THE BURNED OVER DISTRICT

If Mitch McConnell's Monster Trumpcare Death bill passes will be the elderly in nursing homes paid for by Medicaid that don't have families to fall back on. As Republicans like Tom Reed tell us, their deaths will be a good thing if it saves money for tax cuts for the wealthy.

“You think you’ve got enough money to last all your life, and here I am,” Ms. Jacobs said.

Medicaid pays for most of the 1.4 million people in nursing homes, like Ms. Jacobs. It covers 20 percent of all Americans and 40 percent of poor adults.

On Thursday, Senate Republicans joined their House colleagues in proposing steep cuts to Medicaid, part of the effort to repeal the Affordable Care Act. Conservatives hope to roll back what they see as an expanding and costly entitlement. But little has been said about what would happen to older Americans in nursing homes if the cuts took effect.

Under federal law, state Medicaid programs are required to cover nursing home care. But state officials decide how much to pay facilities, and states under budgetary pressure could decrease the amount they are willing to pay or restrict eligibility for coverage.

“The states are going to make it harder to qualify medically for needing nursing home care,” predicted Toby S. Edelman, a senior policy attorney at the Center for Medicare Advocacy. “They’d have to be more disabled before they qualify for Medicaid assistance.”

States might allow nursing homes to require residents’ families to pay for a portion of their care, she added. Officials could also limit the types of services and days of nursing home care they pay for, as Medicare already does.

The 150 residents of Dogwood Village include former teachers, farmers, doctors, lawyers, stay-at-home parents and health aides — a cross section of this rural county a half-hour northeast of Charlottesville. Many entered old age solidly middle class but turned to Medicaid, which was once thought of as a government program exclusively for the poor, after exhausting their insurance and assets.

A combination of longer life spans and spiraling health care costs has left an estimated 64 percent of the Americans in nursing homes dependent on Medicaid. In Alaska, Mississippi and West Virginia, Medicaid was the primary payer for three-quarters or more of nursing home residents in 2015, according to the Kaiser Family Foundation.

“People are simply outliving their relatives and their resources, and fortunately, Medicaid has been there,” said Mark Parkinson, the president of the American Health Care Association, a national nursing home industry group.

With more than 70 million people enrolled in Medicaid, the program certainly faces long-term financial challenges. Federal Medicaid spending is projected to grow 6 percent a year on average, rising to $650 billion in 2027 from $389 billion this year, according to the Congressional Budget Office.

Even if Congress does not repeal the Affordable Care Act, Medicaid will remain a target for cuts, experts say.

“The Medicaid pieces of the House bill could be incorporated into other pieces of legislation that are moving this year,” said Edwin Park, a vice president at the Center on Budget and Policy Priorities, a Washington nonprofit that focuses on how government budgets affect low-income people. “Certainly, nursing homes would be part of those cuts, not only in reimbursement rates but in reductions in eligibility for nursing home care.”

AWith or without families, most of the elderly need specialized care to survive because most people do not put granny in a home if she can still function. Those geezers with families will be lucky to last a few months longer.