After spending most of 2017 defending the Affordable Care Act from GOP attacks, a growing number of Democrats believe the law's reliance on private insurance markets won't be enough and the party should focus instead on expanding popular government programs like Medicare and Medicaid.
The emerging strategy — which is gaining traction among liberal policy experts, activists and Democratic politicians — is less sweeping than the "single-payer" government-run system that Sen. Bernie Sanders (I-Vt.) made a cornerstone of his 2016 presidential campaign.
Many Democrats still fear such a dramatic change would disrupt coverage for too many Americans, but they have also concluded that the current law's middle-ground approach to build on the private insurance market — originally a Republican idea — isn't providing enough Americans with adequate, affordable health coverage.
These Democrats see the expansion of existing public programs as a more pragmatic and politically viable way to help Americans struggling with rising costs and correct the shortcomings of the 2010 law, often called Obamacare.
"What is clear is that the Democratic Party as a whole is coming to the conclusion that stand-alone private market solutions to healthcare do not achieve affordability and coverage for all," said Chris Jennings, an influential Washington health policy advisor who worked for Presidents Clinton and Obama.
"But there is a recognition that you can't just snap your fingers and have political consensus. … And one of the lessons learned from 2017 is that you better do your homework."
Democrats are eager to avoid mistakes made by Republicans, who proved unprepared last year as they struggled unsuccessfully to fulfill their years-long promise to repeal the current health law.
Developing a new healthcare agenda doesn't promise to be easy, as liberal activists and others in the progressive wing of the Democratic Party remain committed to the single-payer solution championed by Sanders and may resist more incremental steps.
At the same time, even more modest moves to build on Medicare or Medicaid will face opposition from hospitals, drugmakers and others in the industry who fear that government health plans would pressure them to accept lower prices.
And no one expects any Democratic plan to go anywhere as long as Congress remains in Republicans' hands and Trump holds a veto pen.
But in the wake of widespread public rejection of GOP healthcare proposals last year, Democrats see an opportunity to seize the initiative and advance the party's long-held dream of universal health coverage.
"We're on offense on healthcare," said Brad Woodhouse, campaign director for Protect Our Care, an advocacy group formed last year to fight the GOP effort to roll back the 2010 health law. "We need to make healthcare the No. 1 issue."
Speaking to a recent conference organized by Families USA, a leading national patients' rights group, Woodhouse cautioned, however, that Democrats must offer voters more than just a defense of the current law.
In recent months, Democratic lawmakers on Capitol Hill have filed a growing number of bills that would expand eligibility for Medicare or Medicaid, which currently limit coverage to qualifying elderly, disabled or poor Americans. The two mammoth government programs are much cheaper than commercial insurance, in large part because they pay hospitals and other medical providers less.
In January, a group of influential liberal health policy experts gathered in Washington to explore these proposals, which typically would allow younger, wealthier consumers to "buy into" one of the two programs.
At the same time, Democratic leaders in several states, including California, New York and New Mexico are exploring state-based initiatives to expand government health plans.
And last week, the Center for American Progress, a leading liberal think tank, released a plan to open up Medicare to all Americans, while still giving workers the option to stick with coverage offered through an employer.
"Democrats have mostly been trying to keep Republicans from repealing the current law," said Sen. Tim Kaine (D-Va.). "Now we need to come up with the next set of ideas about how to improve coverage and affordability."
Kaine and Sen. Michael Bennet (D-Colo.) are cosponsoring yet another proposal — which they call Medicare X — for a new government program based on Medicare, particularly for consumers in parts of the country with limited commercial options.
The renewed interest among Democrats in government health insurance has buoyed the hopes of those who support a more ambitious push to create a single public health plan for everyone.
"What has been happening in the last few years is that millions of working people and young people are getting involved in the party … and the grassroots movement is overwhelmingly clear about what it wants from healthcare," Sanders said in an interview.
"That means that the debate over Medicare-for-all changes, and I think that is what is happening now."
Indeed, Sanders' Medicare-for-all bill, which would create a new government plan like Medicare for everyone, has drawn support from nearly every major Democrat in the Senate who is expected to seek the 2020 presidential nomination.
But many Democrats who aspire to something like Sanders' proposal still worry about the cost and disruptions that would likely be necessary to create a large new government plan for everyone.
"I share the desire for universal coverage," said Bennet. "The question is what approach is more practical to achieving that objective."
Nearly a decade ago, Democratic leaders, concerned about the politics of expanding government health plans too aggressively, created the Obamacare insurance marketplaces, which rely on private insurers to provide coverage for Americans who don't get health benefits through an employer or through a government program.
Democrats even rejected a proposal for a limited government plan to be sold on the marketplaces as a "public option."
But the ceaseless GOP attacks on the marketplaces, which had been a conservative idea, and the failure of private health insurers to make more affordable plans available — even before Trump took office — has caused more Democrats to back a bigger role for government.
"That is a huge shift," said Jacob Hacker, a Yale political scientist who helped develop the public option proposal.
Further emboldening Democrats is growing evidence that the public overwhelmingly supports existing government health plans, especially in the face of GOP threats to scale them back.
Eight in 10 Americans held a positive view of Medicare in a recent nationwide poll by the nonprofit Kaiser Family Foundation.
And majorities of both parties favor allowing more people to buy into the program, the survey found.
Medicaid enjoys similarly broad support, with three-quarters of Americans expressing a favorable view.
By contrast, the GOP proposals to roll back the 2010 health law and slash funding for Medicaid were overwhelmingly unpopular, drawing support from just one in five Americans in several nationwide polls.
Even supporters of this emerging Democratic healthcare agenda acknowledge it will take years to develop and may not be fully debated until the campaign for the 2020 Democratic presidential nomination gets underway next year.
But many say it is not too early to begin planning.
"We saw support for Medicaid [during the 2017 GOP repeal push] that took even many longtime Medicaid advocates by surprise," said Rep. Ben Ray Lujan (D-N.M.), who is sponsoring a proposal with Sen. Brian Schatz (D-Hawaii) to allow people to buy into the Medicaid program.
"There is an opportunity now to build on that momentum," Lujan said.