Obamacare is finally safe.

With the Democrats’ retaking of the House, Republicans will no longer have the votes to try, once again, to “repeal and replace” Obamacare with their latest ghoulish plan to block millions from the healthcare system. In an era where voters consistently rank health care as their number one issue, the election results were widely seen as a repudiation of right-wing ideology on health care.

Like practically every partisan fight over the future of Obamacare, the midterm battles foregrounded the law’s most popular plank: protection for people with preexisting conditions. So supportive are voters of that policy (recent polls register approval at over 80 percent) that Republicans publicly pledged their commitment to the cause: “All Republicans support people with pre-existing conditions,” Donald Trump tweeted in October. “And if they don’t, they will after I speak to them.” Midterm voters, it seems, were justifiably skeptical of this promise, which contradicted both the party’s legislative record and the logical underpinnings of right-wing economic policy.

But if Republicans want to leave sick people at the mercy of the market, it’s worth noting that people with preexisting conditions are hardly protected under the Obamacare status quo. The American healthcare system continues to impose enormous burdens on people for simply trying to access health care. This means that people are still being punished for being sick — a violation of the principle that those with preexisting conditions (half of the country) are worthy of our defense. Genuine protection for preexisting conditions requires establishing a universal public system that’s free at the point of use.

Before the ACA, the landscape for Americans with preexisting conditions was undeniably grim. For-profit insurers could refuse to sell insurance plans to individuals with pricy health needs (or charge exorbitant rates), offer coverage that carved out exceptions for certain types of care, and impose lifetime caps on what they’d pay out for a given person’s treatment.

The result was that people with a history of illness encountered extraordinary challenges getting the care they needed: those who weren’t rejected as clients outright were bilked outrageously, or stuck with junk insurance plans that didn’t actually cover anything important. The ACA famously introduced several measures to alleviate these problems: a “guaranteed issue” rule requiring insurers to sell plans to anyone who wanted them, premiums that could only take into account age and smoking status, and plans that had to cover a minimum of “ten essential health benefits” with no lifetime caps.

And yet, since the ACA’s implementation, the health insurance industry has still placed ever-increasing financial and administrative responsibility onto individual patients. Over 40 percent of Americans with private insurance have high deductibles, frequently exceeding what the average household has in liquid assets. This year, the maximum out-of-pocket expense for individual ACA marketplace policyholders is over $7,000 for in-network care — an eye-popping sum by any measure, but especially so when you consider the rise of surprise out-of-network bills. Medical debt, the avoidance of necessary treatment because of costs, and medicine rationing all remain quite high, even after the ACA.

All of these amount to a tax on the sick, because they naturally fall on the shoulders of those with the most frequent encounters with the healthcare system: people with preexisting conditions. Cost-sharing in health insurance — shifting the price of care onto patients themselves, on the basis of use — has the gravest impact on sick people, by definition.

That so many Americans feel defensive of people with preexisting conditions is laudable. But this immoral situation won’t be solved by tinkering with the current market-based system, which individualizes the responsibility for health. Until we all bear the costs of health care according to our ability to pay, rather than our bodies’ relative need for it, people with preexisting conditions will still be made to suffer more than those lucky enough to have perfect health.

The only solution is a universal, public, Medicare-for-All system. Until then, we’re preserving a system that profits from harming people with preexisting conditions — we’re just squabbling over how much.