Medicare First! Special Kidney Edition
At the end of my PJTV appearance on Glenn Reynolds's show last month we discussed what the dialysis and transplant system might tell us about the national health care debate. (Click on "Lessons from Kidney Donation" to go to that part of the video.)
The two lessons I drew:
1) A fiscal explosion is more likely than tight (or "rational") rationing.
2) Under a uniform system, inertia tends to set in, so that technologies and practices don't improve, even when better ones are available.
This excellent, in-depth USA Today article on the dialysis system confirms both those observations. Rita Rubin writes:
Only 8% of U.S. dialysis patients treat themselves at home. The vast majority of the more than 350,000 Americans on dialysis are treated in centers, where three treatments a week, three or four hours each, is the norm — not because it's optimal but because that's the way it has been done for nearly four decades.
A growing body of evidence suggests that longer and/or more frequent dialysis treatments, either at home or in a dialysis center, are far superior to the status quo. Although the USA spends more per dialysis patient than other countries, that does not result in higher survival rates or even, many argue, a better quality of life.
"The standard of care is really inappropriate," says Brenda Kurnik, Lustman's doctor, who practices in Marlton, N.J. "Basically, it prevents people from dying, and that's about all it does."
So why doesn't the USA do better? Many blame Medicare's End Stage Renal Disease Program. Launched in 1973, it's the only federal program that entitles people of all ages to health-care coverage on the basis of a single diagnosis: chronic kidney failure. By paying for lifesaving care for hundreds of thousands of Americans, the program is a testament to what health insurance reform might achieve if Congress were to adopt it.
But it also may be a cautionary tale: Its cost has far exceeded initial projections, and some doctors and other analysts question whether Medicare get its money's worth and whether patients get the best treatment. Less than one-quarter of dialysis patients ages 18 to 54 are well enough to work or go to school.
As I've argued before, we already have a large, government-run health care system called Medicare, which suffers from plenty of well-known inefficiencies. Before doing anything else, government reformers ought to work on improving it. Medicare First!