House Republicans’ legislation to repeal and replace ObamaCare could loom large over the 2020 elections, when both President Trump and a handful of GOP senators in Medicaid expansion states will be up for another term.

If the current legislation passes, millions of Americans who receive health insurance through ObamaCare’s Medicaid expansion are projected to lose coverage a year before the critical election, creating the potential for political backlash at the ballot box.

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Trump, who has embraced the House GOP’s repeal bill, will be running for his second term, and nine Republican senators up for reelection are from states that expanded Medicaid.

The current GOP bill proposes a restructuring of Medicaid that would do away with the extra federal money given to states by the end of 2019. The bill also would cap Medicaid payments to states.

Current enrollees could stay on Medicaid indefinitely, though many typically remain in the program — which primarily helps the poor and disabled — for only a few years.

The nonpartisan Congressional Budget Office (CBO) projects that 14 million people would lose coverage by 2018 under the House GOP’s plan. And when changes to subsidies and Medicaid kick in, the estimate increases to 21 million in 2020. Thirty-one states, as well as Washington, D.C., have expanded Medicaid.

The CBO’s analysis found that the bill would cut $880 billion from Medicaid over 10 years, estimating that the changes would lead to 14 million fewer enrollees in the program by 2026.

The proposed Medicaid changes have divided the Republican Party. Some centrists won’t support a bill that scraps expansion or want a longer delay before the changes are implemented. But more conservative lawmakers believe waiting until the end of 2019 is too long and want what they see as an entitlement to be rolled back immediately.

Repealing ObamaCare is expected to have political implications, but Medicaid may prove less politically fraught than making adjustments to programs like Medicare, which seniors, a reliable voter bloc, rely on. Changes to Medicaid could potentially have less political consequences for Republicans.

“It’s my belief that [Republicans] don’t fear the Medicaid issue politically,” said a Democratic strategist familiar with the Senate.

“There’s probably very little that will happen with the bill that will have as much impact as underfunding and undermining Medicaid expansion.”

The Democratic strategist noted that some GOP senators don’t back the changes but added, “At the end of the day, there’s still this kind of ‘voters don’t care that much’ and ‘we can get away with it.’ And it’s one of the reasons they seem more willing to grind on it.”

Nine Republican senators up for reelection 2020 represent states that have expanded Medicaid: Shelley Moore Capito Shelley Wellons Moore CapitoGOP senator to quarantine after coronavirus exposure Hillicon Valley: Zuckerberg acknowledges failure to take down Kenosha military group despite warnings | Election officials push back against concerns over mail-in voting, drop boxes Bipartisan senators call for investigation of popular fertility app MORE (W.Va.), Cory Gardner Cory Scott GardnerHouse approves bill to secure internet-connected federal devices against cyber threats Congress needs to finalize space weather bill as solar storms pose heightened threat Trump courts Florida voters with moratorium on offshore drilling MORE (Colo.), Tom Cotton Tom Bryant CottonLoeffler calls for hearing in wake of Netflix's 'Cuties' Health care in the crosshairs with new Trump Supreme Court list Cruz says he wouldn't accept Supreme Court nomination MORE (Ark.), Joni Ernst (Iowa), Dan Sullivan (Alaska), Steve Daines (Mont.), Bill Cassidy (La.) and Senate Majority Leader Mitch McConnell Addison (Mitch) Mitchell McConnellSenate Republicans signal openness to working with Biden Hillicon Valley: DOJ indicts Chinese, Malaysian hackers accused of targeting over 100 organizations | GOP senators raise concerns over Oracle-TikTok deal | QAnon awareness jumps in new poll The Hill's Campaign Report: Biden asks if public can trust vaccine from Trump ahead of Election Day | Oklahoma health officials raised red flags before Trump rally MORE (Ky.). Medicaid expansion has been temporarily halted in North Carolina, where Sen. Thom Tillis Thomas (Thom) Roland TillisHillicon Valley: DOJ indicts Chinese, Malaysian hackers accused of targeting over 100 organizations | GOP senators raise concerns over Oracle-TikTok deal | QAnon awareness jumps in new poll Republican Senators raise concerns over Oracle-TikTok deal Democratic Senate candidate 'hesitant' to get COVID-19 vaccine if approved this year MORE will run for reelection.

Four Republican senators have already said they won’t support any repeal bill that rolls back the Medicaid expansion. Of those four, two — Capito and Gardner — could be on the ballot in 2020.

Cotton, who faces reelection in 2020, has been one of the more vocal Senate critics of the House GOP bill. He has argued that the current measure won’t be able to pass the upper chamber, saying that the House should slow down the repeal process.

The Arkansas Republican, who has been floated as a potential presidential contender, warned that if the House does vote for the proposal, it has the potential of putting the GOP’s House majority in jeopardy in 2018.

Other 2020 Republican senators have voiced skepticism about the House bill, including Tillis. Both Ernst and Sullivan have expressed concerns about changes to Medicaid. And, following the release of the CBO score, Daines said that “we need to do better” on a repeal bill.

Prior to the House GOP’s release of its bill, Louisiana’s Cassidy teamed up with Sen. Susan Collins Susan Margaret CollinsThe Hill's Campaign Report: Biden asks if public can trust vaccine from Trump ahead of Election Day | Oklahoma health officials raised red flags before Trump rally Gideon leads Collins by 12 points in Maine Senate race: poll Senate leaders quash talk of rank-and-file COVID-19 deal MORE (R-Maine) to introduce their own bill. Their version would allow states to re-implement most parts of ObamaCare, including Medicaid expansion, and keep the existing federal funding levels.

The leading bill faces a tough battle in the House. Even if it passes there, numerous Republican senators have warned that the House legislation will be “dead on arrival.”

But if it were to pass in both chambers and Trump signed the bill into law, the president could also face political blowback. Trump had repeatedly promised on the campaign trail that he would repeal and replace ObamaCare, but he has also said that “everybody will have insurance,” a promise that conflicts with the fallout predicted in the CBO score.

McConnell has said that the House GOP’s bill will make it to the Senate floor. But the majority leader could face political backlash in his own state, which expanded Medicaid.

Still, Republicans warn that failing to repeal ObamaCare will hurt them far more in upcoming elections than any consequences from rolling back Medicaid or other parts of healthcare programs.

“I think the political consequences of not repealing ObamaCare are far more severe for the GOP than the politics of repealing,” said Rob Jesmer, a Republican strategist and National Republican Senatorial Committee executive director from 2009 to 2012.

Not all of these Republican senators up for reelection in 2020 are certain to be in competitive races, but the potential that millions of Americans will lose insurance could put them in more precarious reelection situations.

Plus, Republicans will have more seats at risk than Democrats will in 2020, as well as the White House. The GOP will be defending a total of 22 Senate seats while Democrats try to protect 11.

Democrats, looking to make major gains over the next few cycles, have seized on opposition to the GOP healthcare plan as a way to split the opposing party.

Republicans’ persistent focus on ObamaCare helped them cruise to huge victories in the 2010 and 2014 elections, eventually taking power in both chambers of Congress.

About a year after ObamaCare was signed into law, Republicans gained six Senate seats and won control of the House in 2010. And four years later, Republicans gained nine seats and gained control of the Senate. Democratic senators like Mary Landrieu Mary Loretta LandrieuBottom line A decade of making a difference: Senate Caucus on Foster Youth Congress needs to work to combat the poverty, abuse and neglect issues that children face MORE (La.) and Mark Pryor Mark Lunsford PryorCoronavirus poses risks for Trump in 2020 Tom Cotton's only Democratic rival quits race in Arkansas Medicaid rollback looms for GOP senators in 2020 MORE (Ark.) lost their reelection races thanks in part to ubiquitous attacks over ObamaCare.

Now that healthcare reform is in Republican hands, strategists say lawmakers need to market their policies to assure voters that their changes will improve the existing law.

“When you’re the out party, you can go attack things. When you’re the governing party, you need to go and sell your agenda,” Jesmer said.

“We haven’t had to do that for a while, but we’re going to have to do it this time.”

Democrats believe they now have the upper hand and hope to harness the backlash to the repeal bill in the 2018 midterm elections.

They point to the historical trend in which the party of the incumbent president loses seats in the midterms. But Democrats face a daunting Senate map in 2018, defending 10 Senate seats in states Trump carried in November.

Some strategists question whether the fallout from repealing ObamaCare will be immediately felt in 2018, but many believe it could be a stronger political force in 2020.

“A lot of people think it will matter right away. It’s hard for me to see that, whether people will really feel the fallout or impact by that election,” the Democratic strategist said about 2018.

“But in a presidential in 2020, I think that’s a different story,” the strategist continued. “It’s at least a 2020 dynamic, and maybe even 2018. They will feel the pain.”