The special (Medicare) status of kidney disease

Special Treatment — The Story of Medicare’s ESRD Entitlement
NEJM, February 16, 2011, by Richard A. Rettig, Ph.D.

"In October 1972, Medicare, which had been enacted for the elderly in 1965, was extended to the disabled by the Social Security Amendments. One provision, added at the last minute, declared that persons with chronic renal disease who required hemodialysis or kidney transplantation “shall be deemed to be disabled” for purposes of Medicare Parts A and B. To be eligible for this Medicare coverage, patients had to have paid into the system long enough to be “fully or currently insured” under Social Security or be the spouse or dependent child of someone who was. This near-universal Medicare entitlement for end-stage renal disease (ESRD) has now been in effect for nearly 40 years.
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In 2008, there were more than 112,000 new patients with ESRD in all eligibility categories (elderly, disabled, and ESRD-only). There were approximately 548,000 U.S. patients undergoing dialysis at the end of 2008, but many of them were not covered by Medicare, either because they had not yet fulfilled the initial waiting period or because they had received transplants and their coverage had ceased after 3 years. Medicare expenditures for ESRD in 2008 were $26.8 billion for Parts A and B. Non-Medicare expenditures for ESRD (covered by employer-sponsored group health plans or paid directly by patients) added another $12.7 billion, for total national expenditures of $39.5 billion.¹ According to an analysis by the U.S. Renal Data System, ESRD beneficiaries represented 1.3% of all Medicare beneficiaries and used 7.9% of Medicare expenditures.
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"So how was it that full coverage for treatment of one specific disease became enshrined in U.S. law? The story began during World War II, in Nazi-occupied Holland, where Willem Kolff invented the artificial kidney; after a visit by Kolff to the United States in 1947, a modified version of his machine was developed and used in Boston by John Merrill and colleagues at the Peter Bent Brigham Hospital. During the Korean War in the early 1950s, proof of concept was provided for treating acute renal failure with this Kolff–Brigham device. In 1960, Belding Scribner and Wayne Quinton, at the University of Washington Hospital in Seattle, invented an implanted arteriovenous shunt that made it possible for a patient to be connected to the machine repeatedly and ushered in the use of hemodialysis as a treatment for chronic renal failure. The shunt was later replaced by a subcutaneous fistula developed by the physicians Michael Brescia and James Cimino at the Bronx Veterans Administration (VA) Hospital.
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" In Seattle, in response to financial limitations, access to dialysis was restricted through explicit rationing carried out by an anonymous lay committee — an approach that was laid bare for the American public in a Life magazine article in November 1962.² Elsewhere, decisions limiting access to dialysis were tacitly incorporated into traditional medical decision making. Dialysis highlighted the tragic choices that had to be made when fundamental societal values encountered problems of scarcity.
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"In November 1971, a patient received dialysis — albeit very briefly — at a hearing of the House Committee on Ways and Means. Many casual observers attribute the passage of the 1972 legislation to this event, overlooking the myriad other contributing developments. But the committee saw that the patient was a family man, in his prime working years, who could be rehabilitated and returned to gainful employment — with help from his government. Ultimately, the ESRD entitlement was added to Medicare because the moral cost of failing to provide lifesaving care was deemed to be greater than the financial cost of doing so."