policy

The Democrats' debt dilemma

Illustration: Aïda Amer/Axios

Democrats find themselves in a political and potentially catastrophic economic quagmire as Republicans stand firm on denying them any help in raising the federal debt ceiling.

Why it matters: The Democrats are technically right — the debt comes, in part, from past spending by President Trump and his predecessors, not only President Biden's new big-ticket programs. But Senate Minority Leader Mitch McConnell (R-Ky.) is saddling them with the public relations challenge of making that distinction during next year's crucial midterms.

Pelosi's endgame

House Speaker Nancy Pelosi appears at a news conference on Tuesday. Photo: Sarah Silbiger/Bloomberg via Getty Images

House Speaker Nancy Pelosi (D-Calif.) began her infrastructure endgame Tuesday, pressuring centrists to ultimately support as much social spending as possible while pleading with progressives to pass the roads-and-bridges package preceding it.

Why it matters: Neither group can achieve what it wants without the other, their ultimatums be damned. The leaders of both acknowledged the speaker's unique gift for pulling off a deal after separate conversations with Democratic leaders.