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The real death panels are coming.

Back in 2009, during the shrill hours of debate over the Affordable Care Act, Sarah Palin warned us solemnly that defenseless Americans “will have to stand in front of Obama’s ‘death panels’ so his bureaucrats can decide, based on a subjective judgment of their ‘level of productivity in society,’ whether they are worthy of health care.”

Many a snooty elitist dismissed those ominous Facebook pronouncements by the former Alaska governor and Republican vice-presidential nominee, but she was hardly alone in uttering such predictions. Palin and many others on the right claimed that President Obama’s struggle to expand health coverage — considered a human right in most of the modern world — was really a nefarious plot to save money by rationing care. All too soon, some tribunal in Washington, D.C. was bound to condemn Grandma to a cruel and untimely doom to save a few bucks.

Eight years later, we know that while Obamacare needs improvement, we have achieved the highest health insurance enrollment in our history –and there is nothing in sight that resembles a death panel.

Not yet, anyway. But severe rationing of medical care, leading to premature illness and many more deaths, is the most likely effect of the Republican “repeal and replace” bill, known officially as the American Health Care Act, that the House passed last week. Although Republican Congressional leaders pushed Trumpcare through without a “score” from the Congressional Budget Office, the CBO analysis of the bill’s previous version showed what its likely effects will be.

The bill is projected to cut almost a trillion dollars in medical spending over the coming decade, by capping and “block-granting” Medicaid — the literal lifeline for tens of millions of poor, disabled, and elderly citizens. Nearly half of all children with special needs receive care under Medicaid, as do almost two-thirds of nursing home residents. And those numbers represent only a fraction of those whose health is improved or whose lives are saved by this essential program.

The House Republican health care bill's massive cuts to Medicaid, which are often skimmed over in the last-minute drama over pre-existing conditions, are fast emerging as a critical source of opposition in the Senate. President Donald Trump said in his speech announcing his 2016 campaign that he would not cut Medicaid, but he did not keep that promise. The Congressional Budget Office estimates the bill's Medical cuts will be 839 billion dollars over 10 years. The cuts are important to financing tax cuts for medical industries and rich people.

Under their scheme, advertised as measures to improve “efficiency,” House Speaker Paul Ryan and President Trump will effectively force governors and legislators across the country to ration health care in their states.

Elected officials will have no choice but to make political decisions to deny vital care in hospitals and nursing homes to those who have no other coverage. They will have to come up with rules and regulations that reduce costs by denying medicine, operations, procedures, hospital stays, nursing visits, tests, and other vital services to those who need them. And another 14 million potential beneficiaries, whose needs are just as pressing, would be denied Medicaid coverage completely.

In short, state officials will have to inflict illness and death on people whose only crime is having no money — or as Palin put it, those who fail the Republican test of “their level of productivity in society.” Those politicians and their appointees who implement the new Medicaid rules will become the death panels.

Which is presumably why so many governors, including Republicans like John Kasich, are asking the Senate to reject the House bill. They don’t want innocent blood on their hands.

According to the original death panels myth popularized by Palin, Obama’s purpose was utopian, which is another way of saying dangerous. In order to reach his goal of universal coverage at an affordable cost — which every other advanced industrial nation on earth somehow achieved long ago — he would have to select some unfortunate citizens for routine elimination. The well-meaning ends would justify the evil means, and so on.

That was all nonsense, as we now know. The purpose of Obamacare was to expand health coverage to all Americans, or as many as possible. But the aim of the real death panels that would ensue from the American Health Care Act is far from utopian (unless like Ryan you are an acolyte of Ayn Rand). It is merely to provide a tax cut of historic proportions for the wealthiest people who have ever existed on this planet.

If this bill becomes law, thousands of Medicaid beneficiaries may well die prematurely. Many of them voted for Trump, believing his campaign promises about providing better care for all. They shouldn’t pay with their lives for that mistake.

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