Americans who are poor, middle-class, chronically or mentally ill, disabled, frail, elderly and young — most of us, really — may need to keep our fingers crossed  that the relentless attacks on health care access fail again.

Partisans who don’t get the concept of health care as a right have opened many fronts and are especially active of late, with proposed bureaucratic re-alignments of the federal government, promotion of “skinny” or junk health insurance plans, and efforts to slash support for public programs that boost the health of tens of millions through Medicaid, Medicare, food aid, and health coverage for kids of the working poor.

If you’re working and get your health insurance through your job, as most Americans do, you shouldn’t think that you and yours will be magically exempted from  Republicans’ hammering at the U.S. health care system.

Where to begin? Others are writing well about the many fronts on which the Trump Administration and congressional Republicans are squeezing health care:

Trillions of dollars in cuts sought to Medicaid, Medicare

It’s worth following how conservatives in the House, after joining with GOP colleagues in the Senate and White House to push for a $1.5 trillion tax cut mostly benefiting wealthy corporations and the richest Americans, now claim that Uncle Sam’s treasuries may be so depleted that social programs must be cut: They want Medicare slashed by a half billion dollars over the next decade, while Medicaid and other federal health programs would be shifted into a capped, state-allocated block grant program, reducing expenditures there by a guesstimated $1.5 trillion. Yes, this is another budget blue print and GOP lawmakers have tried these tactics before without success. But now they can blame the $1 trillion hole they blew in the federal deficit with the tax cut as the reason social programs must be cut.

Medicaid matters a lot, not just to the poor, disabled, seniors, and kids. Many middle-class Americans benefit from the program, too, but may not know how widespread its effects have become. As for Medicare, it already touches the lives of almost 1 in 5 Americans and will only grow as the nation grays.

The U.S. Senate has shown it will resist some administration proposed cuts in social programs, for example, in a recent vote rejecting a presidential proposal to eliminate $15 billion in already approved funding for the Children’s Health Insurance Program, which provides health coverage to 9 million kids from working-poor families who earn too much to qualify for Medicaid.

A reorganization plan to cut social aid programs

For many taxpayers, a bunch of moves affecting the names and duties of an array of federal agencies matters about as much as the taste of postal stamp glue. Watch out. To those who bet on where the little ball under the cups ends up as President Trump and his men shuffle around Cabinet departments the outlook is clear: a big goal of the administration’s proposed government re-organization is to whack at programs that help the poor and middle-class, whether to see that fewer Americans go hungry (via the Supplemental Nutrition Assistance Program) or by imposing harsh rules on those who need help through Medicaid.

New research has come out on the effect of Indiana’s path-breaking efforts to make the poor document their efforts to find jobs, work, and to pay relatively small sums so they have “skin in the game” when receiving government assistance with their health care via Medicaid. The studies show these efforts don’t save, they end up costing money to set up, maintain, and oversee, and they prove detrimental to the health of Medicaid recipients.

Part of the way partisans hope to tar government support programs, of course, is by describing them as entitlements (though taxpayers fund the programs and have done so for decades) or even worse as welfare, programs benefiting the greedy and lazy. Trump officials hope to collect as many safety net programs as they can and put them into a “welfare department,” which they can stigmatize and slash funding for.

If you want to see how this is under way, just look at partisans’ slashing of food programs for the poor, as funded under the farm bill. It provides tens of billions of dollars in subsidies for Big Agriculture, while cutting off hundreds of thousands of American poor from food stamps.

It’s also worth seeing what happens to the federal Food and Drug Administration, which would see major changes in its role, too — its industry-disliked oversight over the nation’s food and nutrition would go elsewhere (maybe to be lost in bureaucrat cracks) and the agency would become the Federal Drug Administration.

Association health plans, aka ‘skinny’ or ‘junk’ coverage

The administration, in yet another attack on the Affordable Care Act, aka Obamacare, has rolled out new federal regulations to promote so-called association health care plans. This is coverage that Americans, especially the younger and healthier, might seek from groups of like-minded interests (say, small businesses) that band together to offer it.

The plans might carry lower monthly premiums. But they also would lack ACA-required protections on conditions they cover and benefit caps. An array of organizations, representing doctors, hospitals, insurers, and others with health care expertise, have denounced the revival of association plans. They say their coverage is so “skinny” that they amount to “junk” coverage, meaning that users, when they most need insurance, will find that whatever they have paid into it will be all but worthless.

The plans aren’t new, and as Bloomberg News Service reported, they were rife with criminal fraud and abuse Obamacare foes have pushed the association plans, hoping that they will siphon off the younger and healthier participants in ACA marketplaces, causing rates to soar. That may occur. But it also may cost taxpayers in the meantime, as the ACA remains in force and Uncle Sam must ante up more in Obamacare insurance subsidies due to rate increases caused by administration attempts to undercut the law that Republicans have hated and fought for more than a decade.

The Trump Administration’s campaign against the ACA already has caused sufficient market uncertainty and instability that proposed rates for next year are skyrocketing on many exchanges, including in Maryland and Virginia. If you’re an American between the ages of 50 and 64 and you make too much money to receive ACA subsidies but don’t get health coverage through a job, you’re catching the brunt of the Trump tomfoolery. Many of you also happen to be his staunchest supporters. By the way, if you get health insurance at your job, and if you’re not already so staggered by premiums that you’re struggling with high-deductibles, just think about this: How long will America’s big companies wait before they start slashing and burning their workers’ health benefits, if they see that skinny and junk coverages are popular and allowed? The ACA’s pre-existing conditions protections already are in GOP cross-hairs in a court case.

Unaffordable care? Midterm elections will matter

Phew. I know this is a lot of health policy stuff to take in, and none of it is clear nor easy. But in my practice, I see the harms that patients suffer while seeking medical services, and their struggles to access and afford safe, efficient, and excellent health care.

While partisans claw at existing efforts for Americans to share and ease the burden of skyrocketing medical costs, they’re not applying that same vigor, say, to reducing ever-escalating drug prices: Due to unacceptable price increases for life-changing insulin, as many as half of the nation’s diabetics who need the medication may be skimping or skipping it, surveys show. A cardiologist posted on social media some painful information about how his poor patients forego life-saving meds due to costs (see above).

We all need to be vigilant about our elected officials’ conduct and actions on as crucial an area as programs with major effects on our health and well-being. Proposals, submitted and resubmitted and resubmitted, have a nasty habit of sneaking through. It may be dead on arrival with midterm elections nearing. But extremist Republicans want Congress, in the dog days of August, to try yet again to repeal and replace the ACA.

The midterm elections may be among the most significant in recent times. If folks consider themselves insignificant, their one vote too minuscule to matter, consider a proverb that’s circulating on social media of late: If you think anything’s too small to count, then you’ve never spent a sleepless night in a dark hot room with a buzzing mosquito.