Some descriptive statements may seem political when they are, in fact, merely stubborn truths. Such is the case with the fact that the contemporary Republican party, at least on the federal level, lacks both the ideas and the will to improve American health care. To be sure, Republicans take positions all the time that will dramatically impact Americans’ health, and in important ways. But those impacts are ancillary, mere collateral damage in wars being waged in the other policy domains, such as concerned with taxes and guns.

Let’s be clear about the present situation. In 2016, the Republican party lined up behind a candidate who lacked strong policy commitments or vision. The red meat he put on offer was repealing the Affordable Care Act (ACA), overturning Roe v. Wade, and building a wall.

Political scientists know that presidential re-election bids are generally referendums on the incumbent, so it falls to incumbents to make the case for four more years. Yet, in a statement that should be uncontroversial, in almost four years Trump has not been able to attain his central health policy aims.

To take just the example of the ACA, the Trump administration undermined the ACA enrollment process in ways that had – even before COVID-19 arrived – already started to undo the ACA’s historic gains in insurance coverage. He and his party were able to repeal the penalty for not carrying health insurance that was supposed to serve as one of the ACA’s cornerstones, but health care markets have been largely stable, and the ACA continues to do the important work it was designed to do.

Trump has, however, made significant strides toward the attainment of his policy aims, even if he failed at accomplishing them legislatively. The ACA’s fate is to be announced by the Supreme Court just months after election day (oral arguments are on November 10), with health care access and the critical anti-discrimination provisions that serve as the ACA’s moral center hanging by a thread. The Trump administration has supported this effort, led by Republican attorneys general, to decimate the ACA without offering a proposal to replace it.

When I say that the Republican Party has failed to provide ideas for improving American health care, I also mean that in another, more formal sense. As readers may know, the Republican Party took the highly unusual step of forgoing the creation of a party platform this year. Instead, the party announced that it stood for whatever Donald Trump stood for. As someone formally trained in political theory, I’ll spare readers a history lesson about what this may mean. But I bet you can guess. Not everybody who will vote for former Vice President Joe Biden loves what he proposes to do to improve American health care. The key difference is that he has ideas to improve American health care at all.

So, what are we to make of the current moment? Let me offer just two thoughts.

First, Trump’s health care vision is even blurrier than it was the first time around. We should all take note of the lack of detail, but also the perversity in Vice President Mike Pence’s claim in last week’s vice-presidential debate that “President Trump and I have plans to improve health care and to protect…pre-existing conditions for every American.” Aside from the fact that these plans remain incoherent after almost four years, Americans should note with interest that Trump administration is actively–as we speak–in the process of taking away the very protections that Trump and Pence say they will fight for in a second term. The ACA mandates so-called “guaranteed issue.”

The second point is even more far-reaching. Though Trump failed to navigate to legislative process to deliver on his 2016 promises – even when his party controlled both houses of Congress – this doesn’t mean that the Trump administration, if it is voted out in just a few weeks, will not leave a decimated American health care system in its wake. The Trump administration has, of course, already solidified its legacy in the area of health policy through its inaction during COVID-19, resulting in the death of 210,000 Americans and counting. It’s hard to imagine, however, that the enduring impact of the Trump years may be only beginning.

I’m referring, of course, to the Supreme Court. We knew from the beginning, because he told us, that court appointments were what really excited Trump. Like the Trump name plastered on the side of hotels, Trump is excited to have his name appended to the Court for decades to come. It’s this focus on appointing judges and justices committed to carrying out the conservative agenda that enabled so many Americans, especially evangelical Christians, to hold their noses and vote for a candidate who represented much that they reviled.

I wish I could say that 2020 election could stop the erosion and even destruction of the American health care system that we are now witnessing. Those who have long fought for health care access, reproductive rights, and a host of other important policy goals hope that a court stamped with Donald Trump’s imprimatur will surprise us by not going as far as we fear they may go. There may be little Democrats can do about Trump’s appointment of Judge Amy Coney Barrett at this point, other than expanding the Court under a Biden administration and Democratic Senate in 2021. But all of that is for the next fight.

For now, Americans need to know the current health care stakes of this election. Having capable and steady leadership to steer us out of COVID-19 is obviously the central health and health care question of the moment. But we need to return, at some point soon, to the hard work of improving the American health care system, and not just running interference to defend ground we thought we had already gained. Having the right people begin this work is what this election is all about. The Republican Party, with Trump now serving as stark reminder, has rarely made such work a priority. With history as our guide it should not be controversial to admit that only Democrats can do that.

Dan Skinner is Associate Professor of Health Policy at Ohio University’s College of Osteopathic Medicine, located on the Dublin campus. He is the host of Prognosis Ohio, a health care podcast produced in collaboration with WCBE, a Central Ohio NPR affiliate. Follow Dan at @danielrskinner.