The Republicans’ last-ditch effort to demolish the Affordable Care Act is so abominable it makes previous attempts look practically benign by comparison.

The Graham-Cassidy bill, introduced by Senators Lindsey Graham (R-SC) and Bill Cassidy (R-LA), retains all of the cruelty of earlier legislation, and then adds some more. Specifically, it would:

Convert funding for Medicaid, a program that covers over 70 million Americans, from an open-ended entitlement to a block grant to states.
Allow states to impose work requirements for Medicaid recipients.
Eliminate the subsidies that make insurance and health care services affordable for low-income individuals.
Allow states to waive coverage of essential health benefits, such as mental health care, prescription drug coverage, and maternity care.
Allow states to end protections for pre-existing conditions. Insurance companies would be free to charge different rates to healthy and sick people.
Eliminate lifetime caps on coverage.
End the employer and individual mandates, retroactive to 2016.

The Graham-Cassidy bill would take all the federal money that currently funds insurance subsidies and the Medicaid expansion under the ACA and dole it out to states according to a complex formula, redistributing it in a way that the bill’s sponsors claim is more fair. However, it would shift money from states that expanded Medicaid to those that didn’t. California, for instance, would get $27.8 billion less in federal funding in 2026, while Texas, a non-expansion state, would get $8.2 billion more. States would have to spend these funds on health-related costs, but not necessarily to help lower-income people purchase insurance. There would be less money available overall; funding would be 34% lower by 2026 than under current ACA rules, according to the Center on Budget and Policy Priorities. All of the grants would end in 2027, putting health insurance for millions in grave jeopardy, unless Congress decided to appropriate more money.

Converting Medicaid disbursement from the system now in place to a block grant to states would be a monumental shift. Under current rules, Medicaid is an open-ended entitlement, meaning that funding expands if more people become eligible. This is crucial during economic downturns or in public health emergencies. If federal funding for Medicaid is capped and inflexible, then states would be forced to make up any budget shortfall. This could result in cost-cutting measures, such as limiting eligibility or reducing benefits.

Earlier this summer, the Congressional Budget Office estimated that a straight repeal of the Affordable Care Act would result in an additional 32 million uninsured by 2026. If Graham-Cassidy passes, the final toll could be even higher, due to the harshness of the Medicaid cuts. Those who do maintain coverage could face sky-high premiums and deductibles for plans that cover very little. Graham-Cassidy might be the fulfillment of a longstanding Republican pledge to repeal Obamacare, but it would cause untold pain and suffering for millions of vulnerable Americans.