Donald Trump made this promise on the campaign trail: "I'm not going to cut Social Security like every other Republican, and I'm not going to cut Medicare or Medicaid."
All politicians make promises they cannot keep, but this one is a particularly devastating deception. The health care bill now being drafted by the House, and enthusiastically endorsed by the president, makes major cuts in Medicaid, the joint federal/state program that protects the most vulnerable Americans.
Like so many of Trump's proposals -- on immigration and refugees, for example -- this one is not just bad public policy. It's also immoral, violating the most basic obligation of Christianity, described in the New Testament as caring for "the least of these brothers and sisters."
As John Kasich, the Republican governor of Ohio, said on NBC's "Meet the Press": "We're talking about lives. ... We better be careful we're not losing the soul of our country because we're playing politics."
The health care debate has focused primarily on proposed alterations to the insurance system established by the Affordable Care Act (Obamacare), but the Medicaid issue is equally important. Under Obamacare, states could utilize federal funds to expand Medicaid eligibility to families earning up to 138 percent of the federal poverty line. Thirty-one states took advantage of the option, adding about 11 million Americans to the Medicaid rolls.
Under the House bill (call it Ryan/Trumpcare), that expansion would be phased out in 2020. According to the Congressional Budget Office, about 5 million people would be forced off Medicaid in the first year, and 15 million would lose coverage by 2026.
Speaker Paul Ryan defends his plan by saying, "We're going to have a free market and you buy what you want to buy." Nice words, which totally ignore the fact that most of those covered by Medicaid cannot afford any health insurance at any price.
But that's not the whole story. Ryan has spent his whole career plotting to do exactly what Trump said he would not do: reduce entitlements. By ardently abandoning his promise, Trump has reinforced the impression that he doesn't really care about policy at all.
What he cares about is winning. So he's bought into Ryan/Trumpcare because he thinks it's the only health plan with a chance of passing.
Fortunately, a number of Republicans are appalled, especially governors who actually have to solve real problems in their states. They cannot afford Ryan's theological crusade against government spending or Trump's refusal to recognize the human misery this proposal would entail.
Many of those governors agree with Kasich, who notes that 700,000 Ohioans have gained insurance coverage under Medicaid expansion. "If they don't get coverage, they end up the emergency room, they end up sicker, more expensive," he told state business leaders. "I mean, we pay one way or another. And so this has been a good thing for Ohio."
It's been a good thing for Massachusetts, too, says Republican Gov. Charlie Baker, where about 300,000 have been added to the Medicaid rolls. "Medicaid is an important safety net for a significant portion of our state's population," Baker told CNN.
Four Republican senators -- Rob Portman of Ohio, Shelley Moore Capito of West Virginia, Cory Gardner of Colorado and Lisa Murkowski of Alaska -- wrote a letter to Majority Leader Mitch McConnell saying that while "structural reforms" could improve Medicaid, those changes "should not come at the cost of disruption in access to health care for our country's most vulnerable and sickest individuals."
Attacks on Medicaid often echo the old debate about welfare, implying that beneficiaries are able-bodied slackers who don't want to work. Of course some people game the system, but they're far from a majority. Many suffer from a range of disabling conditions: physical handicaps, mental illness and substance abuse, for example.
Republican Gov. Brian Sandoval of Nevada says Medicaid expansion has "allowed thousands of Nevadans needing mental health treatment to receive care." Kasich says a "big chunk" of those covered in Ohio "are mentally ill and drug-addicted and have chronic diseases."
Impoverished seniors who cannot afford nursing care are also major Medicaid recipients. Under Ryan/Trumpcare, says Tom Wolf, the Democratic governor of Pennsylvania, "You're either basically consigning the seniors to less care or the commonwealth of Pennsylvania to spend more, or a combination of both. That's a real problem."
Those real problems are not limited to governors who would have to administer Medicaid under Ryan/Trumpcare. The Republicans who vote for it also stand to pay a large price: Their souls, as well as their seats, could well be at stake.