The Ethical Mess of Our Health Care System

Jonathan Moreno, PhD, and Penn President Amy Gutmann, PhD, write in New York Times Opinion:

"The recent Democratic primary debates in Detroit made at least one thing clear: The party exclusively responsible for passing the Affordable Care Act is now waging political warfare over whether to reform it or eliminate it. Senator Bernie Sanders was loud but not lonely in advocating “Medicare for all,” which would supplant the A.C.A. with a single-payer system and virtually abolish private employer-based health insurance. His predictable answer to who will fund its high price is apparently the 1 percent who need to pay their fair share.

But there is another 1 percent, and they are not the privileged ones you’re thinking of. They are the roughly 1 percent of Medicare patients who have end-stage renal disease and cost the system $34 billion every year. No matter how rich or poor, young or old, Medicare kidney patients are guaranteed treatment mostly paid for by American taxpayers.

The product of vigorous lobbying and minimal deliberation, this one-disease carve-out that Congress passed in 1972 exemplifies the highly politicized patchwork design of the American health care system and its scandalous lack of universal coverage and adequate cost controls.

Anyone with a sense of compassion can applaud saving three-quarters of a million Americans with failing kidneys from death each year. But this program is exorbitantly expensive, and preventive therapies and other effective treatments can be made available at lower costs. It enriches two for-profit companies that control about 70 percent of the dialysis market. It has created perverse incentives for health care providers to supply too many patients with dialysis while devoting scant resources to preventing end-stage kidney disease and providing more kidneys for transplants.

These problems have long been known. Yet for decades policymakers faced insurmountable obstacles in Congress to making valuable reforms, such as controlling the price of renal dialysis, incentivizing less expensive and more convenient at-home dialysis and increasing the number of kidneys available for transplant.

This one-disease benefit raises a broader ethical question: Why is renal dialysis worthier of such generous federal funding more than other lifesaving treatments for other deadly diseases? While almost 750,000 Americans have end-stage kidney disease, over 30 million are diabetic, over two million are insulin-dependent and diabetes treatment costs less and saves many more lives. Why shouldn’t treatment for severe cases of diabetes and other life-threatening diseases like hemophilia, leukemia and other cancers also be fully funded by Medicare?"