Read: Trump settles on his reelection message

Few Republicans have talked much about repealing the ACA since Democrats rode to sweeping gains in last November’s election; the Democrats did so in large part behind their promises to defend the law, particularly its provisions protecting patients with preexisting health conditions. Many Republicans have seemed anxious to put the debate over the ACA behind them.

But over the past several days, Trump has repeatedly reaffirmed his desire to uproot the law. In a succession of tweets and public comments, the president has condemned the late Republican Senator John McCain of Arizona for his 2017 votes that blocked repeal. And in the administration’s budget for the 2020 fiscal year, Trump endorsed a specific plan to replace the law.

In the fall of 2017, Senate Republican leaders had embraced that very plan, put forward by Senators Lindsey Graham of South Carolina and Bill Cassidy of Louisiana, as their last chance to replace former President Barack Obama’s signature health-care law. But it died amid opposition from the same three GOP senators who had blocked earlier efforts to undo the ACA: Susan Collins of Maine, Lisa Murkowski of Alaska, and McCain.

The Graham-Cassidy plan that Trump is now reviving would have deeply retrenched the federal government’s role in health care. It would have repealed both the subsidies the ACA provides to help the uninsured purchase private insurance and the law’s expansion of Medicaid coverage to more of the working poor. It proposed instead to replace those funding streams with a single block grant given to states for covering the uninsured. The bill would also have ended Medicaid’s status as an entitlement, available to anyone who met the eligibility criteria, and instead reconfigured it into a program that would provide states with only a fixed annual sum to cover health care for the needy. It would have allowed states to free insurers from the ACA’s requirements to provide coverage at no extra cost to consumers with preexisting health problems, as well as the law’s mandates to guarantee a wide array of essential health benefits, including maternity care. In a final twist, it would have reallocated money from the mostly blue states that have expanded Medicaid under the ACA to the red states that have not, by basing the future block-grant allocation on a state’s total number of low-income people, not its level of health-care expenditures.

The version of Graham-Cassidy proposed by the president would impose even larger spending cuts than the original. Compared with projected spending over the next decade under existing law for the ACA and Medicaid, Trump’s new plan would cut federal dollars by a resounding $774 billion.

“The administration’s proposal would provide meaningfully less funding than Graham-Cassidy would have,” says Matthew Fiedler, a fellow at the Schaeffer Initiative on Health Policy at the Brookings Institution. “They have taken Graham-Cassidy as the starting point and reduced the block grants that are provided to the states, and [proposed] even deeper Medicaid cuts.”