In a damning column for the New York Times, Nobel Prize-winning columnist Paul Krugman called out Republican lawmakers for turning their backs on the needs of their constituents saying it is nothing less than incomprehensible cruelty.

Pointing to a Washington Post article on the desperate need for medical services for the poor in red-state Tennessee, Krugman said that Americans in rural communities that voted heavily for Donald Trump are bearing the brunt of the GOP’s desire to gut the Affordable Care Act.

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“Since the focus of the [Washington Post] report was on personal experience, not policy, it’s understandable that the article mentioned only in passing the fact that Tennessee is one of the 14 states that still refuse to expand Medicaid under the Affordable Care Act. So I’m not sure how many readers grasped the reality that America’s rural health care crisis is largely — not entirely, but largely — a direct result of political decisions,” Krugman suggested.

“The simple fact is that the Republicans who run Tennessee and other ‘non-expansion’ states have chosen to inflict misery on many of their constituents, rural residents in particular,” he continued before adding, “So if rural America is suffering, a large part of the explanation is gratuitous political cruelty. This cruelty has denied health insurance to millions who could have had it with a stroke of the pen. And rural hospitals are closing, rural doctors leaving, in large part because people can’t afford to pay for care.”

According to Krugman, Republican lawmakers cynically play on their constituents hatred of Washington D.C., making it looks like out of touch bureaucrats are to blame for their plight. In fact, as he illustrates, neglect of their needs can be directly attributed to Republican governors and GOP-dominated statehouses.

“While rural Americans often tell reporters that they feel neglected and ignored by big-city coastal elites, the people preventing them from getting health care aren’t in New York or D.C., they’re in their own state capitals, ” he wrote before asking the big question: “But why are Republican state-level politicians so determined to punish their own base?”

According to the economist, it comes down to old-fashioned “mean-spiritedness.”

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“Some of it may reflect the general meanspiritedness, the embrace of cruelty, that was already infecting the G.O.P. even before Donald Trump, and has now become one of the party’s defining traits. Yes, that’s harsh, but you know that it’s true,” he wrote, answering his own question before calling out GOP lawmakers over their cynicism.

“One way to make people feel hostile toward those elites is to block their access to federal benefits, and hope they don’t realize who’s actually causing their misery,” he explained. “Is it conceivable that conservative politicians have that much contempt for their base? Yes.”

You can read the whole thing here.