Time flies.

Debate about health policy in the United States seems to be moving toward the idea that limiting public spending on care for older patients in grave conditions is a necessity.

Just a few years ago, some opponents of the legislation that became the Patient Protection and Affordable Care Act (PPACA) tried to block enactment by arguing that the PPACA treatment effectiveness research program would lead to “death panels.” Times have changed.

A few weeks ago, one team concluded that 11 percent of patients in hospital intensive care units (ICUs) maybe getting futile care, and crowding out patients with a better chance of survival.

Uwe Reinhardt, one of the best-known health policy economists, said the country needs to package public health care for the poor and reference-based priced care for middle-income people in such a way that Congress can ration care without publicly admitting that it’s rationing care.

The Institute of Medicine — which sounds like an august body of sages that dresses in white robes and sips ambrosia on Mount Olympus, while discussing health policy issues in Attic Greek — has suggested in a report on end-of-life care that the country needs end-of-life care quality statistics, and that one focus of the death care statistics should be encouraging advance planning, to reduce use of unnecessary care and of unwanted care. The institute didn’t even balance the idea of reducing use of unwanted care with a phrase or sentence, suggesting that some people might use planning to request that they get as much death care as circumstances permit.

Personally, I would want to minimize the use of death care on myself. One of my relatives who saw her mother die of cancer thinks of Dr. Jack Kevorkian — a strong advocate of assisted suicide for people with serious health problems — as a saint.

Of course, our public and private payers must and do ration care, by steps as simple as charging $10 co-payments for office visits to limiting clinic office hours. The idea is that people who don’t need care enough to pay $10 or wait a limit might not need care very much.

But, on the other hand, I’ve known people who were in pretty good health in old age who suddenly came down with conditions that eventually killed them. It wasn’t obvious to me whether treating them was really futile.

I know a man who fell from a roof and was in a coma. Doctors thought he would never come out of the coma. He now needs a little more help to get around than he did before the fall, but he can walk, talk and go to basketball games. You never know.

Some people have strong religious convictions that all people should try to live as long as they can, and that doctors and hospitals should take whatever steps they can to keep people alive until the last possible moment.

To me, it seems as if one strong argument in favor of buying private long-term care insurance (LTCI) is that having it may reduce the role of money on decisions about how much care to provide people who appear to be nearing the end of life. People who know they would want to go quietly and quickly can work their long-term care (LTC) planners to figure out what they want, express those views in the appropriate legal documents, and get those documents in the hands of the right people.

People who think they would want to keep fighting, or that their loved ones would be happier if doctors left no stone unturned, and returned to the old stones if the supply of new stones ran out, can use LTCI and other products, such as permanent life insurance, to make that approach financially feasible no matter what managers of government health programs decide to do.