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WASHINGTON — After two years of Republicans’ unsuccessful attempts to repeal the Affordable Care Act, Democrats won back the House majority in 2018 with a unified focus on health care.

Now the scalpels are out, and the issue is swiftly becoming one of the clearest dividing lines in the Democratic presidential primary.

In dueling speeches and barely veiled potshots this week, former vice president Joe Biden and Vermont Senator Bernie Sanders ratcheted up the debate over whether to shore up Barack Obama’s signature achievement by creating an option to choose health care from a government system, as Biden wants, or to transition to a fully government-run system with no role for private insurance companies, which is Sanders’ long-held dream. Meanwhile, candidates such as California Senator Kamala Harris have been accused of waffling as they grapple with the politics of the issue.

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As the health care battle turns increasingly bitter, what was so recently a political winner for Democrats, akin to kissing babies, is transforming into a minefield that could expose breaks in the party on a fundamental issue and, some worry, threaten the eventual nominee’s success against President Trump.

“Due to sheer incompetence, the president has handed Democrats a political gift,” said Jim Manley, a veteran Democratic consultant who worked to pass the Obama-era Affordable Care Act as a top Senate staffer. “I just don’t want to see us squander it by getting sidetracked on debates that aren’t going to lead to real legislation.”

The contours of the argument reflect the party’s leftward drift a decade after Democrats were unable to muster support to include the public option — the ability of people to choose to pay for a government-run health care plan — into the Affordable Care Act. But the debate also has Democrats nervous that a drawn-out fight could cede their advantage on the issue back to Republicans, whose efforts to gut provisions of the health care law, like protections for people with preexisting conditions, have been broadly unpopular.

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Progressives, however, are determined to make their case for a more sweeping overhaul — Medicare for All — that would put everyone into a single-payer government health care system with expanded benefits. They are frustrated by what they see as distortions of Sanders’ plan, which left-leaning candidates including Senator Elizabeth Warren endorsed with a show of hands at the first Democratic debates.

“I think we knew when the moderators at the debates asked candidates to hold up their hands, we all knew that it could be used against them,” said Rebecca Katz, a progressive political strategist. “We just thought it would be the Republicans who did it.”

For some Democratic voters, anxiety about Medicare for All has become a motivating issue.

“Medicare for All sounds absolutely wonderful,” said Sandra Jones, 73, a mental health counselor who went to see Biden in Dover, N.H., last week, and is leaning toward supporting him. But, she added, “I know that many people have health care that they like, yes, that works for them. So a plan needs to accommodate everybody.”

The party’s smackdown is unfolding in the context of a larger battle between crusading liberals who are dazzling progressive voters and frustrated moderates trying to push back on controversial proposals like the decriminalization of crossing the border and student loan forgiveness.

“Maybe what we’re talking about is the difference between tenable and untenable positions, or positions where we can actually make progress versus those where we can’t,” said Senator Michael Bennet of Colorado, a Democratic presidential candidate who has positioned himself as a pragmatist. “It’s important to have this discussion now so we don’t follow Bernie off a cliff that will make us lose the general election.”

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Sanders hit back against those criticisms on Wednesday in a 43-minute speech at George Washington University, in which he decried a bloated insurance industry and astronomical health care costs. He also suggested a transition to government-run insurance would be much less painful than his critics have suggested and defended the tax increases it would require.

“My Republican friends and some others,” he said, “seem to think that people hate paying taxes but they love paying insurance premiums.”

Biden, by contrast, has cast himself as a defender of the Affordable Care Act.

“I oppose the Republican Party trying to get away, get rid of Obamacare. . . . I oppose Democrats who are trying to do that,” Biden said in New Hampshire last week, over a dripping ice cream cone, before calling out Sanders and his advocacy for Medicare for All.

“He says it’s going to end all private insurance. I mean, he’s just straightforward about it. And he’s making this case,” Biden said.

Biden calculates that the public is not ready for a totally government-run system.

But his own plan of creating an option for consumers to choose government health coverage could come with risks. His promise this week that people who like their insurance plan could keep it echoed Obama’s much ballyhooed — and incorrect — promise that people who liked their doctors could keep them under the ACA.

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Candidates including Warren and Harris could benefit as Biden and Sanders, whose poll numbers have slipped, fight it out. Neither has released a comprehensive health care plan of their own.

Health care has long been a thorny issue for candidates of both parties. Bill Clinton was unable to enact universal health care. Obama faced a hurricane’s worth of blowback after he passed a health care overhaul in 2010. And the Republicans who assailed it have so far been unable to come up with an alternative.

Specialists say Sanders’ proposal for Medicare for All faces steep odds, including opposition from interest groups and uncertainties over whether Democrats will win control of the Senate in 2020, or unify behind the proposal if they do.

Medicare for All is popular among Democrats, but some party elders worry aspects of it could leave the party vulnerable.

“What the public wants is to have a choice,” said Howard Dean, a former Democratic presidential candidate who has been the governor of Vermont and top party official. “I do think, ‘They’re going to get rid of your health insurance programs’ is a great point of attack for Republicans.”

But that is not to say campaigning on Medicare for All is certain to be toxic. During the 2018 midterms, some Democrats who supported the idea won in swing districts.

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“The opposition to it didn’t really break through as a national message,” said David Wasserman, the House editor of the Cook Political Report. “That could be really different in 2020 if the Democratic nominee has a proposal that pleases the left of the party.”

Even if liberal Democrats win the argument and make it to the White House, they could face political costs as they try to implement a health care program. Vermont spent years trying to build a single-payer system before the Democratic governor, Peter Shumlin, abandoned the effort in 2014 after complaints over its cost.

“When I got into office, I found you can’t just fix the payment system when your system’s broken in the first place, when it’s gobbling up money faster than you mint it,” Shumlin said in an interview. “Who can come up with a plan that delivers better quality care to everyone for less money?”


Jess Bidgood can be reached at Jess.Bidgood@globe.com. Follow her on Twitter @jessbidgood