Before his inauguration, incoming President Trump made this promise about health care in the country: “We’re going to have insurance for everybody. People can expect to have great health care. It will be in a much simplified form. Much less expensive and much better.” Today, eighteen months later, U. S. health care is worse off than ever after the Trump administration’s ongoing sabotage of the Affordable Care Act (ACA) which itself fell so short of universal coverage, cost containment, and improved quality of care.

Although Trump and congressional Republicans failed to repeal and replace the ACA, they own what has become TrumpCare. Their sabotage of the ACA includes repeal of the individual mandate, loosening of the ACA’s restrictions on health insurers, and state waivers that will allow states increased responsibility (with less federal money) to design their own Medicaid and other programs. Annual and lifetime caps on Medicaid coverage, together with increased cost sharing for its beneficiaries, are becoming common as 30 million Americans are uninsured and tens of millions more under-insured.

To be sure, there are both winners and losers with TrumpCare, both of which are built into this new, increasingly unaffordable system, with losers representing much of the population—the most important—patients, their families, and taxpayers. A look at both ends of this spectrum reveals how unfair, unsustainable and cruel TrumpCare is, as well as how health care will be a leading political issue as the midterm elections approach.

TrumpCare winners include large corporate mergers with growing market power to set their own prices, the drug industry which has again avoided any price controls, corporate CEOs and their shareholders, middlemen in our market based system such as pharmacy benefit managers, Wall Street and lobbyists. Private health insurers have been the big winners as they gain more ability to market short term, limited benefit plans that are really junk insurance, to avoid the ACA’s coverage requirements, and to deny coverage to sicker patients. Profit margins for the six top insurers for the first quarter of 2018 were the highest in ten years while their CEOs took in more than $17 million in 2017.

Patients are the biggest losers under TrumpCare, whether by losing the ACA’s protections, losing access to care because of unaffordable costs, increasingly restrictive coverage if insured, losing Medicaid through cutbacks, being underinsured, or losing coverage altogether. Women are disadvantaged by GOP and Trump attacks on reproductive health care and loss of maternity coverage in short term plans. Mental health care is poorly covered as many mentally ill continue to be jailed without treatment. Seniors lose by having to pay higher premiums as they increasingly face bankruptcy because of medical costs despite being on Medicare.

Residents of rural areas are at increasing risk as more and more rural hospitals are forced to close because of inadequate reimbursement and difficulty in recruiting physicians and other health professionals. Physicians lose by being buried in time-consuming billing and clerical tasks that reduce their time for direct patient care. The National Academy of Medicine reported last year that more than one-half of U. S. physicians are showing signs of burnout, including a “high degree of emotional exhaustion and a low sense of personal accomplishment.”

Is there a fix to this mess? Emphatically yes—through single-payer Medicare for All, as represented by H. R. 676 in the House and a similar bill in the Senate (S 1804), and that will be the subject of another Op-Ed.