Needless to say, the ACHA will hardly achieve President Trump’s goal of “insurance for everybody” as he said on the campaign trail—in fact it seems to do the opposite. It would appear that what Trump meant to say was the more Paul Ryan-esque party line that he would ensure “access to health insurance for everybody”.

Let’s dig into that distinction a bit. When Republicans say that they want to increase “access to health insurance”, they claim they would do so by eliminating burdensome regulations that drive costs up. Their argument is simple enough: the government has made insurance too expensive by meddling in the free market and they will make it cheaper by getting the government out of our healthcare.

It’s worth noting that insurance premiums have actually been rising at a relatively low rate recently, but that’s almost besides the point when it comes to the politics of insurance — whatever rate costs go up at, people feel the effect.

A key change that the AHCA would make would be the elimination of the individual mandate’s penalties for not purchasing insurance, which would likely result in fewer people who either can’t afford insurance or don’t feel the need to own it purchasing plans.

Paul Ryan doesn’t necessarily view that as a bad thing, arguing that, “We’re saying the government’s not going to force people to buy something that they don’t want to buy,” and “And if we end an Obamacare mandate that says you must buy this government one-size-fits-all plan, guess what? People aren’t going to buy that.”

This perspective is predicated on the assumption that in a free society, health insurance is a privilege to be purchased on a free market by those who want and can afford it.

What exactly will happen to these uninsured individuals if they suffer some sort of catastrophic medical event remains one of the unaddressed questions — by training doctors will treat anyone who needs it, but will those patients simply be resigned to crippling debt for the rest of their lives as a consequence?

It’s a question that gets at the heart of one of the United States’ deepest examples of ideological cognitive dissonance. On one hand, our culture espouses individualistic values of personal responsibility, freedom, and liberty to live one’s own life the way they choose free from government micromanagement. Republican rhetoric has been chock full of this sort of language since the day the ACA was introduced.

On the other hand, however, our inherent moral framework through which we view the world is not one in which we allow people to die on the street. We believe in the idea of no man left behind, that to allow our fellow humans to wither and die on the streets with no help would be amoral - we’re not quite the social darwinists we make ourselves out to be when it comes down to it.

This dissonance is how we ended up with poor, older, rural voters — many of whose lives depend on healthcare they wouldn’t have if it weren’t for the ACA, ultimately buying into the rhetoric of politicians who want to eliminate it. That, and they were sold a complete bill of goods by President Trump when he promised universal coverage without mentioning a single detail of his health plan.

The one ‘subsidy’ that the Republican plan does provide for is a tax credit for individuals purchasing insurance on their own. The credit is income based, scalable and refundable, ranging from up to $2,000 a month for people in their mid 20s to up to $4,000 for those in their early 60s. This structure would cover most plans for younger, healthy individuals while leaving few options for those at the upper end of the age range.

While the ACA mandated that insurance companies cannot charge older patients more than 3x the premiums of younger patients, the AHCA will raise the limit to 5x. The logic goes that as older people consume more healthcare, they ought to pay more.

Additionally, the ACA set an “actuarial value” requirement that in order for companies to sell health insurance the plans they offer must cover at least 60% of all costs. This regulation will be eliminated under the new law, allowing insurers to sell plans with cheaper premiums that will ultimately cost patients more when they need care.

The result is a healthcare bill that would essentially do the opposite of the ACA: decrease costs for young people and either price many older Americans out of the market entirely, or leave them with largely insufficient coverage.

The CBO report says that if the AHCA were to be signed into law and implemented, many older people would simply be forced to leave the market because their plans are too expensive. Rural Americans ages 50–64 (right up to the age Medicare kicks in) are expected to see the sharpest price increases. If Republicans pass this bill, they will have bitten the hand that feeds them.

Not surprisingly, the bill also includes a substantial tax cut for wealthy Americans. This chart helpfully illustrates how much money the richest among us would save under the plan on average:

Meanwhile, Republicans can’t seem to agree on anything at the moment — from what they want to do with the bill to whether the CBO report is accurate.

House Speaker Paul Ryan embraced the report, choosing to focus on the deficit reduction it predicted and projected premium decreases two years out.

The White House adopted a more selectively skeptical tone, with Press Secretary Sean Spicer saying that “CBO coverage estimates are consistently wrong and more importantly do not take into consideration the comprehensive nature of this three-prong plan to repeal and replace Obamacare with the American Health Care Act.”

Spicer quickly contradicted himself in the same briefing, later stating that “In the portion of its analysis, the focus is on what the office is really about, the CBO concedes that the American Health Care Act would actually reduce the deficit by over $330 billion and bring health insurance premiums down 10 percent.”

His claim is paradoxical because the CBO’s estimated deficit and premium reduction is largely based on their estimates of how many people would be covered. Therefore, the White House directly contradicts itself by simultaneously claiming that coverage estimates are inaccurate but deficit estimates aren’t.

Additionally, numerous freedom caucus members in the House along with libertarian leaning Senator Rand Paul (R-KY) have called the bill “Obamacare lite” and labeled it “dead on arrival”. As if that wasn’t enough of a headache for Paul Ryan, the pressure is now coming from both wings of the party, with more moderate Senator Susan Collins (R-ME) saying that she has “a lot of concerns” about the AHCA and that Republicans should “slow down”.

The bill has been moving at an abnormally steady clip since being introduced, with amendments already made before the CBO score was released. Republicans are also attempting to pass it through budget reconciliation, a process that would leave many ACA regulations in place but would only require 50 votes in the Senate — although it’s unclear if that is currently possible.