Senate Republicans are releasing the latest version of their health-care plan today, and there’s a temptation to focus solely on what’s changed from the previous iteration. The changes are important, and we have to understand them. But what we shouldn’t do is allow a relative judgment (maybe it’s better in this way but worse in that way) to distract us from the big picture, because what’s still in the bill from before is even more important than what has changed.

The big picture is that this bill is an absolute nightmare that would cause a spectacular amount of human suffering — and yes, even deaths — if it were to pass. It would mean fewer people with coverage, more people having trouble affording coverage, less protection and less security.

Let’s go through the major provisions in the bill:

  • The bill would utterly eviscerate Medicaid, which is relied on by tens of millions of poor, elderly and disabled Americans. It would roll back the Affordable Care Act’s expansion of Medicaid and cut hundreds of billions of dollars from the program. It would also transform the program into a block grant, for the first time allowing states to kick enrollees off their coverage and cut back benefits.
  • The bill allows insurers to sell bare-bones plans that go by the name “insurance” but cover very little, as long as they also offer a plan that meets the “essential health benefits” requirement of the ACA. This in effect sets up two pools, one containing young and healthy people, and one containing people who are older or who have more serious health needs. The insurance industry, along with many analysts, predict that this could produce a death spiral of skyrocketing costs for those with preexisting conditions.
  • The bill retains the ACA’s 3.9 percent tax on investment income and 0.9 percent payroll tax for wealthier Americans.
  • It eliminates the ACA’s cost-sharing subsidies after two years, but creates a fund with $182 billion (over 10 years) for states to use to help patients with out-of-pocket costs and those with high medical expenses.
  • It allows people with tax-preferred Health Savings Accounts to use their HSAs to pay premiums, which they are currently not allowed to do. Note that HSAs overwhelmingly benefit wealthier people, because they’re the ones with spare money they can put into them to gain the tax benefits.
  • Though it slashes the Medicaid through which many opioid addicts now receive treatment, it sets aside $45 billion to combat opioid addiction.
  • It has a new provision allowing people to use tax credits to buy catastrophic plans with extremely high deductibles that cover no routine care.
  • It replaces the ACA’s subsidies with stingier tax credits based on what high-deductible plans cost and allows insurers to charge older people more than they can now.
  • As before, it eliminates the individual and employer mandates, bars tax credits from being used for any insurance plan that covers abortion and prohibits women on Medicaid from getting any treatment at Planned Parenthood facilities.

If your Republican senator votes for this plan, he or she is supporting gutting Medicaid, taking away health coverage from at least 20 million Americans and potentially the end of real protections for those with preexisting conditions, higher deductibles, less help for those with modest incomes, potentially the return of lifetime limits on coverage (outlawed by the ACA), which turn a health-care challenge into a financial calamity, and an attack on women’s health choices.

In short, this bill is an abomination. No one should be able to get away with saying, “Well, it’s a little better than it was before.” All that does is obscure how spectacularly cruel it is.

We don’t know yet what the bill’s chances of passage are. Yesterday, Sen. Rand Paul (R-Ky.) said, “The new bill is the same as the old bill — except for worse.” Sen. Susan Collins (R-Maine) said, “If the Medicaid cuts remain the same in the new version of the Senate bill, I will vote no on the motion to proceed.” Well those cuts are still there, so presumably she’s a no vote.

So might be Sen. Lisa Murkowski (R-Alaska), who reportedly begged the GOP leadership to put aside the assault on Medicaid, to no avail. Paul and Collins look like hard no-votes, which means Senate Majority Leader Mitch McConnell (R-Ky.) would have to retain every other Republican, including Murkowski and Sen. Dean Heller of Nevada, whose career is basically finished if he votes for this bill (and it might be anyway; he’s the most vulnerable senator up for reelection next year). Heller told a reporter today that he’s undecided on the motion to proceed (though it’s possible to vote yes on that motion and then vote no on the bill itself).

All that means that things are going to be very close. But no senator who supports this bill should fool themselves into thinking that it’s okay because there was a nip here and a tuck there. It’s still a monstrosity — and their constituents aren’t going to forget where they stood.