The Affordable Care Act does allow, through Section 1332, for states to have some flexibility to waive these and other requirements, but only if they meet very rigorous conditions or “guardrails” that ensure coverage remains available, affordable, and high-quality. This is where the new Senate bill makes significant—and dangerous—changes. The bill drives straight through these carefully crafted guardrails. Today, to waive requirements like essential benefits, a state must show that the alternative insurance being provided is “comprehensive,” and “will provide coverage and cost-sharing protections against excessive out-of-pocket spending.” These careful conditions on quality are removed in the Senate bill, replaced with a bare-minimum requirement that the alternative doesn’t increase the federal budget deficit. States will be able to easily waive the requirement to cover Essential Health Benefits, without any careful conditions to ensure the quality and affordability of coverage.

As a result, insurers will offer skinny plans with less coverage that falls far short of the needs of those with serious health conditions. This is how it used to work: Before the Affordable Care Act, according to the Kaiser Family Foundation and the Department of Health and Human Services, almost one in 10 Americans in the individual market didn’t have coverage for prescription drugs. Young and healthy people will opt for those plans, leaving those with pre-existing conditions in their own, much more costly, market. In the end, the effect is the same as if companies could just outright discriminate against those with serious health problems.

Consider, for example, a family with a spouse or parent with cancer whose drug treatment costs thousands of dollars for their drugs. They think they have a victory in that under the Senate plan, their insurance company can’t explicitly charge them more because of their family member with a pre-existing condition. But, unfortunately for them, they find that they live in a state that allows insurers to offer plans that don’t cover prescription-drug costs. This family will face nothing but bad choices.

Because the skinny, incomplete plans are a non-starter for them, they can’t take the cheap option. But everyone who’s young or healthy does. The only people choosing the alternative, signing up for a plan that actually meets their needs, are those with serious conditions. This will further drive up the costs of these plans—the only plans that actually cover the treatment that seriously sick people need—and will further drive the young and the healthy away.

The state may not explicitly say they are making those with pre-existing conditions pay more, but that will be the impact. Many of those families will simply not be able to afford the care they need. And it could get worse. A thoughtful analysis by Matt Fiedler at the Brookings Institution found that where states can waive Essential Health Benefits, insurance companies and employers could reinstate annual and lifetime limits on coverage.