On Tuesday, as the Trump administration sunk further into the maw of the Russia scandal, Vice President Mike Pence took a trip to the headquarters of the Department of Health and Human Services and delivered a speech to the staff.

“Now I know this room is filled with men and women who care deeply about bringing high-quality health care to every American,” he said, “and rest assured, President Donald Trump wants exactly the same thing.”

That commitment — echoed elsewhere in the speech by a call for a “brighter health care future for every American” and a promise to “give the American people access to the world-class health care that every American deserves” — is entirely consistent with the rhetorical approach Donald Trump took on the campaign trail.

Candidate Trump was a different kind of Republican. More comfortable with overt racism and Islamophobia, less steeped in the norms of American political conduct, but also more heterodox on core domestic policy issues. He was going to protect Medicare, Medicaid, and Social Security from cuts and replace the Affordable Care Act with a “terrific” new system that would “cover everyone” and offer the lower premiums and deductibles the American people wanted.

Pence speaking Tuesday offered reassurance that nothing has changed, promising only “historic flexibility to reform Medicaid in ways that will best serve the most vulnerable in their communities” and thanking the HHS staff for the “leading role in making the best health care system in the world even better.”

The only problem is that it’s all lies. Trump’s health care plan doesn’t protect Medicaid, it loots it to finance hundreds of billions of dollars in tax cuts. The new “flexibility” it gives to states will ensure that the most vulnerable are the most hurt. In addition to slashing the Medicaid rolls by millions, the Trump health care plan will see millions more lose coverage, and the remainder will face higher premiums for plans that cover less.

There’s nothing remotely terrific about it, unless you happen to be one of the small number of high-income Americans who can expect to reap a large tax cut paid for by the suffering of millions of newly uninsured people. It’s an enormous con perpetrated on people Trump duped into believing they were in on the scam. And while the Russia situation is certainly a big deal, Trump has at least never made a secret of his admiration of Vladimir Putin — his up-is-down approach to health care deserves to be seen as the biggest Trump scandal of all.

Donald Trump made big, clear promises on health

Donald Trump did not run a wonkish campaign heavily focused on detailed white papers or background briefings with experts. He did, however, make some pretty clear promises on health care policy.

“I’m not going to cut Social Security like every other Republican and I’m not going to cut Medicare or Medicaid,” Trump told the conservative Daily Signal way back in May 2015. “Every other Republican is going to cut, and even if they wouldn’t, they don’t know what to do because they don’t know where the money is. I do.”

I was the first & only potential GOP candidate to state there will be no cuts to Social Security, Medicare & Medicaid. Huckabee copied me. — Donald J. Trump (@realDonaldTrump) May 7, 2015

This was, strikingly, not a general-election pivot to the center, but a commitment Trump made as a candidate in the GOP primary.

That fall, his promises got even bigger. "I am going to take care of everybody," he told 60 Minutes. "I don’t care if it costs me votes or not. Everybody’s going to be taken care of much better than they’re taken care of now."

Even after the election, Trump continued to insist that his plan was to offer patients a more generous deal than they were getting from the Affordable Care Act.

In an early January interview with the Washington Post, he said that Trumpcare would feature “insurance for everybody,” in contrast to an ACA that, while bringing the uninsurance rate to a historic low, has still left 25 million people without coverage. The plans, he said, would have “much lower deductibles.” And ability to pay, he said, wouldn’t be an issue. “There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.”

When the American Health Care Act passed the House in March, Trump once again reiterated his core promises. “Your premiums,” he said, “they're going to start to come down.”

Back in the bad old days of the Affordable Care Act, “when it comes to deductibles, they were so ridiculous that nobody got to use their current plan.”

But, Trump insisted, help is on the way. “Make no mistake about it,” he said, “make no mistake. I think most importantly, yes, premiums will be coming down. Yes, deductibles will be coming down.”

AHCA doesn’t do any of that

The centerpiece of the Trump-endorsed American Health Care Act, by contrast, is a $600 billion tax cut. Families with incomes below $208,500 per year will see their taxes fall by an average of $0 per year, receiving none of that money. But members of the top 0.1 percent of the income distribution — households with an annual income of more than $3.75 million — will see their taxes fall by an average of $165,090 per year.

If you are a multimillionaire and someone in your family gets sick, in other words, AHCA is going to be great for you.

But when you take $600 billion out of the American health care system and funnel it to a small, elite group of people, the inevitable result is that everyone else has to get by with less.

Specifically, under the House bill, about 14 million more people would be uninsured in 2018, according to the Congressional Budget Office, increasing to 23 million in 2026. On the regulatory side, one-sixth of Americans live in states that CBO expects to pursue broad waivers from Obamacare regulations prohibiting insurers from charging sick people more than healthy people and requiring certain services to be covered. The analysts predict that the individual insurance markets in those states would start to destabilize after 2020, as insurance becomes unaffordable for people with high medical costs.

As Republicans are eager to point out, there is obviously some uncertainty around these CBO estimates. But this only gets you so far. HHS’s own actuaries think the CBO is too pessimistic about coverage, but still see 13 million more uninsured under the Republican plan, with premiums rising for most people. It’s also worth noting that the key variable here is it’s hard for the CBO to predict exactly how many states will seek the kind of “flexibility” that congressional Republicans are offering them. The most benign scenarios are the ones in which conservative ideas have the least uptake. If it’s not a sixth of the population but a third or half who ends up living in waiver states, then the toll on the sick will be even worse.

Trump’s slashing Medicaid, and other programs are next

The savage cuts to Medicaid — reducing enrollment by a staggering 14 million — are particularly cruel in light of Trump’s explicit promise not to do this. But what’s truly shocking is that the Trump administration thinks this isn’t enough. His budget proposal for the next fiscal year includes even more Medicaid cuts that, paired with AHCA, would cut the program nearly in half.

To make things even more disturbing and outrageous, not only is Trump breaking his promise on this score, his administration is simply in an ongoing process of lying about it. Health and Human Services Secretary Tom Price went on CNN on May 7 and maintained with a straight face that you can cut $880 billion in Medicaid spending and it will “absolutely not” result in anyone losing coverage.

HHS Secretary Tom Price says the $880B cuts to Medicaid will "absolutely not" result in millions losing coverage https://t.co/s2QDMsFjEh — CNN Politics (@CNNPolitics) May 7, 2017

Voters ought to consider the credibility of Trump’s other promises in light of his willingness to promise not to cut Medicaid, then to propose gutting it, and then to have his subordinates lie on national television about it. Already his administration has piloted a thin edge of the wedge by proposing large cuts in Social Security Disability Insurance and claiming that’s consistent with his pledge to avoid Social Security cuts on the theory that Social Security Disability Insurance isn’t really part of Social Security (a theory that would come as news to the Social Security Administration).

Vox’s Tara Golshan reported earlier this week that Rep. Tom Cole (R-OK) is already laying the groundwork for a big Medicare cut bill that he believes he can get Trump to sign. After all, if Trump sold out his promises on Medicaid and Social Security, why wouldn’t he sell out the Medicare promises too?

This is a new and disturbing pattern

Oftentimes when Trump says things that aren’t true, he’s bullshitting — throwing chum out into the mediasphere to see what happens.

But on health care he is mounting a proper campaign of political deception. He knows that the American people are, rightly, dissatisfied with the fact that the Affordable Care Act left most of us with premiums and deductibles that are higher than we’d like and has fallen short of its promise of universal coverage. He would like us to believe that his health care initiatives would alleviate or solve these problems, when in reality they will do the opposite — sucking money out of the provision of health care and using it to finance a large tax cut for affluent families.

And as far as political deception campaigns go, Trump’s health care lies are breathtaking in score. Many liberals took issue with the financial forecasts underlying George W. Bush’s tax cut proposal, but he never tried to deny that he was proposing a big tax cut. Trump is proposing a large rollback of the safety net and pretending he’s enhancing it.

Political scientists have found that, historically, politicians make a good faith effort to enact their campaign promises. In part that’s because orchestrating a vast conspiracy in which you say you’re doing one thing but then need literally thousands of legislators and staffers across multiple branches of government to do something else is way too hard to pull off. And in a sense, it has been way too hard to pull off. For all the various shenanigans Republicans have pulled — having the House vote on a bill without a CBO score, having the Senate GOP caucus negotiate in secret with no hearings and no bill text — journalists who cover the story are not being fooled. We are aware that Trump is not going to cover everyone, lower premiums, or cut deductibles.

But at the same time, Trump has succeeded in persuading the media and the political system to process these highly public lies as a kind of banal non-story, even while a leak that Jeff Sessions maybe misstated the number of times he’s met Sergey Kislyak is a three-alarm fire. The truth, however, is that both kinds of lies are important. Trump’s decision to build his approach to one-sixth of the economy on a foundation of enormous lies is a huge scandal.