President Trump and the GOP are hell bent on repealing Obamacare as one of Trump’s first acts in office. And though in the last weeks we’ve seen a few Republicans get weak in the knees over how swiftly the deal can be done, by and large they are united in the spirit of this assault on working people.

According to the Tax Policy Center, repealing Obamacare will result in a massive tax cut for the 1% while kicking 20 million people off their health insurance. We need a massive movement of people out in the streets to defeat this attack on healthcare and build the broader fightback against the right-wing assault on women, unions, LGBTQ people, immigrants and people of color.

The Reality of the Affordable Care Act

With measures expanding Medicaid in many states and the elimination of pre-existing conditions as barriers to coverage, millions of people gained desperately needed health insurance. Allowing people to stay on their parents’ insurance until age 26, improving access to birth control and eliminating the gender cost disparity are all extremely popular aspects of the legislation. They should be fiercely defended.

At the same time, Obamacare left the for-profit health system in place. Last year, the drug companies raked in profits to the tune of $50 billion while 1 in 5 Americans couldn’t afford the prescriptions their providers said they needed. Also, Obamacare failed to prevent tens of millions of working class people from facing escalating medical costs and deductibles. It is clear that getting health insurance isn’t the same as getting health care. In fact, in the lead up to the election, a report that people would be paying higher premiums for Obamacare in 2017 seriously hurt Clinton’s election campaign.

To truly fix the U.S. health care system – to deliver high quality, efficient care to everyone at a fraction of the cost – a single-payer, universal health system is desperately needed. This can be summarized as Medicare for All. The U.S. is the only industrialized country that leaves millions of people without access to healthcare.

A Long-Term Republican Goal

The Republians have attacked Obamacare relentlessly since it passed in March 2010. Trump, who in the past voiced support for universal health care several times, cynically used the understandable frustration with climbing out of pocket costs to fuel his campaign. The GOP-dominated Congress and President agree that Obamacare must be repealed. However, cracks are appearing on the timing of the repeal and what the replacement would look like. The most prominent divide is between those who want to throw the entire legislation in the trash and those who want to preserve the more popular aspects of the legislation and their careers.

Last week, the GOP used the budget resolution process to pass rules preventing the Democrats from filibustering any repeal efforts. The budget resolution requires House and Senate health care committees to make cuts that would reduce the deficit by $1 billion over the next decade, by repealing parts of Obamacare (although the more likely scenario is that repeal would massively increase the federal deficit). This includes the federal funding for the Medicaid expansion and subsidies for the insurance exchanges. This measure could be passed by a simple majority of 51 votes in the Senate.

However, a few Republicans senators, seeing growing awareness among the public about what “repeal” of Obamacare would really mean, are voicing hesitation over supporting this budget resolution process without a plan to replace it. The uncertainty over what would replace Obamacare has left some of the Republicans in disarray.

Repeal of Obamacare would target the federal funds that were allocated to expand Medicaid, which provides health care for people with limited resources through funding to the states. Astonishingly, many Republican governors turned down this additional funding. The Trump administration could launch further attacks. As governor of Indiana, VP elect Mike Pence expanded Medicaid under Obamacare, but required recipients to pay monthly premiums for plans they qualified for – just to punish poor families. Missing a payment would disrupt coverage for six months. Republican Speak of the House, Paul Ryan, favors implementing block grants to Medicaid, which would limit per capita spending.

These attacks are despite evidence that Medicaid expansion has brought economic gains from “increased employment; increased revenues to hospitals, physicians, and other providers; decreases in uncompensated care; and savings in other states programs, such as state-funded behavioral health or corrections” (Kaiser Family Foundation, December 6, 2016).

The GOP also plans to defund Planned Parenthood which provides vital healthcare to 5 million people a year, including cancer screening, pregnancy and STI testing, abortion and birth control. Loss of those services through attacks on Planned Parenthood would have a disproportionate negative impact on women, people of color and the LGBTQ community.

What Will Happen Next?

The next step for Trump and the Republicans is to pass a budget reconciliation bill, which will likely aim to defund the Medicaid expansion and the subsidies to help people buy insurance coverage. But with many Republicans already getting cold feet on the process, Trump has complicated the delicate situation with his recent claims that everyone will have insurance, that deductibles will go down and that Medicare and Medicaid will start negotiating drug prices.

Obamacare was based on the plan implemented in Massachusetts by Republican Governor Mitt Romney. Both use tax-payer money to fund private healthcare, subsidizing profits for the insurance companies. We can expect the Republicans to keep that basic premise in place. The GOP has given lip service to maintaining the most popular Obamacare provisions, including covering pre-existing conditions. This might be accomplished in part by forming high risk pools, though on the state level these have proven to be extremely expensive. Mandates for reproductive coverage will likely be stripped. The ongoing process of cost shifting onto patients will likely be escalated via rising co-payments and deductibles, discouraging people from accessing the care they need, and exactly contrary to what Trump is promising.

Universal Health Care is Hugely Popular

Bernie Sanders’ presidential campaign drew the enthusiastic support of millions from broad layers of society with his call for Medicare for All, the type of plan enjoyed by the rest of the industrialized world. Universal healthcare, everybody in, nobody out is more efficient and provides better outcomes than our broken for profit system. Obama could’ve and should’ve put this in place in 2008, when he enjoyed even greater majorities in Congress that Trump will have in 2017. Such system would have been extremely popular, and we likely wouldn’t find ourselves in the position we’re in today, defending minor gains. But Democratic Party leaders including Hillary Clinton and Obama opposed this.

In early January, thirteen Democrats voted against Sanders’ proposal to allow Americans to buy medications from Canada and other countries, which are often significantly cheaper. Time and again we’ve seen that the Democratic Party is financially linked to big business, including big Pharma and the insurance companies. We shouldn’t be surprised their representatives aren’t willing to threaten billions of dollars in profits all for the sake of our health.

To realize efficient, high quality health care for all, we must demand single payer, Medicare for All. 280 million people have insurance that is too expensive for them to properly use. As Sanders said recently, I have access to buy a million dollar home, that doesn’t mean I can afford it.

Our first step must be to defending the gains made under Obamacare. This will require the strongest possible movement. The January 15 protests across the country were a good start, but we have to build upon that momentum through further collective action, holding rallies and direct actions to send a clear message to Congress – stop the attacks on health care; we want Medicare for All. Unions must urgently bring their considerable resources to bear in this critical fight. National Nurses United has led the way for years in advocating for Medicare for All.

We’ll also need to broaden out the movement to build strength, linking up with those fighting against the right wing assault on immigrants, on union rights, on education and the environment. To get to Medicare for All, we’ll need a united movement that fights on all fronts, for gains big and small. If the Republicans win at the federal level, we’ll take our fight to the states. There have been a number of efforts to win Medicare for All at the state level in recent years. Repeal of Obamacare could give these efforts more momentum especially in some crucial big states. Wins on this front can embolden the broader fight against Trump.

But in the coming days and weeks the key issue is to bring the maximum pressure to bear, especially in the streets, to force the Republicans in Congress to step back from their assault on healthcare. Trump and the Republicans can be beaten; this is the first crucial opportunity to do exactly that.

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