Donald Trump’s transition team announced on Tuesday morning that the president-elect has selected Georgia Rep. Tom Price as secretary of health and human services. The move sends at least two very loud messages. First, the incoming White House is dead serious about scrapping the Affordable Care Act. Second, it may well be open to ending Medicare as we know it.



Price, a former orthopedic surgeon who chairs the House Budget Committee, has not merely been a strident critic of the ACA: He’s also authored a 242-page bill to replace it, which Sarah Kliff has explored in some detail at Vox. The legislation would entirely eliminate the Affordable Care Act’s Medicaid expansion and give extremely modest, age-based tax credits to Americans who need to buy insurance. It’s parsimonious even by the standards of Republican replacement proposals. This past June, however, Price signed on to House Speaker Paul Ryan’s own replacement proposal, unveiled as part of the GOP’s “A Better Way Platform,” which in theory might be a better-funded, if still deeply conservative, approach to health care reform. For example, Price’s plan would have spent $3 billion to fund high-risk insurance pools for Americans with pre-existing conditions for just three years. Ryan’s plan would spend $25 billion over a decade and make the pools permanent.



Price is similarly keen on Ryan’s plan to transform Medicare by turning it into a voucher system where the government would give seniors money that they could use to purchase private insurance. He included those changes in his 2015 budget, and recently told reporters that he expected Republicans to tackle Medicare “reform” some time in 2017, echoing Ryan’s own post-election comments.



As health and human services secretary, Price would ultimately be in charge of administering programs like Medicare, Medicaid, and the Affordable Care Act—and presumably serve as Trump’s point man on health policy. Given that the president-elect is by all accounts a deeply impressionable man with little to no policy expertise, Price is almost certainly set to play an extremely influential role in any negotiations over health care legislation. Aside from steering the administration’s legislative priorities, Price will be able to meddle with Obamacare directly using his powers as secretary. As Margaret Hartmann notes at New York magazine, the man is notoriously opposed to the federal regulation that requires insurers cover contraceptives at zero cost and could undo it by using the administrative process to rewrite some of Obamacare’s rules.

Trump briefly seemed to soften his stance on the Affordable Care Act after meeting with President Obama earlier this month, suggesting that he might like to keep some of the law’s key provisions like rules banning insurers from discriminating against patients with pre-existing conditions. But with Price’s selection, any hope that the White House might resist the House GOP’s minimalist approach to reform seems to be dead. His presence in the Cabinet also seriously calls into question Trump’s early campaign promises not to cut Medicare, which helped distinguish him from the rest of the Republican pack among older voters deeply attached to their health care benefits. Words don’t mean much to our new president. But as the saying goes, personnel is policy.