On a Saturday morning in September 1972, with less than 30 minutes of floor discussion, a nearly half-empty Senate adopted a far-reaching amendment to the Social Security laws that is costing $2.1 billion this year. Signed into law a month later by Pres. Richard Nixon, the amendment provided Medicare support for virtually anyone with permanent kidney failure.
In 12 years, patient enrollment in the program has swelled from a few thousand to 75,000. And its cost, instead of declining as suggested, has spiraled- from $283 million in the first year to a projected $6 billion by 1990. That, by the way, is when the Medicare part of the Social Security system, left untouched in last year's much-ballyhooed "rescue" of Social Security, is expected to go broke unless Congress comes up with a fix. And Medicare's outlays for treating kidney patients now account for 10 percent of its supplementary medical expenditures (that's for everything except hospitalization).
Of course, the victims of permanent kidney failure -"end-stage renal disease," ArreRp, in government lingo- are being saved. But as I investigated the program, I found that the price being paid, not only by the taxpayers but by the patients themselves in quality of care, is far too high under government financing of treatment.
Congress has wedded itself to a program that turns out to be riddled with all the inadequacies and sometimes tragedies of the typical government boondoggle. I found that cost overruns, mismanagement, and even fraud have beset the government's ESRD program. None of the kidney-treatment providers reimbursed by Medicare has had any incentive to hold down the cost of the pro-and all have had plenty of incentives to do just the opposite. Meanwhile, kidney patients have suffered as the program has stifled treatment innovations and encouraged the use of less-desirable forms of treatment. ESRD patients are becoming the victims of the very program designed to save and enhance their lives.
The ERSD program, with all its unanticipated consequences for patient care and costs to taxpayers, is of special interest to me, for I have been a patient in the program. In September 1979 I walked into my doctor's office thinking I had the flu and came out knowing that I had permanent, irreversible kidney failure. I spent nearly nine months having hemodialysis treatments on a kidney machine three times a week, with a quality of life I don't like to remember but can never forget.
Then on May 5, 1980, my older brother donated a kidney for me, so I could, at the age of 32, begin a normal life again. Side by side, we were wheeled into an operating room and experienced first-hand the technological twilight zone of modern medicine. According to observers, the surgery was flawless, as not a thimble of blood was lost from either of us during the three-hour procedure.
When I awoke following surgery I was immediately relieved to have passed the first test-I was alive. I was told that my new kidney had started functioning right on the operating table. My brother was fine. I was fine. Then my eyes wandered around the intensive-care transplant unit at the University of California, Los Angeles (UCLA), finally settling on the maze of machines and intravenous tubes that were hooked to me. I managed to stay awake for 60 seconds or so, just long enough to gather in what had transpired. My kidney transplant was complete.
I slept until the following day. When I awoke the second time, I learned that my blood chemistry was beginning to stabilize, as the accumulated toxins of a chronic illness slowly disappeared. Like a car with a new fuel filter, the impurities began leaving my system.
Within a week, as my condition improved (without any hint of my body rejecting the new kidney), I became confident that my life would return to normal. A dream come true (and, thanks largely to the government's ESRD program, at no expense to me). I left UCLA on May 12, 1980, and never looked back. Today, my brother and I are both in better shape than we were as teenagers. He swims five miles a week, and I play racquetball regularly. When people see me, it is hard for them to believe I was terminally ill.
Until about 25 years ago, people suffering permanent kidney failure were doomed to certain death. But development of a modern lifesaver, hemodialysis, changed all that. Today, the lives of ESRD patients are being prolonged for years by this phenomenal procedure.
Most simply, hemodialysis is a mechanical process whereby blood is drawn from the body and cleansed of impurities in a process mimicking the body's kidneys. Outside the body, the blood is passed along one side of a man-made membrane, with a special solution on the other. Due to the laws of chemistry and physics, certain molecules pass through the membrane, eliminating waste products and excess fluids. The blood is then returned to the body, in a continuous process of cycling and cleansing.
The history of dialysis is rather short.
As early as 1913, scientists experimented with the external dialysis of blood in laboratory animals, with some degree of success. But it was not until the 1940s that a dialysis machine was used to save a human life. Developed in Nazi-occupied Holland by Dutch physician Willem J. Kolff (see sidebar, page 27), it was used on 17 patients in 1943. Only one survived, but the modern age of hemodialysis was upon us.
From the time of Kolff's brilliant discoveries until 1960, kidney machines were primarily used to treat people with temporary kidney failure. Those with permanent loss of function could only survive as long as they stayed hooked to a machine.
Then in 1960 Belding H. Scribner, a doctor at the University of Washington Medical School in Seattle, devised a way to repeatedly hook and unhook patients from machines, using implanted tubes that are connected outside the skin with a teflon device. Scribner's invention allows for normal circulation until time for a kidney treatment, when the tubes are disconnected from each other and a dialysis machine is "plugged in."