Since the Affordable Care Act was passed in 2010, America has failed to become a health care nirvana. Premiums have continued to rise, though at a slower rate than before the law was passed. Likewise, overall health spending is still increasing, though it has slowed. There are still people without insurance, though 20 million more have coverage because of the law. And, believe it or not, you can still get sick and even die.

Now that Republicans are about to take control of the entire federal government, they have an answer to these shortcomings of the ACA: They're going to make things much, much worse. You think health insurance is a hassle now? Just you wait.

Earlier this week, Donald Trump announced that Rep. Tom Price (R-Ga.) will be his secretary of health and human services, making him the administration's point person on health care. This was a clear signal of Trump's intentions, so far as he has them. Price, a hard-right conservative with an ardent hatred of the ACA, will now be the second most important player in shaping whatever form "repeal and replace" takes, after House Speaker Paul Ryan. (And yes, that includes Trump himself, who has amply demonstrated that he neither knows nor cares a whit about the details of health care policy; he'll sign whatever they put in front of him.)

Price has his own health care plan, which as Sarah Kliff explains, "would replace the law with a plan that does more to benefit the young, healthy, and rich — and disadvantages the sick, old, and poor." While his plan probably won't be adopted in full by Congress, he and Speaker Ryan are in agreement about many things. Here's some of what they're inclined to do:

  • Roll back the ACA's expansion of Medicaid, which would immediately toss over 10 million Americans off their health coverage.
  • Cut funding for Medicaid and make it a block grant, allowing states to more easily cut benefits and throw people off their coverage.
  • Remove the ACA's iron-clad guarantee of coverage for those with pre-existing conditions; in some cases you might avoid getting charged enormous premiums only if you were lucky enough to have never had a lapse in your coverage, and in other cases you'll be shunted to a "high-risk pool," which is likely to be shockingly expensive.
  • Allow insurance to be sold across state lines, which will produce a race to the bottom as states with the weakest regulations attract insurers.
  • Allow the return of bare-bones policies that are cheap but provide little more than the illusion of coverage.
  • Phase out Medicare in favor of giving seniors vouchers with which they can try to buy private insurance.

When you hear Republicans talking about their preference for "patient-centered" care, this is what they're talking about. Or in other words, "You're on your own."

There's obviously a complicated political and policy history underlying this issue, but at its heart is a basic conflict of values and priorities. When they passed the ACA, Democrats had two primary goals rooted in their values: Get as close as possible to getting everyone insured, and make health care secure for everyone. There were other things they very much wanted to do, including bringing costs under control, but those two were the most critical. As liberals, they believe no one should go without coverage, and that everyone's coverage should be secure — not based on your income, or the whims of your employer, or whether you've had an illness before, or how cruel your governor and state legislature happens to be.

This is really important to understand: Republicans do not believe in either universality or security. That's not to say that in the abstract they actively oppose everyone getting coverage or people's coverage being secure; it's that neither of those things is particularly important to them. They aren't going to try to accomplish them, except in half measures meant to insulate them from political blowback. Millions of Americans being uninsured didn't bother them before the ACA was passed, and it won't bother them in the future. Nor will the idea of everyone being vulnerable to losing their coverage. What's far more important is that government have as minimal a role as possible.

That's the primary value they want expressed in health care: Government is bad, and the private sector is good. You can see this in their response to the expansion of Medicaid. Before the ACA went into effect, each state set their own eligibility limits, and Republican states (particularly in the South) were extraordinarily stingy. For instance, Texas' eligibility level is 18 percent of poverty, or $3,628 — make more than that as parents in a family of three, and you're too rich to qualify (and single people aren't eligible for coverage there at all). The ACA tried to change that by allowing anyone making up to 133 percent of the poverty line ($26,812 for a family of three) eligible, including single people. But Republicans sued, and successfully got permission to opt out.

Which means that Republican states like Texas turned down a huge pot of federal money — under the law the federal government picks up almost the entire tab for the expansion — because they literally would rather have their poor citizens go without health insurance than see them get it from the government.

That's also why they've wanted to privatize Medicare for so long. It's not that they want secure, quality health coverage for seniors, because seniors already have that with Medicare as it exists (which is why the program is so popular). And it's not that they genuinely believe that privatization is going to save money overall, because Medicare is less costly than private insurance, both because it has lower overhead costs and because its size allows it to dictate lower prices for the care it reimburses. No, they want to privatize Medicare because its very success — as a huge, single-payer government program its recipients love — is an ongoing offense to everything Republicans believe about government.

Chances are that they're going to abandon Medicare privatization, because the political backlash will be too intense to withstand. But they'll repeal the ACA in some form, and make health insurance, which was maddening enough already, significantly less secure and more cumbersome. If you're lucky enough to have employer-sponsored care and you never lose your job, you'll be insulated from the worst of it. But otherwise, you should watch out — and if you're poor, you're in real trouble. It isn't going to be pretty.