During the debate leading up to the passage of the Patient Protection and Affordable Care Act (commonly known as the “ACA” or “ObamaCare”), one idea to help reduce medical costs did not make it into the final version. This was to allow a small amount of federal money to be used for end of life planning and it was modeled after a popular program in La Crosse, Wisconsin. In this town of 50,000 inhabitants, 96% of those who die have signed an “advanced directive” stating how they would like to die and what end of life care they wish to have. As you may guess from such a high participation rate, La Crosse has the lowest per capita health care costs in the country.

Allowing medical providers to get paid with federal dollars for end of life consultations did not make it into the ACA thanks to Sarah Palin’s August 7, 2009, Facebook post in which she characterized this proposal as “death panels.” That claim was later voted to be the Lie of the Year by PolitiFact’s 5,000+ website readers with more than 61% of the vote, but the damage was done. “Death panels” kept the end of life consultations out of the ACA, unless of course, medical providers wanted to work for free. Many of them chose to do just that in La Crosse.

More than half of all health care spending in the United States goes to pay for the medical “needs” of just 5% of the sickest Americans, and most of those costs are incurred in the last year of life, largely in hospital-based treatment programs. What they discovered in La Crosse, however, is that family members are more likely to pursue extraordinary medical options to extend their loved ones’ lives unless the patient specified ahead of time what he or she wishes. It may be guilt or concern that someone may criticize them for not doing enough or another strong emotion, but whatever the reason, it is expensive and generally not what the patient would have wanted. Most people choose a more dignified way to die if asked ahead of time and would not like to live an extra month or two if it means being stuck in a hospital bed with all the indignities that come with it.

The House Republican health care bill contains something much more deadly than Sarah Palin’s Death Panels – “high-risk pools.” That language in the American Health Care Act or AHCA and the likelihood that some states will apply for waivers which allow insurance companies to enact annual and lifetime limits and refuse coverage for pre-existing conditions will leave many people without coverage.

About half of nonelderly Americans have one or more pre-existing condition. Imagine the burden on those of limited financial resources. Do they pay for an expensive high-risk pool insurance policy or pay the rent? Do they skip the insurance coverage for a year and try to limit their health care costs by stretching their 30 day supply of medicine to 45 days? The AHCA also eliminates the 0.9% Additional Medicare Tax on individuals earning more than $200,000 per year and couples earning more than $250,000 per year which would make Medicare insolvent in eight years. This tax break for the wealthy likely means poorer older Americans will not receive the care they need because there won’t be money to pay for it.

And that’s serious. Nearly 30% of all Medicare spending occurs in the last 6 months of a person’s life. What will poorer retirees do without Medicare? It’s not a good answer, and that’s exactly why President Lyndon B. Johnson signed the bill that created Medicare and Medicaid into law on July 30, 1965. People were dying.

Wealthy older Americans have many more options. There will be supplemental insurance plans they can purchase, or because they are reliable Republican voters, the GOP will likely carve out special benefits for them from the limited health care resources.

The AHCA does not offer the same promises of protection to poorer Americans, regardless of age. Over the years, high-risk pools have been attempted in various states or regions with unimpressive results. Since medical cost inflation is much higher than general inflation, it’s likely today’s new high-risk pool experiment will face bigger obstacles than previous attempts. As with Medicare, the wealthier people in the high-risk pools will be able to pay for coverage, but the poorer people will not. They will probably have to postpone care, use emergency rooms when something can’t be ignored, and face bankruptcy as a result of medical bills they can never pay off.

The good news is that the AHCA is very unlikely to become law in its current iteration, but the bad news is that it has gotten this far. What other attacks are coming from this House of Representatives on the American value of protecting those in need? Without a doubt, the AHCA will mean that many fewer Americans receive health care and that high-risk pools, accelerated Medicare insolvency and allowing insurance companies to choose profits over coverage will kill people. The AHCA is a plan of death pools.