Nothing makes you feel old like having a memory in politics. I doubt that anyone much younger than me remembers what “death panels” were, or were supposed to be, circa 2008. The idea was that, if Barack Obama were elected president and pushed through some kind of single-payer health-care bill, which he cravenly refused to do in 2010, a gang of technocrats would meet in darkened council chambers, no doubt wearing robes and masks pulled straight from Eyes Wide Shut, to decide whether it was time for grandma to meet her maker.

The dream, or rather the nightmare, of death panels died with the Tea Party, but the same basic idea rears its head every time a Republican politician talks about “rationing” in health care. I am never sure exactly what is being decried or otherwise objected to here. Resources for the provision of medical care are indeed limited like those of any other sort, which means that prudential decisions have to be made about their distribution. The only question is what criteria should govern such decisions.

At present the most important one is the ability of individuals to pay. Which is how millions of Americans find themselves in the horrifying scenario explored by a recent article in Vox, in which the mother of a toddler who had ingested Dramamine decided not to bring her daughter to the emergency room for evaluation because she knew that she would not be able to afford the eventual bill. Something similar happened to my own family only a few months ago when our impossibly dexterous two-year-old managed to climb to the top of a 10-foot-tall shelf and open a bottle of acetaminophen in the time it took my wife to answer a 30-second phone call. Had it not been for my bizarre arithmetical habits, which allowed me to conclude eventually that she could not have swallowed more than a single pill, we would have had to decide whether to take our chances or pay $1,000 to know beyond any reasonable doubt that she was safe.

This is a decision a parent should never have to make. No amount of money is too much to save the life of a child, but the crushing reality that a routine — if for the wee one terrifying — procedure like a stomach pump could, thankfully, turn out to be both unnecessary and expensive leads many parents to conclude that the most sensible decision is simply to hope for the best. This is not irresponsible parenting. It is hard-nosed pragmatism.

Thank goodness in the case of Lindsay Clark and her daughter, the family profiled by Vox, the worst did not come to pass. The Clarks’ situation is hardly unique. In their home state of Texas, one in 10 children have no health coverage of any kind, in large part because successive Republican governors have refused to allow their citizens to take part in the expansion of Medicaid that has proven one of the only universally successful parts of the Affordable Care Act. Even with excellent insurance coverage, out-of-pocket expenses for emergency care can run into the four-figure range before the deductible kicks in. Meanwhile, the least fortunate Americans are those who find themselves just wealthy enough to be disqualified from Medicaid but poor enough to find their employer-sponsored health insurance plans beyond their means. Nor are families with children the only people who find themselves making life-or-death decisions on the basis of cost. As I write this, more than 10 percent of Americans are refusing to take medication prescribed by doctors because they cannot afford to pay for them.

All of which is to say that, whatever the GOP argues to the contrary, we have rationing in America already. The question is whether we should be rationing on the basis of the need of patients rather than on that of wealth — or willingness to incur life-crippling debt. To whom should our limited health-care resources be devoted to if not the young, the elderly, and the disabled? This year millions of Americans will have elective surgeries while millions of others go to bed thanking God that another day has passed without one of their children becoming injured or seriously ill — or dead.

The only thing more terrifying than the death panels Sarah Palin warned us about are the ones we already have.