Did the controversial in Congress dialysis of 1971 change Medicare?

Some Kidneys (not an actual photo)

Lets look back to 1971!

Dialysis was invented for patients with kidney disease in 1960 but the cost of this procedure was (and continues to be) extremely expensive and private insurance did not cover it. It was a market failure. During the 1960’s, stakeholders for kidney patients sought to have dialysis included as a benefit in existing health programs such as the VA. When Medicare came around the pressure increased to include dialysis as an option for people with kidney disease. At its inception however, Medicare only covered those over 65.

Then in late 1971, the Ways and Means Committee of the House of Representatives (the committee in charge of Medicare), was having a hearing on dialysis. At this hearing Shep Glazer implored Congress to cover the treatment and then was dialyzed in front of the committee. The folklore is that this hearing caused Congress to pass ESRD coverage.

Politics, however, is much messier than that. In order to be passed, the inclusion of ESRD would be part of the less controversial bill that included coverage of disabled individuals in Medicare. During negotiations, the Senate Finance chairman, Russell Long, was pushing hard for Medicare drug coverage (which was an initial recommendation by Medicare for inclusion). Long lost this battle and settled for ESRD coverage in hopes that this would further other similar conditions to be covered by Medicare.

So while an “in Congress dialysis” did do a lot for public opinion and raising the issue of dialysis, like all things in politics negotiations and appearing to “win” was the real reason that hundreds of thousands of people with kidney disease can afford coverage.

Interestingly, Glazer experienced a sudden drop in blood pressure five minutes into the procedure in the Ways and Means Committee room and the physician ended the dialysis immediately. So in reality there were two myths to this story: the testimony did not draw Congress to act and a full dialysis was never preformed.

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Are you a political elite?

John Zaller in his 1992 book The Nature and Origins of Mass Opinion looks at what makes a person a political elite. I really liked this paragraph. See if it describes you!

Although most Americans are, to use Down’s (1957) apt phrase, rationally ignorant about politics, they differ greatly in the degree of their ignorance. There is a small but important minority of the public that pays great attention to politics and is well informed about it. Members of this minority can recognize important US senators on sight, accurately recount each day’s leading news stories, and keep track of the major events in Washington and other world capitals. They are, thus, heavily exposed to elite discourse about politics.

This pretty much describes every 20 to 30-something at bars in DC. But just because a person pays attention doesn’t mean they are part of the political elite. Political elite shape the policy whether or not they pay attention. We hope they do, but this isn’t a necessary condition for the elites to shape our viewpoint of politics and in turn drive political decision making.

Public Health Heroes

Today, the Harvard School of Public Health received a donation of $350 million from The Morningside Foundation, established by the family of the late T.H. Chan.  For full disclosure, I am a public health professional and student at Harvard University in a program related to the renamed Harvard T.H. Chan School of Public Health. This generous gift will: 

focus on four global health threats: pandemics old and new, such as malaria, Ebola, cancer, and obesity; harmful physical and social environments such as those resulting from tobacco use, gun violence, and pollution; poverty and humanitarian crises such as those stemming from war and natural disasters; and failing health care systems around the world.

I am thrilled that people are talking about the importance of public health and have been paying even closer attention to public health workers with the recent horrific Ebola outbreak. However, this pails in comparison to the credit that public health workers deserve and to the amount of accolade they have received in the past.

Here is a quote from Samuel H. Preston in American Longevity: Past Present, and Future

So this explanation [of the cause of increase in life expectancy] emphasizes a fundamental scientific advance, the germ theory, as implemented by public health officials and, perhaps more importantly, aggressively disseminated by them to an extremely eager audience. Public health officials were heroes. Shortly after his death in 1923, Cornell University students and faculty proclaimed Herman Biggs, former Public Health Commissioner of New York City and then of New York State, their most outstanding alumnus. It’s hard to imagine a bureaucrat of any stripe, let alone a health commissioner, receiving such and accolade today. 

So thank a public health professional today. They improve your water, vaccinate your children, fight heart-wrenching outbreaks, clean your air, and most importantly help you live longer. Make them heroes again. 

Five ways to lower health care costs from an economist’s perspective

In Victor Fuch’s “Who Shall Live,” he lays out a simple economist perspective of how health care costs could be reduced. Sarah Kliff went in to a bit more detail about the problems of the American health care system today.  

These age old principles examine some of the economic arguments to reduce the problem of health care costs. These theories center on the basic argument that cost is a combination of price and quantity. Therefore, if you want to reduce the cost, you either can reduce the price or the quantity of use, or both. 

For those that like formulas:

Cost=Price per unit of care*Quantity 

Price=Productivity * price paid for services

1. Increase the number of hospitals and physicians- This is the theory, that increasing the supply of doctors will reduce the price or increase productivity, because doctors will compete against each other in the market. This implies price transparency, which has not been made available to the consumer or market. 

2. Improve the health of the population- In this theory, improving the general public health would reduce the quantity of people needing health services. This implies that we know how to target public health measures and that they will see results. 

3. Add administrative controls and planning- This theory is used for many drug formularies or utilization review committees. Many people may think that this is limited to government controls and regulation, when in fact this approach could occur within a hospital, manufacturer or provider office. Imposing controls could reduce the price paid for services, reduce the quantity or improve productivity based on which levers are pulled. 

4. Impose greater cost consciousness in consumers- Co-payments and deductibles are at the heart of this theory. If the consumer sees more of the cost for a service, they are less likely to agree to it. This reduces the quantity of services.

5. Physician control costs- This theory is based on the assumption that changing the way we pay physicians could reduce the quantity of services that a physician provides.  This theory focuses on the problem of paying for each service, known as fee-for-service payments.