DONALD TRUMP’S ONE BIG BEAUTIFUL BILL effectively accomplishes what he failed to do in his first term: repealing much of the Affordable Care Act.

Estimates are that almost 12 million people will lose Medicaid coverage and an additional 5 million will lose insurance because the enhanced subsidies to purchase insurance on the Obamacare exchanges will not be renewed and because of a new rule imposed on the marketplaces. Together, these actions will reverse about 70 percent of the ACA’s coverage gains.

It will be devastating from a public health perspective, with an estimated 51,000 deaths that would have been prevented, and additional suffering and strain on vulnerable American families. From a political perspective, the grim stories and harsh headlines will create an opportunity for Democrats—though perhaps not as simple of one as they hope.

Rather than gnash their teeth and demand the reversal of Trump’s bill, Democrats must propose clear reforms to both Medicaid and the ACA. If they want to really strengthen health insurance and convince the public that they’re a pragmatic, solutions-oriented party, the time is now. They can’t just defend old programs. They should call not just to “Repeal” Trump’s bill but (to borrow a phrase) to “Repeal and Replace” it.

Simply defending Medicaid fails to recognize that the program has serious flaws, ones that have been there from its start, in 1965, when it was built on the model of a failed initiative—Eldercare—that had been launched to encourage states to cover the health care of elderly patients. Sixty years later, Medicaid is showing its own age. It needs to be overhauled, dramatically, to fulfill the goal of giving quality health care to all Americans who lack employer-sponsored insurance or Medicare.