The Conjurer (1502) by Hieronymus Bosch.

Last night’s CNN Town Hall with House Speaker Paul D. Ryan (R-Wis.) held some troubling clues to the vision — or lack thereof from a moral standpoint — that the Republicans have in formulating a replacement plan for the Affordable Care Act (ACA) after they repeal it. It’s not pretty. If you only watch one clip from the broadcast, watch this exchange between Ryan and a former Republican who stated unequivocally that President Obama and the ACA saved his life when he was diagnosed with cancer — you will get a glimpse behind the mask of false empathy and compassion to show what Republicans truly believe in their hearts.

Inherent in Ryan’s response to the gentleman was the belief that there are those who are deserving of affordable healthcare and then there are the rest: the people with illnesses (“your type”) who need to be ostracized and pooled away from the rest of us because they are weak and sick. And not only that, they have the audacity to cause the rest of us to pay more out of our own pockets, which is patently unfair in Ryan’s passionate Ayn Randian worldview. I will go even further and note that his response was also dangerously close to the Nazi designation of “life unworthy of life,” Lebensunwertes Leben.

But more specifically, what Paul Ryan did when he invoked “high-risk pools” was revealing the Republicans’ hand in how they will try to qualm deep concerns about gutting the popular component of the ACA that over 70% of the public supports — the ban to prevent health insurers from denying coverage or charging grossly higher premiums to people with pre-existing conditions.

Hey, Americans, are you starting to have the same fear and dread that you had in the pre-ACA years that you would be dropped from your insurance, or your premiums and deductibles would be jacked up after you’ve been diagnosed with a condition, or that you would be turned down cold for new insurance because you have a pre-existing condition? Don’t worry, Paul Ryan has the answer for you: we should go back to having state high-risk pools to make sure you’re covered.

Quite frankly, it’s a cruel lie. With a nod to Bilbo Baggins from “The Lord of the Rings,” high-risk pools are the butter scraped over too much bread. And not just that, it’s a lesser quality of butter which is damn too expensive at that.

Before getting into the specific details of how a repeal, with its focus on high-risk plans, will affect everyone — whether it’s the plan put forth by Rep. Tom Price (R-GA), Donald Trump’s nominee U.S. Health and Human Services secretary, or Ryan’s “A Better Way” plan or a combination of something in-between — we need to acknowledge a couple of general points upfront.

According to a recent independent study, repealing the ACA, “would result in nearly 3 million lost jobs by 2021.” Additionally, “from 2019 to 2023, there will be a cumulative $1.5 trillion loss in gross state products and a $2.6 trillion reduction in business output (combined transactions at the production, wholesale, and retail levels). State and local tax revenues also will fall during this period, dropping by $48 billion.”

These studied projections represent such an explosive admission — repealing the ACA will cost much more on so many levels than not repealing it — that the Republicans in the House tucked a provision into the failed attempt to gut the Office of Congressional Ethics last week which would have directed the Congressional Budget Office (CBO) to not include the repeal of the ACA in its 10-year cost analysis. In other words, the GOP has already tried to lay the groundwork to keep the true cost of repealing the ACA from the American public. Of course this is unusual — and highly revealing of Republicans’ true motives — because a cost-analysis is done for each bill reported by the House so lawmakers can, unsurprisingly, make relatively sound decisions when they cast their vote.

Okay, onto the specifics of high-risk pools. According to Charles Gaba, who carefully and steadfastly tracks these types of ACA numbers, at least 30 million people will be kicked off their policies through the Republican repeal of the ACA.

Paul Ryan stated in his scenario last night that he believes it would be approximately 8% of these Americans who would be banished, err directed, to these high-risk pools — that’s 2.4 million people.

But according to Ian Millhiser, these high-risk pools designed to cover the “uninsurable” are extremely inefficient because they cost so much more for what they actually deliver. Ryan was being being willfully dishonest in his response during last night’s town hall when he tried to paint these high-risk pools in rosy colors because he knows that they have demonstrably failed in several states because of the astronomically high premiums and other severe limitations such as waiting periods and substantial deductibles and co-pays. But more than anything else, he has not once alluded to the fact that the biggest obstacle to the success of these high-risk pools has been the dogged consistency of inadequate funding that usually follows implementation.

Republicans have consistency shown in the past that they are cowed by these huge, scary numbers, as evidenced by their recent reticence to fund the Pre-Existing Condition Insurance Plan, the stop-gap measure needed to cover uninsurable people before the ACA exchanges and Medicaid expansion took full effect in 2014.

Of course, I suspect this is precisely why the Republicans are pushing the high-risk pools as a replacement for the ban on pre-existing conditions: this will give them a way out when they ultimately decide to pull back the funding for these pools.

Because whether it’s the $1 billion per year price tag (over a three-year period) as proposed by Price or the $2.5 billion per year price tag (over the coming decade) as proposed by Ryan to cover these high-risk pools, it will be nowhere near to what will be realistically needed.

And we also need to be clear in these discussions, high-risk pools are designed with the sole purpose to help cover health insurers from the catastrophic heathcare costs of their very sick enrollees, it’s not the other way around. So, if these pools are not adequately funded, take a wild guess of where insurers will shift those costs?

But, let’s continue with Millhiser’s numbers: In 2008, it would take $7.0 billion per year to cover 875,000 people. Remember, according to his own numbers, Ryan stated that 2.4 million would need to be covered in these high-risk pools. Thus, if we were in 2008, it would have cost $19.2 billion per year.

But we’re not in 2008 and adjusted for inflation, it would cost at least $21.1 billion per year to adequately fund these high-risk pools for those 2.4 million people. Paul Ryan’s numbers are not realistic if he is only proposing $2.5 billion a year for funding when the reality of past numbers shows it will take at least nine times that amount.

Additionally, it is estimated that between 16% and 60% of all Americans have pre-existing conditions — as defined by different insurers — and Ryan hasn’t even talked about those millions of people outside of the 8% directed into the high-risk pools he proposes. He leaves those of us who have chronic but relatively minor conditions out in the cold, to again be at the mercy of the insurance companies like so many of us were in the years before the implementation of the ACA.

With the stark incongruity of these numbers, we have no choice but to conclude that the Republicans are not serious at all about putting forth a realistic, practical and workable replacement plan for the ACA once they repeal it. And, they are trying to take cover by counting on the American public to hear “high-risk pools” and be comforted that those of us who have pre-existing conditions will somehow still be covered.

In the end, the Republican replacement plan will be less and worse healthcare for many more people at a higher price tag for all of us. Don’t be fooled if Paul Ryan tries to tell you otherwise.