In October 1972, after a month of deliberation, Congress launched the nation’s most ambitious experiment in universal health care: a change to the Social Security Act that granted comprehensive coverage under Medicare to virtually anyone diagnosed with kidney failure, regardless of age or income.
It was a supremely hopeful moment. Although the technology to keep kidney patients alive through dialysis had arrived, it was still unattainable for all but a lucky few. At one hospital, a death panel—or “God committee” in the parlance of the time—was deciding who got it and who didn’t. The new program would help about 11,000 Americans for starters, and for a modest initial price tag of $135 million, would cover not only their dialysis and transplants, but all of their medical needs. Some consider it the closest that the United States has come to socialized medicine.
Now, almost four decades later, a program once envisioned as a model for a national health-care system has evolved into a hulking monster. Taxpayers spend more than $20 billion a year to care for those on dialysis—about $77,000 per patient, more, by some accounts, than any other nation. Yet the United States continues to have one of the industrialized world’s highest mortality rates for dialysis care. Even taking into account differences in patient characteristics, studies suggest that if our system performed as well as Italy’s, or France’s, or Japan’s, thousands fewer kidney patients would die each year.
...Conditions within clinics are sometimes shockingly poor. I examined inspection records for more than 1,500 clinics in California, New York, North Carolina, Ohio, Pennsylvania, and Texas from 2002 to 2009. Surveyors came across filthy or unsafe conditions in almost half the units they checked. At some, they found blood encrusted in the folds of patients’ treatment chairs or spattered on walls, floors, or ceiling tiles. Ants were so common at a unit in Durham, North Carolina, that when a patient complained, a staffer just handed him a can of bug spray.
Hundreds of clinics were cited for infection-control breaches that exposed patients to hepatitis, staph, tuberculosis, and HIV. A Manhattan facility closed in 2008 after cross-contamination infected three patients with hepatitis C within six months. Prescription errors were common: 60 clinics had at least five citations for them. In dozens of instances, patients died or were hospitalized after suffering hemorrhages like Baer’s, when dialysis needles or tubing dislodged and staffers failed to adhere to safety guidelines.
...Medicare’s record of making sure that clinics meet health and safety standards has been spotty. Clinics are supposed to be inspected once every three years on average, but as of late 2009, almost one in 10 hadn’t had a top-to-bottom check in at least five years, as shown by data from the Centers for Medicare and Medicaid Services (known as CMS). Nursing homes, by contrast, must be inspected once every 15 months, and in 2006, CMS reported that 99.9 percent had been.
Even when inspectors find that clinics are not meeting government standards, the consequences are seldom meaningful. CMS can demand that facilities submit correction plans, but it cannot fine violators as it can nursing homes. The agency almost never imposes its toughest sanction—termination from Medicare—because clinic closures could hinder access to care. From 2000 to 2008, the agency barred just 16 dialysis facilities; federal regulations set no limits on how many violations are too many. “It’s a judgment call,” said Jan Tarantino, deputy director of CMS’s survey-and-certification group.
This captures everything wrong with government-managed health care, as good intentions are trumped by the reality of surging costs and poor quality. It's not difficult to see what is going on here. If someone were to walk into a typical establishment, be it anything from a shoe store to a Dairy Queen, and found blood encrusted walls or insects crawling on the floors, chances are that person would be walking right back out. Why spend your money to support such filth? The store likely wouldn't have many customers and would soon be out of business (unless it is GM).
So why would people put up with this when it comes to something as critical as dialysis? Simple, they aren't the customer -- Medicare is. The business doesn't have to please the customer, they just have to make sure that Medicare keeps the money flowing. The results are utterly predictable.
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