Donald Trump and Republican leaders in Congress have made clear they are serious about repealing Obamacare , and doing so quickly. But dont assume their dismantling of government health insurance programs will stop there.

For about two decades now, Republicans have been talking about radically changing the governments two largest health insurance programs, Medicaid and Medicare.

The goal with Medicaid is to turn the program almost entirely over to the states, but with less money to run it. The goal with Medicare is to convert it from a government-run insurance program into a voucher system while, once again, reducing the money that goes into the program.

House Speaker Paul Ryan (R-Wis.) has championed these ideas for years. Trump has not. In fact, in a 2015 interview his campaign website highlighted, he vowed that Im not going to cut Medicare or Medicaid. But the health care agenda on Trumps transition website, which went live Thursday, vows to modernize Medicare and allow more flexibility for Medicaid.

In Washington, those are euphemisms for precisely the kind of Medicare and Medicaid plans Ryan has long envisioned. And while its never clear what Trump really thinks or how hell act, it sure looks like both he and congressional Republicans are out to undo Lyndon Johnsons health care legacy, not just Barack Obama s.

Of course, whenever Trump or Republicans talk about dismantling existing government programs, they insist they will replace them with something better implying that the people who depend on those programs now wont be worse off.

But Republicans are not trying to replicate what Medicaid, Medicare and the Affordable Care Act do now. Nor are they trying to maintain the current, historically high level of health coverage nationwide that these programs have produced. Their goal is to slash government spending on health care and to peel back regulations on parts of the health care industry, particularly insurers.

This would mean lower taxes, and an insurance market that operates with less government interference. It would also reduce how many people get help paying for health coverage, and make it so that those who continue to receive government-sponsored health benefits will get less help than they do now.

Its difficult to be precise about the real-world effects, because the Republican plans for replacing existing government insurance programs remain so undefined. Ryans A Better Way proposal is a broad, 37-page outline without dollar figures, and Senate Republican leaders have never produced an actual Obamacare replacement plan.

But the Republican plans in circulation, along with the vague and shifting health care principles Trump endorsed during the campaign, have common themes. And from those its possible to glean a big-picture idea of what a fully realized version of the Republican health care agenda would mean.

Obamacare

Obamacare has expanded and bolstered health insurance mainly through two sets of changes: a straightforward expansion of Medicaid eligibility, which the 31 states and the District of Columbia now offer, and a makeover of the insurance market for people buying private coverage on their own rather than through employers. The net effect of the Affordable Care Act is an estimated 20 million fewer uninsured than before the law.

Obamacares makeover included writing new rules for insurers: All policies must now include comprehensive benefits, for example, and carriers can no longer deny coverage to people with pre-existing conditions nor charge them higher rates than healthy people.

The newly reformed insurance system also offers subsidies: to assist people who could never afford coverage before; and to offset the higher prices insurers charge now that they must cover more services, without turning away the people most likely to use them.

Repealing the law outright would increase the number of uninsured Americans by 22 million, according to the Congressional Budget Office . Republicans have vowed to replace Obamacare with something better great health care for much less money, as Trump put it on 60 Minutes Sunday.

But GOP plans would scale back the federal commitment to Medicaid, then unwind the changes to the individual insurance market by reducing the regulations on coverage. GOP plans would also eliminate the health insurance exchanges through which more than 10 million people get access to private insurance and those all-important subsidies. Republican schemes envision new forms of financial assistance, but generally lower income people would get less money , and (depending on the details) many middle-income people would too.

Some of the regulatory changes would be indirect. Allowing insurers to sell across state lines an idea Trump mentioned frequently would let all insurers relocate to states with the fewest rules, effectively gutting requirements more progressive states might impose on coverage. Overall, the result would be less coverage and protection than Obamacare provides.

And while some people would benefit, others would suffer. To take one example, healthy 25-year-olds could buy cheaper, skimpier policies than the law now allows. But 55-year-olds with high blood pressure would tend to face higher premiums because insurers could resume charging them more and bigger copayments at the pharmacy.

Republicans talk a lot about preserving Obamacares most popular provisions, like protections for people with pre-existing conditions.

But the fine print of their proposals shows their guarantee is different and less ironclad. Insurers could still turn away people who dont maintain continuous coverage . Thats no small thing. People who lose jobs frequently let coverage lapse and itd happen more commonly in a world without the generous financial assistance Obamacare provides.

Conservatives say they have a solution for this: They would create special insurance plans, called high-risk pools , for people insurers wont cover.

This idea has been tried before, at the state level and it didnt work very well . The plans typically offered weaker coverage at higher prices, and required vast infusions of money that state governments rarely provided. Tellingly, Ryans budget allocates just $25 billion over 10 years for high-risk pools. Even conservative experts believe it would take far more money for the pools to be the viable alternatives that Republicans imagine.

In September, RAND Corp. researchers analyzed Trumps health care reform principles and determined that his plan would increase the number of uninsured by 16 million to 25 million people, with a particularly tough impact on people with serious medical conditions who would face higher out-of-pocket charges.

Thats a very rough guess, and a worst-case scenario. You can find analysts who make assumptions more favorable to conservative plans and end up more sanguine about the results. But the basic effect of all GOP replacement plans is clear: fewer people with insurance, less protection for people who have it, or some mix of the two.