Your health care and Republican majority, at stake in Congress starting in 3-2-1 …

This new year brings brings fresh choices and fresh controversies in health care. President Trump and Republicans tried last year to repeal the Affordable Care Act and, when that failed, to chip away at the law in other ways. But in the end, with no legislation passed, the principal result was to galvanize a once ambivalent public.

Now we enter 2018 with health care as a top concern of American voters and the ACA as popular as ever. More importantly, Americans recognize the ACA’s flaws and by large margins just want them to be fixed.

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There is plenty about the ACA that isn’t working as well as it could. Seven years of no improvements and the peeling away of key elements will do that to any law.

Serious proposals from both sides should be listened to. Republican ideas for more flexibility, more innovation and the role of personal responsibility have a place in any debate about how to improve health care. Democrats want to address drug costs. But instead of considering those ideas, the 2017 dividing line was over cuts —specifically, cutting Medicaid and the ACA to pay for corporate and personal tax cuts.

Substantive policy debates won’t be any more likely in an election year like this one. But in four critical areas there are decisions ahead that will have major ramifications for millions of Americans — and potentially for what happens in November, when control of Congress is at stake.

Medicaid cuts: Republicans failed in their attempts to cut health spending last year in various repeal bills, but that didn't stop them from going ahead with the sizable tax cuts the repeal was intended to fund. That created a $1 trillion-plus IOU. Now House Speaker Paul Ryan wants to pay it off — arguing that with less revenue coming in, it's even more important to cut spending on Medicaid and Medicare.

But there’s less appetite for deep Medicaid cuts in the Senate and even less in the electorate. If Ryan is serious about reforming Medicaid, his best bet would be a bipartisan panel to recommend solutions that reduce long-term costs while improving care. I partnered with a Republican from the first Bush administration, Gail Wilensky, to propose such an approach last year. It would be a smart move now.

ACA repeal: Sen. Lindsey Graham, R-S.C. still burns a candle for repealing and replacing the ACA. He and Sen. Bill Cassidy, R-La., last year proposed a system of block grants to states, with fewer strings attached to the money and fewer protections for sicker or older people. It didn't have the support to pass then. Should Congress take it up again, it will be sure to aggravate a very active and alert public in an election year. Perhaps more to the point, the Republican majority in the Senate is narrower than last year, and moderates and many conservatives aren’t excited to live through the last year again.

ACA fixes: If there’s a way for Trump and the Republicans to score a win of sorts, it is simply by undoing some of the damage they did to the ACA in 2017. The administration stopped paying Cost-Sharing Reduction payments to insurers, designed to keep insurance affordable for low-income people, and repealed the individual mandate that encourages broad participation by both the healthy and the sick. Those steps  collectively raise premiums by as much as 30% for families. 

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Congress should pass a permanent  program allowing insurance companies to buy reinsurance to offset the risk of their most expensive cases. That would reverse some of that damage and decrease rates across the country, according to an analysis by Oliver Wyman. This would be a smart political move as these premium decreases would come out right before the election. You can imagine Trump’s tweets on how he’s “fixed” things. No matter that he would be only partially fixing what he just broke.

Trump’s actions: With his executive order last year, Trump signaled that he would undermine the ACA’s protections by allowing insurance plans that don’t have to cover even the basics. Trump calculated that would bring the Democrats to the table, but Democrats are wise to stay away on those terms. Early in 2018, the administration has to decide if and how to implement this executive order as well as whether to approve requests from states to impose work requirements or require drug testing for Medicaid beneficiaries. These decisions are likely to draw a range of legal challenges and protests. Trump may welcome the controversy, and if he proceeds with more unilateral action, he and the entire party will certainly get it.

How Republicans decide to handle the Children's Health Insurance Program as part of the 2018 budget process this month will set a clear tone for the year. Not renewing this program serving 9 million children was one of their biggest blunders of 2017. Now they have a chance to pass a long-term renewal without any of last year's poison pills in the form of House proposals to cut Medicare and ACA coverage.

The action starts immediately and triggers a series of important choices. The overall path that helps the most Americans is, as it usually is, also the path that makes the most political sense.

Andy Slavitt, a member of USA TODAY's Board of Contributors, is a former health care industry executive who ran the Affordable Care Act and the Centers for Medicare and Medicaid Services from 2015 to 2017. Follow him on Twitter: @ASlavitt