The Republican Party s assault on the Affordable Care Act continued Monday as the Trump administration found yet another way to undermine the laws insurance rules.

Health care has become a defining issue of next months midterm elections, and Republicans across the country, including President Donald Trump , are promising voters that they care deeply about protecting people with pre-existing conditions.

But Mondays rule change almost certainly means that, overall, people with serious medical problems are likely to have a harder time finding coverage and, ultimately, paying their medical bills.

Under guidance from the Department of Health and Human Services that takes effect immediately but likely wont affect insurance markets for another year, state governments will have new leeway to request waivers from some of the federal health care laws core requirements.

That includes requirements affecting which benefits insurance plans cover, as well as requirements on who gets financial assistance and how much, and how the people choosing insurance can use that assistance.

Its a complicated set of changes , but it means that some residents of states seeking the waivers could end up with easier access to cheaper, skimpier health plans , providing an alternative to those who cannot afford to pay for comprehensive coverage that the Affordable Care Act has made available.

The Trump administration is touting this possibility as proof that it is improving choice and affordability and, in the words of Seema Verma, the Trump administration official in charge of overseeing federal health programs, that it is working to mitigate the damage of Obamacare.

Verma, who addressed reporters in a conference call Monday, insisted that the new rules would not hurt people with pre-existing conditions. In so doing, she echoed claims that Trump and countless Republican candidates for federal and state office have made with increasing insistence over the past few weeks , as their longstanding support for repealing the Affordable Care Act has become a clear, possibly fatal political liability.

But this latest regulatory change is a reminder that the GOP has never given up on its goal of wiping Obamacare off the books, and that people with serious medical problems are likely to suffer as a result.

The less generous plans that Verma and the Trump administration are touting, and that Mondays rule change will favor, frequently leave beneficiaries exposed to catastrophic costs if they get seriously sick or injured, precisely because they leave out benefits that people need when they have serious medical problems. Often, the buyers of these plans arent even aware of the limits until its too late, because deciphering the fine print of these plans is so difficult.

And people who want or need comprehensive insurance say, because they have diabetes or are cancer survivors are likely to have a harder time getting such coverage, because of how the markets will change .

This new guidance allows states to set up parallel insurance markets that may be able to attract healthy people with plans that have lower premiums but fewer consumer protections, leaving ACA plans with a sicker pool and higher premiums, Larry Levitt , senior vice president at the Henry J. Kaiser Family Foundation, told HuffPost on Monday.

Levitt called the regulatory change a major end run around the health law.

The change raises the stakes on the 2018 midterms, because it means, among other things, that state officials, many of whom appear on this years ballot , will have even more power to shape (and reshape) their health care markets.

Some states will keep working to expand coverage to the uninsured and keep it affordable and adequate, [and] in other states well see a race to deregulate, with the result that comprehensive coverage will be more expensive for those who need it most, Sabrina Corlette , a research professor at Georgetown University, said.

The GOPs Obamacare Sabotage Campaign

Mondays announcement represents the latest in a series of GOP efforts to accomplish through regulation what Republicans could not accomplish through legislation when they tried, and just barely failed, to pass legislation that would have repealed the Affordable Care Act outright.

These steps include dramatic cuts in funding for enrollment outreach and promotion , as well as a change in federal regulations that will allow people to hold on to limited-benefit, short-term plans for nearly three years. That change, along with repeal of the individual mandates financial penalty for people who dont have comprehensive coverage, makes these short-term plans a more viable alternative for people.

These plans typically cover a lot less than the sorts of plans available through the Affordable Care Act. They may have weak coverage of prescriptions, if they have any at all, and leave out mental health altogether. Usually they do not cover pre-existing conditions and are often not available to people who have them.