The health care industry is spending about $1.5 million a day on lobbying efforts in Congress. Most of those dollars are spent fighting against the threat of “rationing.” That doesn’t count the money that’s spent on TV ads in which disgruntled people from Canada tell why they come to the United States for surgery ( supposedly because public plans ration care.) The rant about rationing is designed to make consumers feel that no one will be able to get in to see a doctor under a public plan, and that grandma will be denied her hip replacement because she’s — heaven forbid — over 65. It’s designed to make efforts at real health care reform fail. Fear can be a powerful motivator, and the lobbyists and advertising campaigns are trying desperately to evoke as much fear as they can in the mind of the consumer, hoping that will influence Congress.

What most Americans don’t realize is that our health care is rationed now. If you aren’t employed by someone who provides health insurance your access to health care is limited by your ability to pay for it. That’s rationing. If you are insured, but your plan doesn’t cover the test your doctor thinks you need, or you think you want, your care is also rationed. It you lose your job, your care is rationed, because you probably can’t afford COBRA. Right now, people who have health insurance that’s provided by their employers feel complacent and, understandably, don’t want reform. That perspective shifts in a minute when they get sick, or are unemployed.

Rationing can be done well. We can ration care that has not been proven to prolong life, or to be effective. My late husband, a radiologist, used to see cancer patients all the time. One of the things that made him most upset was when a patient was given chemotherapy or radiation therapy that would make them sick immediately with only a small chance of prolonging life for a few weeks. He thought that practice was permanent employment for oncologists, and he often counseled his friends to refuse treatment and live well, if not healthy, until they died. Not everybody can be saved.

When he became ill, he looked at his own X-rays, realized he was terminal, and did the same thing he told his patients to do: he refused treatment. He happily played with grandchildren and went out to dinner until a week before he died, and then he asked me to make sure he would not receive anymore treatment that wasn’t just to relieve pain and suffering.

Most of the health care dollars are spent in the last six months of a person’s life, and often the patient doesn’t even want the extraordinary measures, or doesn’t know he or she is receiving them. It’s the family that “tries anything” and authorizes the medical staff to use extreme measures. It’s not the elderly person having a hip replacement that we should ration — it’s the elderly person who wants to die peacefully, but whose relatives won’t let go, whose care should be “rationed.

And who should make that decision? The patient: far in advance of the moment it occurs. If we could get people to take charge of their own health, create “Advance Directives,” and ask their families to abide by them, we’d have plenty of money to take care of the people who can actually benefit from the care they get.