President-elect Donald Trump probably does not lose much sleep over it, but millions of Californians have spent wakeful nights since his election wondering what will happen to their healthcare if he follows through on his promise to “eliminate Obamacare on Day 1.”

That day is five weeks away. If the promise is kept, it could affect 4.6 million Californians whose health insurance is at least partly funded by President Obama’s Affordable Care Act.

They either buy insurance plans under the Covered California exchange or they have joined the federally-subsidized Medi-Cal, the state’s low-income health care plan, since Obamacare began subsidizing expansion of the program in 2014.

Unless Congress has acted prior to Mr. Trump’s inauguration, he won’t be able to do away with all this on Day 1. Most analysts say it would take an act of Congress to undo state exchanges and the Medicaid expansion of which Medi-Cal’s growth was a part.

Even if it doesn’t happen on Mr. Trump’s first day, when he has promised to reverse many Obama executive orders, changes will come.

House Speaker Paul Ryan of Wisconsin has in the last couple of weeks unveiled the general outlines of a Republican plan to “replace” the ACA, which now provides health care to about 20 million Americans who couldn’t get it before.

Mr. Ryan’s plan, almost certain to be adopted by Mr. Trump with only small changes, would offer tax credits rather than direct subsidies to help people pay for insurance. It would keep Obamacare’s protections for persons with pre-existing conditions. Mr. Trump has said he wants to keep Mr. Obama’s rule allowing young people to retain coverage under their parents’ policies up to age 26.

But Mr. Ryan’s blueprint would not force anyone to buy insurance, nor would it impose fines on individuals who don’t buy into the system, as Obamacare does. That means less money will be coming into the insurance system, which in the Ryan plan translates to much higher deductibles and higher premiums as policy-holders age.

Same as Car Insurance

Mr. Ryan would add a high-risk pool to the insurance picture, much as high-priced auto insurance is available to high-risk drivers. This would mean high-premiums for persons with cancer and chronic conditions that are expensive to treat. So much for that pre-existing condition protection.

These provisions will be subject to tweaking and to input from Mr. Trump’s new secretary of Health and Human Services, current Georgia Rep. Tom Price, who has long sought to dump all of Obamacare.

Bottom line: Most individuals covered under Obamacare will see premiums rise and coverage drop, in spite of Mr. Trump’s promise to replace Obamacare with better insurance at lower prices.

In California, that will likely affect 3 million persons now on Medi-Cal  who are subsidized by Obamacare.

Young people will be affected most of all: The share of children covered by Medi-Cal or the state’s Healthy Families program grew from 32.8 percent in 2009 to 40.3 percent in the most recent figures reported by UCLA’s Center for Health Policy Research.

That helps explain the several protest rallies involving nurses, doctors, patients and healthy senior citizens that have been held around the state in the last month.

“The actions threatened by Trump and the Republican Congress are a direct attack on healthcare for the most vulnerable,” said one doctor at a Los Angeles rally. “California has done more to expand healthcare access than any other state. We need a massive effort to protect California’s…progress toward healthcare for all.”

Unless similar rallies spread far beyond California and draw huge crowds, don’t expect much sympathy for those views from Republicans in Congress. Most have wanted to ax to Obamacare since before it took effect.

With the backing of the President-elect, there is nothing to stop them from moving now against those who benefit most from Mr. Obama’s law: the poor, the very young and the legal immigrants.

Mr. Elias may be contacted at tdelias@aol.com. His book, “The Burzynski Breakthrough: The Most Promising Cancer Treatment and the Government’s Campaign to Squelch It,” is now available in a soft cover fourth edition. For more Elias columns, go to www.californiafocus.net