To fully capture the bill’s implications, we must recognize how we got to this moment and how this history can shape our resistance efforts. The AHCA’s predecessor, the Affordable Care Act (ACA, better known as Obamacare), midwifed the current legislation in ways that unions, health-care justice organizations, and the Left must understand. The far right capitalized on Obamacare’s failures, convincing significant sections of US society to support more extreme forms of austerity.

If enacted, the American Health Care Act (AHCA) will be the most devastating attack on New Deal/Great Society programs that the United States has seen in the last forty years. It will shape the experience of working-class life, as well as the political, ideological, and economic terrain of class struggle more than perhaps any other single piece of legislation in the post-financial crisis era.

Robin Hood In Reverse

House Speaker Paul Ryan and President Donald Trump would like us to believe the AHCA “repeals and replaces” Obamacare. It doesn’t. Much of the ACA’s framework would stay in place: most importantly, Trumpcare maintains the provisions that subsidize private insurance costs through tax credits.

To get the bill passed, Trump and Ryan are squeezing it through the budget reconciliation process, a filibuster-proof system that only requires a simple majority vote. This strategy restricts the AHCA to funding provisions, leaving important regulations on the health-insurance industry intact. This represents the bill’s only virtue; these regulations, along with Medicaid expansion, were pretty much the ACA’s only progressive elements.

What the AHCA does, however, is drastically modify the procurement and allocation of roughly $500 billion in annual health-care spending. While it doesn’t alter the programs this money funds — Medicaid and Medicare, insurance subsidies, and a vast network of health-care institutions — it does qualitatively change where that money comes from, how much is available, and where it goes.

Put simply, Trumpcare takes funding away from the poorest Americans and transfers it to the richest.

As with the ACA, the media has largely focused on how the AHCA will affect coverage. Its changes are, indeed, profound. The Congressional Budget Office (CBO) has predicted that twenty-six million people will lose health coverage over the next ten years, returning the overall number of uninsured people in the United States to more than fifty million.

Most of these people will be working and non-working poor people cut from Medicaid’s rolls. But a sizeable chunk will be those who can no longer afford their premiums because of the AHCA’s subsidy changes.

Under the proposed bill, tax credits are pegged to age, not income. Further, Trumpcare drastically reduces these discounts, so most beneficiaries will pay significantly more for their health insurance.

People in their twenties will receive a $2,000 annual subsidy. Their insurance will be fairly cheap, but the available plans will belong to the “low premium, high deductible and co-pay” category that already plagued the ACA exchanges. The AHCA also allows insurance companies to charge older people five times more than younger folks, and the tax credit for Americans aged sixty and above will total just under $5,000.

Precisely the people who need coverage the most won’t be able to afford it. And that’s on purpose. The AHCA aims to stabilize the insurance markets in the absence of the individual mandate by getting older patients with higher costs to drop out. Once you lose coverage, you have to pay a 30 percent surcharge to your insurance company to sign back up.

These fifty million uninsured Americans will undoubtedly delay necessary medical treatments and flood emergency rooms for care. There, they’ll be joined by people who do have insurance but, thanks to high deductibles and overcrowded facilities, now rely on urgent care for many of their health-care needs. Public health providers, already severely weakened by the Affordable Care Act, will become extremely overburdened.

Beyond this wholesale reduction in coverage, the changes to funding streams and what they will do to the viability of entire sections of American health care is even more catastrophic.

Disemboweling Medicaid is the economic and ideological axis on which this legislation turns. Currently, the federal government allocates Medicaid funding to states based on utilization. Each state determines the scope of benefits and pays about 25–50 percent of the total, with the federal government covering the rest. Most basically, how much health care is used determines the amount of federal funding.

The AHCA would instead give states a fixed amount based on the number of enrollees, an amount that the government will intentionally set very low. States with higher per-capita health-care expenditures — because they have sicker populations, because their property values are higher, and for a host of other reasons — will have to figure out how to make up the difference.

Trumpcare also freezes all federal matching funds for new Medicaid enrollees after 2020. The CBO report estimates that this will reduce federal Medicaid expenditures by a staggering $880 billion over ten years. This guts a key element of the US social safety net to an unprecedented degree.

The resulting fiscal crisis will turn every state budget fight into an all-out war. Politicians will have to choose between enacting huge tax increases or approving equally huge cuts to Medicaid and other state-funded programs. Without a serious movement for taxing the rich, the latter will prevail.

The New York State Department of Health, for instance, estimates that the AHCA will cost the state $4.5 billion over the next four years. That figure includes reducing Medicaid enrollees ($1.6 billion), eliminating funding for undocumented immigrants ($1.5 billion), and cutting direct funding to other programs ($1.4 billion); these figures are probably low estimates, as they do not incorporate the impact of per-capita funding, which will significantly increase the state’s expenditures.

The AHCA would eliminate almost every tax-based funding mechanism the ACA created. For the most part, Obamacare’s funding had a progressive structure, meaning that higher-income people paid higher tax rates. Trumpcare does away with these provisions, turning it into a massive tax cut for the wealthy. Eliminating the Medicare tax surcharge alone will cost the program $117 billion by 2026. (This after the ACA already slashed federal Medicare expenditures by an average of $60 billion per year.)

It’s a sobering fact that a bill that includes the largest tax cuts for the wealthy since the Bush era will end up reducing the federal budget deficit. This net gain comes from deep cuts to federal health-care funding.

The giant vacuum of wealth extraction from the bottom to the top will create a new epidemic of hospital and clinic closures and more consolidations and mergers, leaving private equity firms and the relatively more solvent academic medical centers to pick at now-bankrupt facilities’ carcasses. In other words, like everything about Trump’s first one hundred days, this is not a drill.

Just as they did when introducing the barrage of executive orders, the GOP and Trump have tried to justify this Robin-Hood-in-reverse barbarism by using racialized, gendered, and anti-poor scapegoating.This bill is premised on the belief that healthcare is not a right, and that it you want state benefits, you should be forced to work for them.

This argument will likely take shape in state legislation that ties Medicaid to work requirements. Indeed, Arkansas is already trying to apply Clinton-era welfare-to-work strategies to Medicaid.

The AHCA will also defund Planned Parenthood, immediately crippling the institution that performs over a third of all abortions in the United States as well as providing other critical reproductive and women’s health services. This move not only reduces federal spending for health care but also shores up anti-abortion support for health-care austerity, returns some favors to the Christian right, and scapegoats women.

Overall, the AHCA belongs with the rest of Trump’s proposals so far: it massively favors the wealthy over the working class; it mines public goods for private profit; and it scapegoats historically marginalized groups to get the job done.