“I used to have to borrow money to get a mammogram,” says Theresa, 37, a waitress in New Orleans who was diagnosed with a breast lump in 1999 and told to get a mammogram twice a year. Thanks to the ACA, she can afford health insurance for herself and her husband, who is self-employed. “I have a family history of breast cancer – my life depends on this coverage.”

Demonstrators that include mostly medical students protest a proposed repeal of the Affordable Care Act in New York, U.S., January 30, 2017.  © 2017 Reuters

Republicans in Congress spent much of January preparing their attack on the Affordable Care Act (ACA), and many people like Theresa across the United States are alarmed at the prospect.

Consider the case of Louisiana. In January 2016, newly elected Governor John Bel Edwards decided to expand Medicaid under the ACA, making Louisiana the first state in the deep South to take full advantage of Obama’s landmark legislation. Louisiana now insures half a million residents under either the insurance exchanges or through the expansion of the Medicaid program. Since July 2016, more than 50,000 adults across the state have had preventive health care or seen a doctor as a new patient; more than 3,000 people living with HIV have access to comprehensive health insurance coverage, and plans are underway to link state prisoners with chronic conditions to Medicaid before they return to the community.

Since July, Women with a Vision, a New Orleans-based nonprofit, has helped hundreds of people with little to no resources apply for Medicaid. “We go under the bridges and ask people if they want to sign up for Medicaid. We have their Medicaid cards sent to our office, and they come and pick them up,” says Nia Weeks, director of policy and advocacy for the group. “Many are getting health care for the first time in years, sometimes decades.”

But Congress and the Trump administration now threaten to repeal the ACA without developing an adequate replacement, or to strip away funding from key programs such as Medicaid expansion and Planned Parenthood via a process called “budget reconciliation.” It is exactly through subsidized premiums and tax credits that the ACA allows low income working people to realize their right to access health services. Louisiana’s investment in health coverage is also good fiscal policy: Governor Edwards estimates savings of more than US$100 million a year from reduced hospital costs alone.

“Budget reconciliation” may sound technical and benign but the moves playing out in Congress could result in devastating loss of health services for those who are most vulnerable, including Theresa and the beneficiaries of Women with a Vision. In Louisiana and other states, attacks on the ACA also put the right to health itself in their crosshairs.