Representative Tom Price on capitol hill in 2015 Joshua Roberts / Reuters

Watching Tom Price warm up the crowd at Donald Trump’s health-themed campaign rally in rural Pennsylvania last month, I didn’t imagine that the representative from Georgia would soon take the helm of American health care.

Price was energetic that day, though that did nothing to make him stand out among the four other Republican doctors-turned-politicians on the stage. Each beamed as he stepped to the mic to express his enthusiasm for Trump, Pence, America, and two-fisted uprooting of the Affordable Care Act. The men often contorted their faces when speaking the word “Obamacare,” as if it produced an acrid taste—though they used the term effusively.

That’s not uncommon among doctors in my experience—especially but not exclusively Republican doctors—so it was easy to dismiss Price as part of a partisan chorus that maligns the law but offers threadbare alternatives.

Tom Price is different, though, by degrees. After two decades of practicing orthopedic surgery, spending years at Grady Memorial Hospital—one of the largest public hospitals in the country—Price gave up practice. In 2005, he headed to Washington bent on fixing the health-care system from the top. There he created a detailed health-care plan that evinces his passion, a 250-page document that he calls the Empowering Patients First Act, which lays out an absolute reconstruction of American health care.

Until now the plan has proven too radical for mainstream adoption, compared to more moderate reforms proposed by the likes of Ted Cruz and Paul Ryan. Representative Price has taken some iteration of the bill to the floor each year since the Affordable Care Act was passed, each time unsuccessfully. As Senator Charles Schumer described Price’s plans this week, these efforts have been seen as “far out of the mainstream of what Americans want.”

But when Donald Trump tapped Price as his secretary of health and human services on Tuesday, the Georgia surgeon’s plan took several sudden leaps toward becoming a part of all American lives.

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Tom Price, who will oversee a budget of more than $1 trillion, is a man of definitive ideology. A founding member of the Tea Party Caucus, he has vowed to fight what he calls “the vile liberal agenda.” That has included the Affordable Care Act, as well as legal access to abortions and marriages. When same-sex marriage was affirmed by the Supreme Court, Price called it “a sad day for marriage.”

Price has painted the health-care reform passed during the Obama presidency as a manifestation of “oppressive” government. He has rallied against the Affordable Care Act since before its passage in 2010, saying it was “doomed to fail from the beginning” and playing a vocal role in seeing that through.

Yet Price’s vision for health transcends simply opposing President Obama, and his work is evidence that he is doing more than echoing partisan rhetoric. This week, The New York Times editorial board described Price as “a man intent on systematically weakening, if not demolishing, the nation’s health-care safety net.”

As Price puts it, though, the goal is rather to improve patient-doctor interactions.

From the perspective of a doctor who went into politics to get government out of the way of medical practice, among the barriers are elements of Medicaid and Medicare—the so-called safety-net programs that provide health care to poor, disabled, and older Americans. In an attempt to contain spending and ensure quality, Medicare and Medicaid come with guidelines that dictate reimbursement. Many doctors find the systems’ requirements tedious and cumbersome—a common and serious complaint among doctors, who tell me they feel the art and autonomy of medicine are lost amid tedious paperwork and other minutiae.

For many doctors, then, wealthy patients who can simply pay in cash, or through expensive private insurance plans, are relatively hassle-free (and more lucrative) prospects. This leaves a clear target for a doctor who is also deeply ideologically opposed to most any form of government intervention. Downsizing these programs would mean freeing doctors from dealing with patients insured by the cost-containing plans that many feel are too bureaucratic.

Of course, as many news outlets were quick to caution this week, such proposals stand to strip millions of low-income and disabled Americans of insurance. Through these programs, millions of newly insured Americans have obtained coverage under the Affordable Care Act that Price has vowed to wholly repeal. And if that happens, the voters who indirectly put Price into this role stand to lose the most.

Low-income and working-class white Americans—like those in the rural Pennsylvania audience, who voted for Trump in disproportionate numbers—have seen disproportionate benefit from the Affordable Care Act. As of now, a record-low number of Americans are uninsured across the board. But the latest numbers are especially dramatic among poor white people without college degrees; their uninsured rate plummeted in the last three years, from 25 percent down to just 15 percent.

Trump has promised not to dial back the programs that have accounted for so many insured Americans, in no uncertain terms (“I’m not going to cut Social Security like every other Republican, and I’m not going to cut Medicare or Medicaid”). But the President-elect’s website has since changed its language on the issue, saying it will “modernize” Medicare. As the journalist Jonathan Cohn noted this week, that’s often swamp jargon for privatizing—or giving people vouchers with which they can attempt to buy health insurance from private corporations.

The problem with vouchers and tax credits, though, is the cost of health care makes the idea impractical. For instance, Price’s plan gives $3,000 in tax credits to people 51 and older. Even a minimal plan for an older person would cost several times that much. The cost of insurance for older Americans would most likely increase when the individual mandate—which currently requires all young people to have substantial health insurance—is repealed.

A common criticism of the Affordable Care Act is that young people are forced to buy more insurance than they should have to. Price’s plan would mean that young healthy people spend less on insurance—which means that insurance companies will have to increase for older, higher-risk people.

Similar increases could also hit anyone with a “pre-existing condition” if insurers are no longer prohibited from charging more to such patients, a hallmark accomplishment of the Affordable Care Act. Trump has said he favors keeping provisions like that, and Price’s plan does include a similar provision, but with a substantial loophole: Insurers are free to charge sick people more if they don’t maintain “continuous coverage.” If you have a gap in coverage—for example, if a sick person gets fired and doesn’t immediately find another job that provides coverage (or purchase individual coverage)—then the insurance companies can raise premiums.

To bail out those people, taxpayers would contribute to a fund for people who couldn’t afford spikes in insurance cost—but Price’s plan has only allocated $1 billion annually to do that. Other Republican plans have proposed several times as much, as insurance companies historically tend to take full advantage of opportunities to raise rates. That would mean a lot of taxpayer money going to private insurance companies instead of directly to doctors and hospitals (as it does through Medicare and Medicaid).

Price also advocates tax-exempt health-savings accounts. As with vouchers and tax credits, the idea of saving a stack of tax-free cash to purchase your health care sounds in ways idyllic—but impractical when care costs as much as it does in the U.S. The average person incurs more than $10,000 in medical costs every year, and millions of Americans have nowhere near that much in savings. The exorbitant system costs are the result of oligopolies: privatized insurance corporations, pharmaceutical and medical device corporations, and health-care systems. All of these things Obama attempted to moderate with the Affordable Care Act, and all stand to be repealed.

Were Price’s plan fully carried out, that could potentially do more to exacerbate the rift between rich and poor than any other cabinet member. As my colleague Vann Newkirk noted this week, the question is just how far Price can take his plans in this role. Republicans like Lamar Alexander, chair of the Senate Health, Education, Labor and Pensions Committee, have said that realistically, any holistic replacement of the Affordable Care Act will take years.

While Price will no longer be involved directly in the passage of new legislation, his anti-government philosophy stands to color the process. As federal programs are pared down and privatized, ever more power is ceded to the corporations that make American health care so uniquely expensive. The gap between the haves and have-nots grows. A divide beyond the repair of any surgeon.

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