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 panel' 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 offering 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.

Eight years later, we know that while Obamacare needs improvement, we have achieved the highest health insurance enrollment ever, 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 among the most likely effects of the Republican "repeal and replace" bill, known officially as the American Health Care Act, passed by the House last week. Although Republican Congressional leaders pushed that vote through without an updated "score" from the Congressional Budget Office, the CBO analysis of the bill's previous version provided ample information about its impact.

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.

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 right-wing Republican test measuring "their level of productivity in society." Those politicians and their appointees who implement the new Medicaid rules will become the real 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 panel 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 has somehow achieved -- 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. 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 of providing better care for all. Neither they nor their children should pay for that mistake with their lives.

To find out more about Joe Conason and read features by other Creators Syndicate writers and cartoonists, visit the Creators Syndicate website at www.creators.com.