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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

CDC: Half of US adults have received one COVID-19 vaccine dose

Data: CDC; Chart: Axios Visuals

Half of US adults have received at least one dose of the COVID-19 vaccine and about a third are fully vaccinated, according to new data from the Centers for Disease Control and Prevention.

Why it matters: COVID-19 cases and hospitalizations are still on the rise, CDC director Rochelle Walensky said during Friday's White House COVID-19 briefing. With cases in many states being driven by variants, public health officials have emphasized the need to ramp up vaccinations.

2 hours ago - World

Israeli intel agencies believe Vienna talks will lead to U.S. return to Iran nuclear deal

Photo: DEBBIE HILL/AFP via Getty Images

Israeli military intelligence and senior officials in the Mossad briefed a meeting of the nation's security cabinet that talks in Vienna between Iran and other world powers will lead to the U.S. returning to the 2015 nuclear deal, two officials who attended the meeting told me.

Why it matters: The Israeli government is very concerned about a U.S. return to the nuclear deal and is trying to convince the Biden administration not to take the pressure off the Iranian regime.

Latino community of 13-year-old killed by police in Chicago reels after shooting

A small memorial of flowers and candles to Adam Toledo in Chicago. Photo: Kamil Krzaczynski/Getty Images

Residents of Little Village, a well-known and predominantly Latino neighborhood in Chicago, are grieving the death of Adam Toledo, a 13-year-old Mexican American boy from the neighborhood who was shot and killed by a police officer on March 29, NBC News reports.

Why it matters: Adam Toledo's killing shines a spotlight on police shootings of Latinos, who are killed by law enforcement at the second-highest rate after Black Americans, according to data from the Washington Post.