Mean, mean, mean.

That is how President Trump Donald John TrumpFederal prosecutor speaks out, says Barr 'has brought shame' on Justice Dept. Former Pence aide: White House staffers discussed Trump refusing to leave office Progressive group buys domain name of Trump's No. 1 Supreme Court pick MORE characterized the House Republican’s health reform bill. Americans — and reluctant House members — were assured that the Senate would “fix” the bill, making it more moderate and compassionate.

This turned out to be just another piece of fake news. The Better Care Reconciliation Act (BCRA), the Senate’s version,, is certainly just as mean as the House bill — in some ways, even meaner.

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Republicans have committed a myriad of process hypocrisies and violations. Back in 2009, they decried secrecy around passage of the Affordable Care Act. Yet today, Republicans have conducted the most secret bill writing process ever known, without a single committee meeting or hearing and a vote scheduled for less than 10 days after the bill was made public. Republicans repeatedly complained that Democrats made no effort to enact a bipartisan ACA and that it was a rammed through by a party line vote. The truth is the Democrats did try to negotiate — remember the Gang of Six? That was a Senate working group on the bill that included three Republicans.

Senate Majority Leader Mitch McConnell Addison (Mitch) Mitchell McConnellDemocratic senator to party: 'A little message discipline wouldn't kill us' House to vote on resolution affirming peaceful transition of power Republican lawyers brush off Trump's election comments MORE and Republicans have not even tried to negotiate with Democrats in their attempts to repeal the ACA. There has not even been the appearance of bipartisanship.

Yet the real problems with the Senate bill are not faults of process, but of substance. The Senate bill keeps one and only one thing from the ACA — allowing young adults to stay on their parents plan until age 26. Everything else in the ACA will be dismantled.

The Republicans have kept the protection requiring insurance companies to continue to provide coverage to Americans who have cancer, multiple sclerosis, heart disease, and other pre-existing conditions at the same premiums as health people in theory but not in practice. They keep the talking point but decimate the substance.

Here’s how: The pre-existing conditions guarantee works only if patients are guaranteed the same health benefits. The ACA does this by requiring all health insurance plans to cover the same 10 essential health benefits, such as physician office visits, drugs, hospital stays, rehabilitation, mental health and substance abuse treatments.

Here is the issue: if insurance companies do not have to provide the same essential health benefits, if they are instead allowed to adjust what services they cover, then the insurance companies can offer different plans to segment the market and leave people with pre-existing conditions only unaffordable plans. The insurance companies will offer very skimpy health insurance plans that lack key services such as drugs or mental health benefits to attract relatively healthy young people. Cancer or multiple sclerosis patients will need more comprehensive coverage but without young healthy people buying such plans, with only sicker people choosing them, the premiums will be sky high — often unaffordable. Thus insurance companies can exclude people with pre-existing conditions not explicitly but by dividing people into different markets and effectively accomplishing the same thing.

The Senate bill allows any state to eliminate the essential health benefits requirement for insurance companies, and all they need to show to do so is proof that it won’t increase the federal deficit. The Congressional Budget Office estimated that at least a third of states would eliminate the essential health benefits requirement. We know that before the ACA’s essential health benefits requirements, insurance companies had no problem denying people with pre-existing condition insurance or charging them exorbitant rates. Only 11 states, for example, required plans to cover maternal care. Therefore, no one should believe Republicans’ claims that their bill will protect the pre-existing disease exclusion. A piece of fake news.

The Republican bill also fails to address issues of affordability. Every American is legitimately concerned about high premiums and ever-rising deductibles. The Senate bill literally does nothing to make health insurance more affordable; if anything, it will actually increase costs for most Americans. The only sustainable way to keep health costs from growing too quickly and too high is to change how physicians and hospitals care for patients. Providers must be incentivized to eliminate unnecessary, inefficiently delivered services, and to better manage patients with chronic illness to keep them healthy and out of the hospital. These types of changes can lower healthcare costs, ultimately resulting in lower insurance premiums and deductibles. The Republican bill does not contain a single provision that advances any such improvements. They offer no promise to make care more affordable or to bring down costs.

More importantly, costs will spike for Americans who buy on the exchange. The ACA determines its subsidies based on a health insurance plan that covers 70 percent of health care costs. The Republican plan knocks this benchmark down to 58 percent of costs—leaving families to pay the difference in premiums. Adding insult to injury, the Republican bill also increases age-banding, allowing insurance companies to charge older people 5 times what younger people pay. Multiple analyses show this will increase premiums for anyone over 40 years of age.

In another effort to raise costs for Americans, families earning under 250 percent of poverty — $70,000 or less will be hurt the most. The ACA currently provides cost-sharing subsidies to pay for this population’s deductibles and co-pays. Republicans will eliminate these subsidies altogether.

And, let’s not forget that if the essential health benefits are eliminated, families will also have to pay out-of-pocket for those health services insurance companies do not to offer. In short, Republicans have made health insurance even more unaffordable, especially for older, sicker, or poorer Americans.

There is so much more about this bill that is terrible and heartless. I have not mentioned the huge cuts in Medicaid that will throw tens of millions of people off coverage — the vast majority of whom are working, often at two jobs, but without employer insurance. I have not mentioned the repeal of the individual mandate, without which exchanges will fall into downward spirals. I have not mentioned the tax advantages for the wealthiest Americans — those who need tax breaks the least.

The Republicans’ health care bill does not fulfill Donald Trump’s promises to the American public that he would not cut Medicaid, that he would keep the ACA’s pre-existing disease reforms, and that he make healthcare more affordable for all. That the Senate bill fails on all these accounts — and is mean, mean, mean — is why every organized medical group, from the American Hospital Association to the American Medical Association to the Catholic Health Association, has come out against the bill. Some calling it “devastating.”

This repudiation of the Republicans’ promises is the best reason for President Trump to threaten to veto the bill. President Trump has made a name for himself in politics as a savvy businessman and a “closer.” If he hopes to maintain that reputation, and that of the Republican Party, he would do well to prevent this shamble of a bill from ever becoming law.

Ezekiel J. Emanuel is Chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania and a senior fellow at the Center for American Progress. He was the founding chair of the Department of Bioethics at the National Institutes of Health. Until January 2011, he served as a Special Advisor on Health Policy to the Director of the Office of Management and Budget and National Economic Council.

Views of contributors are their own and not the views of The Hill.