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Mike Johnsons rise to speaker of the House over the past week was so quick and so improbable that its only now his record is starting to get attention.

Hoo boy, is there a lot to consider.

The Louisiana Republican now in his fourth term led efforts to overturn the 2020 election . He voted for a national abortion ban . He has called for criminalizing gay sex .

But wait, theres more. Johnson also has supported repeal of the Affordable Care Act a.k.a. Obamacare .

You might be thinking it doesnt really matter. Republicans control neither the Senate nor the White House, after all, and these days they dont seem especially interested in health care anyway. During the big 2019-20 legislative fight over President Joe Bidens proposal to lower prescription drug costs , the most notable thing about the Republican opposition was the lack of it. They barely said a word.

The same goes for the Affordable Care Act , which is quite a change from the many years Republicans talked endlessly about repealing it. They finally got their chance in 2017, while Donald Trump was president and Johnson, then new to Congress, voted yes . The effort famously failed, but not before provoking a massive political backlash that helped Democrats retake control of the House and, two years later, the presidency and Senate too.

These days, its news when a Republican even says the word Obamacare.

But that doesnt mean Republicans have made their peace with the 2010 health care law, or that theyve given up on their ideas for replacing it with conservative alternatives. And youll find no better proof than in a 2019 proposal from the Republican Study Committee , which at the time Johnson was leading .

The word repeal appears only a few times, always in a narrow context. But the pieces of repeal legislation are all there. Three in particular stand out.

A Rollback Of Preexisting Condition Protections

About half of the 58-page document is a look at the high cost of American health care, its effects on individual Americans and the many ways, according to Republicans, the Affordable Care Act is responsible for these problems. A big focus is the laws regulations prohibiting insurers from denying coverage or charging higher premiums to people with preexisting conditions, and requiring that all policies include basic, essential benefits.

The report says these regulations made insurance more expensive, which is true in the sense that it means insurers today cant turn away people with serious medical needs or stop paying their bills. That costs money. And while the GOP report acknowledges that the Affordable Care Acts tax credits offset those higher costs for most people, it says thats an inefficient way to get people coverage and warns that it still leaves many Americans with high bills.

Again, theres a lot of truth to both. But the Republican alternative Johnson and his allies supported would roll back the existing regulations, preserving guarantees of coverage only for people who keep continuous coverage and ending the federal requirements on essential benefits. And it would end the current subsidy scheme, replacing it through a mix of tax changes and support for new savings accounts.

Its hard to be precise about the effects this would all have today, because the GOP report doesnt have a detailed budget. But, at a conceptual level, this is pretty much what Republicans were proposing with their repeal bills in 2017: Fewer rules governing what insurance has to cover, and less government assistance to help people buy insurance.

Virtually every independent analysis at the time concluded people in good health could get access to cheaper insurance premiums, but only because people in worse health would be stuck with higher premiums or out-of-pocket expenses or no ability to get coverage at all.

To put it more simply, it was a way of shifting the costs of medical care onto the people who need it . Theres every reason to think the proposal Johnson and his allies published in 2019 would do the same thing.

An End To Medicaid Expansion

The GOP report has a whole section on what it calls The ACAs failed Medicaid expansion. Thats a reference to arguably the laws most consequential change: Federal funding that allows states to expand Medicaid, the half-century-old insurance program for low-income Americans, so that anybody with income below or just above the poverty line is eligible. Previously, most states limited enrollment to certain groups of people, like children and pregnant women.

The expansion, which all but 10 states have now adopted, is the primary reason the number of Americans without insurance has plummeted to historic lows. A large body of academic research shows that Medicaid expansion has made a real difference in peoples lives , by improving their financial, emotional and physical well-being. But of course it too costs money, with the federal share alone exceeding a hundred billion dollars every year.

And thats not the kind of spending Republicans or Johnson have ever supported for this sort of program.

The GOP document envisions ending the expansion in a two-step process. It would start with a moratorium on new state expansions, at a time when resistance in holdout states has been softening. (Expansion has even picked up some momentum in Mississippi .) Then the federal government would reduce the extra money its been providing states for expansion, until there was no extra money at all.

Analysis of similar provisions in the 2017 repeal proposals predicted a rollback would cause millions to lose their insurance coverage. The GOP document doesnt directly acknowledge this. Tellingly, the word uninsured appears only a half dozen times.