Partisan battles over the fate of the Affordable Care Act (ACA) in the last days of the Obama administration are a prelude to the planned gutting of federal programs under the Trump Administration. Although a problematic and compromised piece of legislation that early on gave up its initial promise of a public option, the ACA (known as Obamacare) expanded the number people living in the US with health insurance–that is, 20 million who were legally mandated to purchase private health insurance. Without an alternative insurance option in place, the continuation of their coverage remains uncertain.

Last night’s senate vote (51-48) to repeal Obamacare leaves the fate of more popular provisions under the current policy up in the air. Of particular concern are the measures that guarantee dependent health insurance for adults up to age 26, access to reduced-price reproductive healthcare, and the ban on insurance companies denying coverage for those with pre-existing conditions.

Conservatives have been salivating over picking apart one of the last public health programs remaining in the US that currently provides partial- to full-coverage government health insurance for 107.6 million Americans.

Along with the ACA, Medicaid and Medicare–the only pseudo-public insurance option for low-income people, the disabled and seniors over 65–will be increasingly vulnerable to attack under a Department of Health and Human Services run by Trump’s appointee, Tom Price.

Medicare and medicaid were historically programs that provided a minimal check on profit-making insurance industry and privatization of hospitals that drove the cost of healthcare to unaffordable levels. Conservatives have been salivating over picking apart the last of the public health programs remaining in the US that currently provide partial- to full- coverage government health insurance for 107.6 million Americans .

Joining Price is Seema Verma, Trump’s appointed head of the Centers for Medicare & Medicaid Services (CMS). She is the CEO and founder of SVC Inc Consulting, a firm she used to design state-level “alternate” medicaid programs palatable to the far-right. A close ally to powerful Republicans, Verma’s contributions to state medicaid policies have included prohibitive provisions such as mandatory work requirements, monthly fees, and harsh consequences including blocked coverage for missed payments. “Non-emergency related” visits to the ER are deemed wasteful and incur a high fee. Failure to pay monthly premiums leads to harsh punishments, including demotions to bare-bones health plans and coverage lockouts for up to six months–in essence leaving the most poor uninsured for large gaps of time.

While Medicaid recipients are forced to pay an increasing number of fees and navigate complicated fines and punitive measures, with Verma’s help, hospitals in Indiana have enjoyed a fatter cut of federal funds, profiting off taxpayer money through higher reimbursements than they would have received from traditional medicaid. Hospital lobbies predictably supported the measure, which increased reimbursements to institutions accepting HIP by 20 percent.

HIP’s elitist proponents decry the wastefulness of medicaid recipients, claiming their alternative insurance plan–with mandatory fees and penalties–will make people think twice about wasteful healthcare spending on the government’s dime.

While Medicaid recipients are forced to pay an increasing number of fees and navigate complicated fines and punitive measures, with Verma’s help hospitals in Indiana have enjoyed a fatter cut of federal funds, profiting off taxpayer money through higher reimbursements than they would have received from traditional medicaid.

Under this twisted logic, low-income users are pre-emptively accused of abusing public resources, serving as a convenient scapegoat while the rich profit further through the privatization of public sector industries. Verma and her consulting company walked away with a $1.2 million contract from Indiana in 2014, footed entirely by taxpayer money. Her track record of health policy consulting includes assistance with similar plans in Ohio, Arkansas and Kentucky, through which she racked up at least a cool $3.5 million in state compensation according to a report by the Indiana Star. Unsurprisingly, her connections to both government and corporate sectors provided rich ground for corrupt insider dealings, including simultaneously representing Hewlett-Packard, who coincidentally received $500 million in Medicaid/Medicare contracts under the new programs.

Verma’s appointment is representative of the tight corporate-government links and rampant conflict of interest that characterize Trump’s cabinet picks, who will no doubt encourage the continuing insertion of private sector in dwindling public programs. Tom Price, for example, is already under fire and potential investigation for his extensive stock holdings and trading in big pharma and health insurance companies, a direct conflict of interest with his role as Secretary of Health and Human Services .

Paul Ryan’s Plans: Private Capital Plunders Healthcare

Paul Ryan, the Republican Speaker of the House has loudly expressed his dismissal of Medicare as a viable government program and has made no qualms about his plan for “medicare reform”. Ryan’s plan would replace government insurance with a voucher system in which seniors would select plans from a private marketplace- a reform ironically similar to Obamacare which mandates Americans earning above a certain income to choose among private health insurance providers. Unlike Obamacare, which also called for expansion of Medicaid and Medicare, Ryan’s plan would uproot Medicare entirely, ending a government-insurance program in favor of vouchers for private choice.

Currently, Medicare operates as a mixed public-private venture, providing basic government insurance for all seniors over 65. Those who can afford it are able to purchase Medicare Advantage—a private insurance upgrade that offers increased coverage for a monthly premium. Under Paul Ryan’s plan, medical access for seniors above the age of 65 will no longer exist, replaced by predictable Republican policy prescriptions– vouchers that will force seniors to buy into privatized insurance plans in return for shrinking coverage. With a stripped down health budget, the voucher amounts will be insufficient to cover the trend of rapidly rising health insurance premiums, determined by an unregulated and emboldened insurance industry. The consequences of reduced coverage will be immediate and tragic- delayed seeking of treatment, punitive lockouts and accumulation of financial debt will be deadly.

The Democrats and the Republicans Play Thumb War

The last vestiges of a public health program–further privatized through the Affordable Care Act–will be up for further “reforms” under incoming policymakers. A smattering of efforts led by liberals and progressives have begun, to prevent the current system’s upheaval.

Bernie Sanders has called for protests to defend Obamacare, expressing moralistic indignation at the now-likely prospects of the ACA’s dismemberment. In the last weeks since Trump’s election, he has stood firmly side-by-side with Democratic Party leaders (Nancy Pelosi & co.), now occupying his new role as ranking member of the Budget Committee.

In his gestures of opposition, Sanders has pointed to vague statements by Trump dating 15 years back, when he ostensibly supported universal healthcare, as grounds for beseeching the president-elect to preserve the health insurance reforms implemented over the last four years.

While liberal figureheads and Democratic party leaders continue their worn-out pleas for to “reach across the aisle” and “save Obamacare,” Trump has made decisive moves, lining up a team of highly conservative, pro-privatization hawks to head up the next administration’s health care policy. Notably, there have been no clear calls for national universal healthcare from the progressive Democratic camp.

In November, a group of nurses affiliated with the National Nurses United (NNU) stormed Paul Ryan’s office in Washington, D.C. to protests his declared intentions to end public medicare programs. Frontline workers and patients have long been forced to navigate an increasingly complex and dehumanizing insurance system with a financial bottom line that has led to deteriorating patient care and working conditions, rapidly inflating premiums/deductibles set by an unregulated and unrepentant insurance industry, and crushing medical debt.

In just one week, the country, insured and uninsured, will enter a new political period in the grips of the Trump Presidency. Alongside the consolidation of power under his reactionary program and team of corporate underlings, we may begin to see signs of growing resistance, independent organization of the working class and oppressed and united, broad-based opposition.