Compassion and conflict: The impact of the medicare end-stage renal disease program

At its inception, the Medicare program was designed to insure that the elderly would not be denied access to the health-care system because of a lack of financial resources. But, with lobbying efforts, the original Medicare bill was amended to add coverage for those individuals with end-stage renal disease (ESRD), permanent kidney failure requiring dialysis or kidney transplant. To date, patients with ESRD are the only disease-specific population entitled to federal coverage for services on virtually a universal basis. \r\n\r\nBecause of the unique nature of funding for the ESRD program, the question arises as to whether it is ethically appropriate for the federal government to allocate monies on the basis of disease status. To answer this question I examine the politics, morality, economics, and human behavior that impact ESRD and the patients, the public, and the political response to it. I will look at the variety of issues, both within and beyond the range of medical practice, that reveal how ESRD is treated in the United States. To address these concerns, this research will explore the history, describe the current conditions, and then suggest possible futures for the ESRD program. \r\n\r\nThrough this research, I will argue that the Medicare ESRD Amendments were a unique phenomenon, the result of a perfect storm. The technology was available to save lives and it worked. Further, not only did the technology save people, but also it had the capacity to restore terminally ill individuals to normal and productive lives. This idea was irresistible. However, while created with good intentions, the ESRD program was a strategic mistake. Caught up in the rescue fantasy, politicians and providers gave inadequate forethought to the ethical, economic, and regulatory demands the program would impose on the federal government. \r\nHowever, for all the problems and unintended consequences, I will argue that the ESRD Amendments are more than just a run-of-the-mill federally funded health-care program. The Amendments created a legal right, a moral promise, and a special covenant, that cannot be revoked, between the federal government and patients with a life-threatening illness.\r\n