Biomedical Politics (1991) / Chapter Skim
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Origins of the Medicare Kidney Disease Entitlement: The Societal Security Amendments of 1972
Origins of the Medicare Kidney Disease Entitlement: The Societal Security Amendments of 1972
Pages 176-214
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From page 176... ...
Art eleventh-hour Senate floor amendment to the bill became Section 2991 ofthe final legislation. For more than 90 percent ofthe nation's population, this provision extended Medicare coverage to those with chronic kidney failure.
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From page 177... ...
An extended treatment can be found in the literature (Rettig, 1981,19821. In 1944, in Nazi-occupied Holland, Willem Kolff first succeeded in prolonging the life of a patient using his primitive artificial kidney machine.
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From page 178... ...
Alarmed by the cost implications of center dialysis, it then awarded 14 home dialysis contracts in 1966. Still seeking to dodge the fiscal implications of even this least costly treatment, in 1969 it let seven organ procurement contracts for organ procurement and combined kidney transplantation/home dialysis programs.
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From page 179... ...
In addition, the National Kidney Foundation at that time had no Washington representative to publicize the report's conclusions. The report, therefore, did not reach enough of the right people.
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From page 180... ...
The House Ways and Means Committee and the Senate Finance Committee were also concerned mainly with Medicare and Medicaid start-up problems. Receptivity to expanding Medicare to individuals under age 65 for treatments that very recently had been regarded as experimental was low.
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From page 181... ...
The number of treatment centers was also steadily increasing. The Seattle Artificial Kidney Center, founded in 1962, pioneered the development of dialysis treatment centers.
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From page 182... ...
The National Kidney Foundation, through the efforts of Schreiner and Plante, focused these developments in the legislative arena much like a parabolic reflector gathers signals from many sources and focuses them on a single point. The foundation provided full-time professional representation of its cause to members of Congress and their staff, supplied them with continuous information, and pursued all available legislative and executive opportunities to advance the cause of kidney disease.
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From page 183... ...
. As one workshop participant said, the Ways and Means Committee, together with the Senate Finance Committee, "raised all of the federal government's revenue and spent half of it." The House Ways and Means Committee had, and still has, an important advantage over the Senate Finance Committee.
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From page 184... ...
The Senate Finance Committee lacked the internal cohesion of the House Ways and Means Committee. On welfare reform, for example, a major element of the social security legislation in 1972, Long favored a
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From page 185... ...
William Fullerton joined the Ways and Means Committee in 1970 as its first professional staff person; in 1972, he was the only such staff attached to the committee. His counterpart in the Senate, Jay Constantine, had joined the Senate Finance Committee in 1966 as its first professional staff person on Medicare, Medicaid, and welfare.
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From page 186... ...
Congress, House, Committee on Ways and Means, 19721. In the Senate, although Finance Committee Chairman Long did not favor comprehensive health insurance measures, he did advocate insurance against the catastrophic costs of health care, indicating the broad interest in expansion of the existing Medicare and Medicaid programs.
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From page 187... ...
Ways and Means: November and December l 971 The House Ways and Means Committee, as part of its hearings on national health insurance, devoted the end of the morning of November 4, 1971, to testimony about ESRD (U.S. Congress, House, Committee on Ways and Means, 1971c)
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From page 188... ...
Glazer, at a New York NAPH press conference on November 3, the day before the hearing, had announced his intention to undergo dialysis before Chairman Mills and the Ways and Means Committee. The National Kidney Foundation opposed the effort directly in discussions with Glazer and indirectly through Eli Friedman, advisor to NAPH.
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From page 189... ...
It seems to those of us who each day work in the field of kidney disease that too many years have already gone by without a national program of catastrophic insurance or a National Health Insurance Act with provisions for catastrophic coverage. The events of the previous week were neither mentioned by the National Kidney Foundation representatives nor raised in the perfunctory questioning after the testimony.
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From page 190... ...
During this time, the supplemental security income benefit was developed on the Senate side. The Senate Finance Committee did not report out a bill, however, until September (U.S.
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From page 191... ...
The key discussions at the Senate Finance Committee staff level occurred during this period. Constantine was inclined against a kidney disease amendment.
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From page 192... ...
Let Hartke do it; we may need him for something else." The Senate Finance Committee report of September 26 revealed the complexity of legislation that dealt, among other things, with old age, survivors, and disability insurance, Medicare, Medicaid, maternal and child health, social security benefits, supplemental security income, jobs for families, child care, aid to families with dependent children, and general revenue sharing; the document was nearly 1,300 pages long. Listed first among the health-related provisions of the House bill that were basically adopted without change by the Senate was the extension of Medicare coverage to disability beneficiaries (U.S.
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From page 193... ...
Of the staff, Mongan was pivotal. He persuaded Constantine to treat the issue as a "pilot" for catastrophic health insurance.
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From page 194... ...
The kidney amendment, although consistent with this broader agenda, was an issue that deserved immediate attention. As Long put it on the Senate floor: The next Congress will tackle health insurance issues, and I am sure during that debate we will deal with health insurance problems in general, and I hope that specifically we will deal with the problem of insuring against catastrophic illness.
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From page 195... ...
The Hartke amendment had included a six-month waiting period between the application for entitlement (following the first treatment for chronic kidney failure) and the period of eligibility for benefits.
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From page 196... ...
First, Senator Hartke was the only source of public information about estimates. On the Senate floor on September 30, drawing heavily on information from the National Kidney Foundation, he discussed costs at length: In terms of indirect costs of mortality lost future income—kidney disease is the highest ranking killer, costing the country $1.~; billion annually.
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From page 197... ...
Where did Hartke get his numbers? The National Kidney Foundation supplied him with figures from the spring of the year onward.
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From page 198... ...
The health actuaries of the SSA worked with the House Ways and Means Committee, the Senate Finance Committee, the Joint Committee on Taxation, and the conference committee to cost out the various provisions under consideration. In 1972, as today, the focus of cost calculations for amendments to the Social Security Act was the amount of increase in the Federal Insurance Contributions Act (FICA)
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From page 199... ...
Consequently, in the first week of October, the health actuaries were asked by both committees for estimates for the conference committee. Trapnell recalls preparing these for zero, three-, and six-month waiting periods and projecting these estimates 25 years into the future.
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From page 200... ...
I also pointed out that the Senate provision effectively had no waiting period due to the impossibility of determining when the onset of chronic kidney [disease] occurred; but dialysis would substantially reduce the costs, as indicated in the estimates provided (average cost of .09% with no waiting period, .06% with a three month waiting period, and .06;% with a six month waiting period)
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From page 201... ...
The "estimates" used by Senator Hartke, which were provided by Scribner and Kountz and transmitted by the National Kidney Foundation, seriously underestimated the costs of the program. Neither the actuaries nor the congressional staff took them seriously; yet no one challenged them, and they became the only available public numbers.
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From page 202... ...
At the time, however, as noted in this paper, it was widely expected that national health insurance or at least some form of catastrophic health insurance would be enacted within a few years of the 1972 legislation. Moreover, the extension of Medicare coverage to the disabled was seen by all key participants as a sine qua non justification of Section 2991.
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From page 203... ...
"It was clear from the beginning that government health insurance would involve costs beyond what anyone was telling you at the time. I thought, how do we move into this thing?
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From page 204... ...
What am I to do? ' "As chairman tof the Senate Finance Committee]
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From page 205... ...
"(f) Medicare eligibility on the basis of chronic kidney failure shall begin with the third month after the month in which a course of renal dialysis is initiated and would end with the twelfth month after the month in which the person has a renal transplant or such course of dialysis is terminated.
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From page 206... ...
(who participated by telephone) , professional staff to the Subcommittee on Health, Senate Finance Committee.
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From page 207... ...
1971a. National Health Insurance Proposals.
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From page 208... ...
1972. Material Relating to Amendments to the Administration's National Health Insurance Partnership Act.
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From page 209... ...
Rettig presents a fascinating account of the enactment of Meclicare coverage for patients with chronic kidney failure. At his initiative, for the first time, many of the principals, legislative assistants, officials of the Social Security Administration, and leading advocates for the program who were involved in passage of the legislation were assembled for a candid discussion of the events immediately preceding the adoption of the program in October 1972.
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From page 210... ...
Advocacy groups consisting of patients, their families, and physicians, as well as the National Kidney Foundation, worked vigorously to stimulate federal and state governments to provide financial coverage for treatment. The issue of equity became even more sharply focused when in 1963 the Veterans Administration announced its intention to establish treatment units in VA hospitals across the country.
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From page 211... ...
The great quandary when the legislation was enacted was whether to proceed with a less than perfect treatment program for the fatal Iy i 11 or wait for a research breakthrough that would cure or preferably prevent the occurrence of chronic renal failure. Twenty-eight years later, th is quandary persists.
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From page 212... ...
But first let us proceed to other features of this story, beginning with the influence of a frequently used instrument of policy—the advisory committee report. Here, it is represented by the 1 967 Report ofthe Committee on Chronic Kidney Disease, which is known commonly, taking the name of its chair, as the Gottschalk report.
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From page 213... ...
Like the advisory committee, it is a vehicle for knowledge seeking, but as a forum for Congress, political purpose openly pervades its use. Rettig sheds a revealing light on the true events occurring on November 4, 1971, when the House Ways and Means Committee provided a forum for testimony on kidney disease therapy and allowed the dialysis of a patient before members of Congress and the press.
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From page 214... ...
Thus, a misreading of the traditions of American health policy accounts for one source of criticism of federal funding of kiciney disease treatment. But there is another facet that helps explain the place of the kiciney legislation as a cautionary tale in the lore of health policy the ambivalent feelings generated in us by its technological mainstay, the dialysis machine.
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