It isn’t hard to understand why so many American expatriates living in Europe, Australia, New Zealand, Canada, Japan or even parts of Latin America dread the thought of ever returning to the U.S. and coping with its dysfunctional heath care system. Universal health care is the norm in most developed countries, whether it is accomplished via government-operated systems, public/private systems or privatized systems that are subject to very strict government regulation. In the U.S., increasing access to health care has been a long, tough, uphill battle—and in the Donald Trump era, millions of people who have suffered from diabetes, cancer, high blood pressure or heart disease live with the constant threat of losing their health insurance at some point in the future.

Whether the U.S. increases or decreases the number of people who have health insurance will depend a lot on who is elected to government. The November midterms, inevitably, will be a referendum on Donald Trump’s presidency, and health care will no doubt be one of the issues that voters have on their minds when they go to the polls. In fact, the future of the Affordable Care Act of 2010, a.k.a. Obamacare, will be on the line in November.

So far, the Trump administration and Republicans in Congress have not succeeded in abolishing the ACA, although they’ve certainly tried. One of the versions of Trumpcare proposed by Republicans was passed by the House of Representatives in 2017 but narrowly defeated in the U.S. Senate when three Republicans—John McCain, Susan Collins and Lisa Murkowski—voted against it, much to the disappointment of Trump, Senate Majority Leader Mitch McConnell and House Speaker Paul Ryan. And so, the ACA survives, although Republicans have done a lot to undermine and sabotage it.

Republicans have attacked the ACA via everything from the Tax Cuts and Jobs Act of 2017 (which eliminated the ACA’s individual mandate) to butchering its advertising budget. And according to the Urban Institute, the results of all this sabotage in 2019 will include 6.4 million more Americans lacking health insurance and premiums soaring by more than 18% in the individual market.

The ACA—for all its flaws, weaknesses and shortcomings—greatly expanded the number of Americans with health insurance and contained some desperately needed reforms (forcing companies to cover Americans with preexisting conditions, subsidies that help the poor obtain insurance, greater preventative screening). According to the National Center for Health Statistics, the ACA decreased the number of uninsured Americans from 48 million in 2010 to 28.6 million in 2016. Of course, the fact that 28.6 million Americans still lacked healthcare is appalling and demonstrates that the ACA doesn’t go far enough. But the American Health Care Act, one of the versions of Trumpcare considered in Congress, would have been much worse and—according to the Congressional Budget Office’s analysis—caused a whopping 23 millions Americans to lose their health insurance by 2026.

Had Trumpcare come to pass and so many Americans lost their health insurance, Trump as well as McConnell and Ryan would have had blood on their hands. But in the Republican Party, harming people would be a small price to pay for eliminating what they see as President Obama’s biggest legislative victory. And the ACA could still be overturned, depending on what happens in the November midterms.

If Democrats manage to retake the House of Representatives and/or the Senate—which remains to be seen—overturning the ACA would be unlikely. But if Republicans increase their majority in the Senate, it’s entirely possible that the ACA will be overturned in 2019 and replaced with some new. version of Trumpcare that will cause the number of uninsured to skyrocket and result in countless medical bankruptcies.

Democrats will likely be campaigning on health care reform in different ways this year. Some will campaign on expanding the ACA and fixing some of its obvious flaws—such as the fact that tax subsidies for singles purchasing individual plans via the online marketplace are only available to those making $48,240 or less. If a single is making $49,000 or $50,000 per year, for example, that is too much to qualify for an Obamacare subsidy. The ACA has done a lot to help the poor and lower middle class obtain insurance, but after a certain point, it leaves the middle class out in the cold.

Recognizing the ACA’s flaws, some Democrats and their allies—such as the independent Sen. Bernie Sanders of Vermont—are aggressively pushing for universal health care via a single payer program. When Sanders introduced a single-payer bill late last year, he obviously knew it didn’t stand a chance of passing in the GOP-controlled Senate. Nonetheless, it was important for him to voice his position—and in 2018, some of the more liberal/progressive Democrats Sanders has endorsed are campaigning on a single payer system, including 28-year-old Alexandria Ocasio-Cortez (who is running for the U.S. House of Representatives in Queens and the Bronx against Republican Anthony Pappas) and Braddock, PA Mayor John Fetterman, who is running for lieutenant governor in Pennsylvania (an important swing state). Universal healthcare has not been an afterthought to Sanders allies like Ocasio-Cortez and Fetterman; it has been a prominent part of their platforms.

In 2018, Democrats need to have a robust conservation about healthcare—and that should include a country-by-country analysis of the many different ways in which universal health care is being achieved in other parts of the world. Universal healthcare is hardly monolithic in Europe, where some countries are achieving excellent results through government-operated systems while others are doing so through carefully regulated private-sector systems. Some elements of the ACA, in fact, are comparable to the Swiss healthcare system—although the ACA would need a lot of expansion and tougher rules before it could be on a par with Switzerland or Germany.

Modern-day Republicans, sadly, have no interest in expanding health care coverage in the U.S. The fact that they so bitterly oppose the ACA even though it was greatly influenced by Republican ideas of the past—including those of the Heritage Foundation, former Massachusetts Gov. Mitt Romney, Sen. Bob Dole and President Richard Nixon—shows that they are more interested in partisan politics than the well-being of Americans.

Even if the ACA isn’t overturned in Congress, it could be struck down by the U.S. Supreme Court. Brett Kavanaugh, Trump’s nominee to replace Justice Anthony Kennedy on the High Court, is a major corporatist—and it is quite possible that Kavanaugh, along with Trump appointee Neil Gorsuch, could apply a “strict constructionist” view of jurisprudence and declare that the ACA is unconstitutional because it interferes with insurance companies’ right to operate their businesses as they see fit. When Republicans declare that they like Kavanaugh because he is “pro-business,” what they really mean is they like him because he’s anti-consumer, anti-competition, pro-monopoly and pro-oligarch.

The U.S. is at a crossroads when it comes to health care. It can achieve universal health care like the rest of the developed world, or it can allow millions of Americans to suffer needlessly—and if Republicans perform well in the November midterms, that suffering is guaranteed.