The Republicans say they want to give states more flexibility. But that flexibility most likely means they could use the money for non-health-care programs, or to close state budget gaps. When given budgetary flexibility with large sums of money, this is a common state tactic.

In 1998, as part of a major settlement with tobacco companies, in which the companies agreed to pay Medicaid costs related to lung cancer, emphysema and other smoking-related illnesses, states got a windfall of a minimum of $206 billion over 25 years. What did they do with the money? A 2001 Government Accountability Office report found that 26 percent was being spent on non-health programs, including infrastructure and budget shortfalls. A mere 7 percent was spent on programs related to getting people to stop smoking.

State flexibility has led to other coldhearted decisions. Before the Affordable Care Act, Medicaid was a categorical program, meaning that Americans were eligible only if they were low-income and had another qualifying condition, such as being a child or pregnant or disabled. States could determine those eligibility requirements. And financial pressures made many pretty callous.

In many states, non-disabled working adults were denied any Medicaid benefits. In Wyoming, a working family of three with an income over $9,480 was not eligible for Medicaid. In Alabama, that family had to make just $4,392 — 24 percent of the poverty line — to be denied coverage. These people were not lazy or, in Mitt Romney’s words, “takers.” About 67 percent of uninsured Americans were in families with at least one full-time worker, and more than 10 percent worked two jobs. The uninsured just happened to work for companies that did not or could not provide health insurance.

State flexibility is a ruse. Per-person allotments are an elaborate cost-shifting mechanism — a fancy way to reduce federal funding and transfer financial responsibility for the health care of low-income Americans to states. A 2014 assessment by the Center on Budget and Policy Priorities of Representative Paul Ryan’s plan, which contained elements similar to those in the current proposal, estimated that this accounting trick would increase Medicaid costs for state budgets by $169 billion by 2026. So, under the banner of flexibility, the current Republican plan would force states to make a series of Hobson’s choices.

This would be even worse than going back to the days before the Affordable Care Act. It would force states to ration care and deny some Americans lifesaving treatments or nursing home care. Cruel only begins to describe the Republican plan.