When the Supreme Court struck down the Affordable Care Act's mandatory expansion of Medicaid by the states back in 2012, observers quickly began focusing on who would "opt in" or "opt out." But from a purely budgetary standpoint, there was never any question that accepting federal dollars to fund 100 percent of that expansion and 90 percent thereafter was a no-brainer.
Studies from the Rand Corporation and others concluded that just saying yes to Medicaid expansion would add coverage for millions of previously uninsured, prevent thousands of needless deaths annually, help rescue financially-troubled hospitals in rural and poorer areas, and ultimately more than pay for itself as state costs for uncompensated care plummeted. (As the Kaiser Family Foundation and Kentucky Gov. Steve Beshear among others later reported, events transpired exactly as we foretold.) As Ezra Klein and Evan Soltas summed up the obvious opt-in case in June 2013:

So then, the math works out like this: States rejecting the expansion will spend much more, get much, much less, and leave millions of their residents uninsured. That's a lot of self-inflicted pain to make a political point.

Now, President Trump and Republicans in the House (if not the Senate) are pleased to perpetrate what might be the greatest act of political spite in modern American history. Replacing Obamacare with the latest incarnation of the so-called "American Health Care Act" (AHCA) wouldn't just leave 24 million more Americans uninsured, 14 million from Medicaid alone. Trumpcare would simply shift about $880 billion in funding for lower-income and elderly health care to giving tax breaks to the wealthiest Americans. With its smaller, slower-growing tax credits, penalties on those failing to maintain "continuous" coverage, comically under-funded "high-risk pools," and its green-light to insurers to charge older Americans much more than under Obamacare, Trumpcare guarantees poorer, sicker, and older people will pay higher premiums for insurance--if they can obtain it at all. And by letting states determine which--if any--of Obamacare's mandatory essential health benefits (EHB's) they will require, what Trumpcare calls "coverage" may no longer look like "insurance" in any meaningful sense of the word.

Not, at least, according to the nonpartisan Congressional Budget Office. For the CBO, many Trumpcare plans won't count as insurance at all.
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