Though health care policy and future of the Affordable Care Act wasn’t one of the defining issues of the 2024 election cycle, it probably should’ve been. Donald Trump, for example, spent much of the year condemning the popular and effective ACA, and he had plenty of partisan company.

Before voters went to the polls, key Senate Republicans opened the door to undermining Obamacare — including future vice president JD Vance, who talked up an idea that would weaken protections for Americans with pre-existing conditions. As Election Day drew closer, House Speaker Mike Johnson publicly endorsed “massive” changes to federal health care policy, adding, “No Obamacare”; Republican Sen. Mike Lee of Utah published an online item that read, “Kill Obamacare now”; and future Republican Sen. Dave McCormick announced his opposition to an ACA provision that allows young adults to stay on their parents’ health insurance plans.

Despite the health care law’s popularity, the party won big — and it’s now following through on its rhetoric. The Washington Post reported:

Congressional Republicans are pursuing changes to the Affordable Care Act that would mean 10.7 million fewer Americans using its insurance marketplaces and Medicaid, a huge reduction that some view as a way to accomplish part of the health-care coverage cancellation that failed in 2017.

Of course, GOP officials aren’t explicitly saying that they’re trying to gut the ACA. In fact, the Post’s headline is emblematic of the fact that these efforts are unfolding largely out of the spotlight: “Shhh. Republicans are trying to repeal Obamacare again. Sort of.”

But the practical results are the same. Matt Salo, former executive director of the National Association of Medicaid Directors, told the Post, in reference to the Republicans’ reconciliation package, “It is very much like a backdoor repeal and replace. They’ve been too cute by half by doing it but not calling it that.”

Larry Levitt, executive vice president for health policy at KFF, describing the real-world effects of the GOP megabill, added, “They’re not calling this ACA repeal and replace, but the coverage losses would be among many of the same people who would have lost their insurance under ACA repeal.”

It’s not exactly a secret that much of the focus on the inaptly named “One Big Beautiful Bill Act” has been on Medicaid, and for good reason. Despite Trump’s promise not to cut the health care program, the GOP legislation would cut roughly $700 billion from Medicaid in the coming years. Just hours ahead of the bill reaching the floor, House leaders added new and punitive Medicaid provisions to shore up support from far-right members.

But for health care advocates, the effects on the Affordable Care Act matters, too. Axios had a good report last week noting that the Republicans’ package would make it harder for people to sign up for ACA marketplace plans, gut the ACA’s Medicaid expansion program, end automatic re-enrollment in ACA plans and shut off provisional ACA subsidies, among other things. A related Rolling Stone report added that the same proposal would also “place further restrictions on enrollment periods and create new bureaucratic hurdles to obtaining premium tax credits, in ways that experts say will cause many to forgo or lose coverage.”

The Post’s report noted that the same legislation, if implemented, “would also delay two Biden-era regulations aimed at easing and streamlining enrollment by helping people more easily transition between Medicaid and Children’s Health Insurance Program and private marketplace plans.”

Perhaps most importantly, the Republican plan would end the expanded ACA tax credit subsidies that made coverage far more affordable for consumers throughout the Biden era — a move that would, according Congressional Budget Office estimates, leave roughly 5 million Americans uninsured.

With this in mind, NBC News reported that new coalition of health care advocates, called Keep Americans Covered, is launching a new seven-figure ad campaign on the issue.

The new commercial features a woman named Jessica, a restaurant manager in Arizona whose daughter has a chronic illness. She says the ACA tax credits “have been particularly helpful for our family” to affording the coverage they need. “We need Congress to take action now. It’s vital for us,” she says in the ad. “We need these health care tax credits passed today.”

The spot is set to run in Washington, D.C., and 12 states, including Louisiana (House Speaker Mike Johnson’s home state), South Dakota (Senate Majority Leader John Thune’s home state), Maine (Republican Sen. Susan Collins’ home state), Alaska (Republican Sen. Lisa Murkowski’s home state) and North Carolina (Republican Sen. Thom Tillis’ home state).

In case this isn’t obvious, in the first year of Trump’s first term, Republicans also went after the ACA, and the political blowback was enormous: The effort inspired progressive activists to get more engaged, put the GOP on the defensive and pushed the president’s approval rating sharply lower. The political damage lingered and did real harm to Republicans in the 2018 midterms.

It would probably be wise for Democrats to focus their messaging accordingly. The Republicans’ megabill is, for all intents and purposes, an anti-health care bill that would take coverage from millions of American families.