If truth is the first casualty of war then the battle to repeal the Affordable Care Act (ACA), widely known by its nickname, “Obamacare,” is no exception. Candidate Trump promised to repeal Obamacare and replace it with a much better plan that relied on market forces to cover everyone at reduced cost. “I am going to take care of everybody. I don’t care if it costs me votes or not. Everybody’s going to be taken care of much better than they’re taken care of now,” (60 Minutes interview, September 2015).

The American Health Care Act (AHCA), the legislation passed by a slim majority of Republicans with the support of the Trump Administration on May 4 does none of those things, except repeal the ACA. The AHCA will forever be known as Trumpcare. If enacted it would represent a savage attack on large sections of the working class and poor, literally killing or shortening the lives of many people who will no longer have access to vitally needed services.

Trumpcare will increase premiums and out of pocket expenses, most markedly for women, for many in rural counties, for older people and for those with pre-existing conditions. It eliminates the requirement that insurers offer a minimum package of essential benefits, which would mean they could go back to not covering mental health care and maternity care. It essentially ends Medicaid expansion and bans all Medicaid funding for any services provided by Planned Parenthood. Lifetime caps on coverage will return. Millions would return to the ranks of the uninsured, or worse yet, be paying for insurance too expensive to use.

Attacking the Most Vulnerable

Internal divisions within the Republican Party prevented the bill coming to a floor vote on two previous occasions. “Moderate” Republicans opposed the measure because it stripped some of the most popular provisions of the ACA, particularly protections for people with pre-existing conditions.

The inclusion of the MacArthur Amendment, which professed to preserve those protections, has been widely credited with bringing enough Republican opponents on-board to pass the measure narrowly, 217-213. The MacArthur amendment does not protect anything. Theoretically, it allows states to choose to preserve protections for pre-existing conditions. Actually, pre-Obamacare, states had the option to regulate protections for pre-existing conditions; however only seven did, because it drives up costs for the insurer.

The ACA is a very complex piece of legislation whose parts interlock like Jenga blocks— pull the wrong one and the whole tower crashes to the floor. ACA’s individual mandate, though never implemented as written, compelled millions of young healthy people to buy health insurance, spreading risk and lowering costs. Only the inclusion of the young and healthy made pre-existing protections, and many other ACA reforms, financially feasible in insurance company “logic.”

Trumpcare eliminates the ACA’s “10 essential benefits” clause which is also necessary for preserving protections for pre-existing conditions and overall access. Under Trumpcare, an insurance company free from essential benefit provisions but bound by pre-existing conditions protections could offer someone with a pre-existing condition a policy which fails to cover the very services that person would need. In addition, while the MacArthur amendment does not allow insurers to refuse to offer plans to anyone, it also doesn’t limit how much they can charge for them. This is a purely formal distinction because prohibitively expensive health insurance is no health insurance at all.

The savagery of the Republicans and their complete lack of connection to the reality of ordinary people is shown by the comment of Rep. Robert Pettinger of North Carolina who said that if Trumpcare passed, people with pre-existing conditions could just move to another state if their state opted out of ACA protections. Not to be outdone, Rep. Mo Brooks from Alabama declared that people who have pre-existing conditions on principle should pay more to help those “who lead good lives” and “live the right way.” As though people with breast cancer or congenital heart conditions are guilty of a moral failure!

The Real Agenda – Looting the Public

If enacted, Trumpcare would transfer literally billions of dollars from the poorest to the very richest Americans by restructuring Medicaid, or, more honestly, eliminating Medicaid as we know it. An analysis of the role of Medicaid in the current health care system reveals the wholesale impoverishment of the American working class over the last 40 years. Medicaid provides coverage for low-income people, primarily children, the elderly, and disabled adults. In 2015, 20% of Americans, a total of 74 million people, received Medicaid benefits and in four states and Washington DC, the percentage is 25% or more.

Trumpcare makes huge cuts to Medicaid funding by eliminating the ACA’s Medicaid expansion, instituting per-capita caps on spending and block granting Medicaid funding to the states. The Congressional Budget Office estimated that these changes would cut $839 billion from Medicaid spending over the next decade and conveniently pay for the $729 billion in tax cuts included in the repeal legislation. These tax cuts benefit medical device companies and the extremely wealthy almost exclusively—the wealthiest 400 tax payers (the 0.00001%) would each get an average tax cut of almost $7 million every year starting in 2017 (Tax Policy Center).

The bill now moves to the Senate. Senate Republicans will not introduce a less draconian attack on health care, only one more competently written and expertly delivered. Senate Republican leaders have already promised to wait for the Congressional Budget Office scores, or estimates of Trumpcare’s impact on the budget, expected by the middle of next week. Further, facing stronger Democratic opposition in the Senate, the Republican leadership has pledged to rewrite the bill so that it actually meets the criteria required of budget reconciliation legislation.

Republicans chose to repeal the ACA using the budget reconciliation process because they only need a simple majority, 50% plus one, to pass their legislation. Outside of that process, any ACA repeal bill would need 60 votes in the Senate to pass. However, there are disadvantages for the Republicans to using the reconciliation process as well, namely, all provisions of the legislation must pertain to the budget and the budget must still be under consideration.

Several of Trumpcare’s provisions are vulnerable to legal challenge because of their tangential connection to the budget. The time frame is tight: the Senate must introduce legislation, pass it, and reconcile it with the House version before a final budget is passed. It appears that this means the Senate Republicans will try to get their bill passed by the end of June. However, it will then have to be reconciled with the House bill and the final product re-voted in the House where the divisions among the Republicans make the outcome very uncertain.

How Did We Get Here?

Though it includes important progressive elements like Medicaid expansion and covering people with pre-existing conditions, serious weaknesses in the basic design of Obamacare make it vulnerable to the current attacks by Republicans. The state exchanges, actually modeled on Republican ideas, only function when insurers are making a level of profit acceptable to their Boards of Directors. That made even subsidized plans expensive for consumers. Insurers pulled out of markets that weren’t profitable enough, limiting choices in those areas.

While defeating Trumpcare in Congress would be a huge blow to the Republican agenda it will not unfortunately prevent the Trump Administration from using its executive powers to undermine the precarious balance that is Obamacare. The administration is threatening to stop funding the cost sharing payment which helped 70% of those participating in subsidized plans afford their portion of the premium and out-of-pocket expenses. Trump pulled funding for the advertising campaign that would have informed the public about Obamacare deadlines and services. The administration also cut the enrollment period to just six weeks. Cumulatively, these changes will increase the number of sick people in the exchanges relative to the healthy ones, increasing costs and pressuring insurers out of even more market places. Trump has the ability to kill Obamacare by a thousand cuts, to bring its internal weaknesses to a crisis. This points to why we need to fight for a healthcare system that works for everybody that is not based on maintaining the profits of the insurance industry.

How do We Stop it?

Democrats in the House and Senate have correctly attacked Trumpcare and they clearly view health care as an effective political wedge against the Republicans in the 2018 mid-terms. But a movement whose aims are limited to scoring political points against the Republicans within the bounds of what is acceptable to the Democrats’ corporate masters is far short of what is demanded by the situation. Obamacare’s weaknesses are what opened the door to the attacks of the right in the first place. There is no standing still. Trumpcare must be defeated and replaced by a Medicare for All type plan which covers everyone regardless of income, employment or legal status.

During his election campaign last year, Bernie Sanders popularized Improved Medicare for All and laid out a very detailed plan to pay for it that could be used as the starting point for a public debate. The idea enjoys strong popular support; in May, 2016, 58% of those polled told Gallup they supported “federally-funded healthcare providing insurance for all Americans”. Key figures in the party have made clear that they oppose Medicare for All.

This includes the Democratic governors of California and Washington who could be in a position to sign into law state based single payer plans which would be a major step towards a national Medicare for All. The health-care debate reveals, yet again, why working and poor people need their own political party which fights unapologetically in their interests and takes no money from the corporations including the insurance and pharmaceutical industries.

Protest has stopped or slowed other Trump initiatives. Trumpcare could be defeated by well-organized and escalating series of mass protests which culminate in a national day of action.

This campaign needs serious support from the unions which support Medicare for All, including healthcare unions like National Nurses United which are playing a leadership role in statewide initiatives for single payer. The coming weeks are shaping up as a critical battle with the Republicans who are prepared to literally put people’s lives at risk for their reactionary agenda.