Medicare dialysis program

It serves as the architect, one might say, for legislation that reaches the Senate. Amendments of The Senate Finance Committee deliberated at length, adopted a bill that the Senate passed, and returned a substantially amended bill to the House in the week between Christmas and the new year.

The Senate announced, however, that it had no time to go to conference to resolve differences. Although the legislation contained many provisions desired by members of the House, they rejected the Senate proposal rather than yield on such a fundamental procedural matter.

No bill was passed as the ninety-first Congress adjourned. There were no subcommittees; all committee work was done by the full committee. Deliberately, every three or four years, the committee took up one of the major statutes under its jurisdiction—tax, international trade, social security, or Medicare.

It then devoted great attention to the issues before it many of which had accumulated since the last time they had been addressed , holding extensive hearings on any given subject. Members debated general legislative issues in executive session until consensus on the main provisions was established, and then, within an agreed-upon framework, the legislative and executive branch staff wrote language that could be implemented. Mills seldom sponsored legislation himself.

Rather, he allowed a bill to emerge from the deliberative processes of the committee. The legislation that went to the floor of the House had a bipartisan seal of approval; Mills took great care to ensure that John Byrnes R-Wis. One tradition of the Ways and Means Committee was to hear any citizen who wished to address the committee. Mills did not engage in selective hearings that were restricted to those advocating a point of view or to organizations representing major constituent interests.

Consequently, hearings of the Ways and Means Committee always included statements by a number of interested individuals. The Senate Finance Committee had comparable legislative jurisdiction, which was exercised under the chairmanship of Russell B. Long D-La. Long, however, did not play the same political role in the Senate Democratic leadership as Mills played in the House. On welfare reform, for example, a major element of the social security legislation in , Long favored a.

Abraham Ribicoff D-Conn. The administration's original proposal, the family assistance plan authored by Secretary of Labor Daniel P. Moynihan, represented an intermediate position. Each of the three parties had roughly one-third of the Senate votes. No one was prepared to compromise to assemble a majority, and the resulting three-way deadlock defeated welfare reform. Finally, it is important to note that congressional staff, although fewer in number than today, exercised great influence and were a tightly knit group with close ties to the executive branch.

William Fullerton joined the Ways and Means Committee in as its first professional staff person; in , he was the only such staff attached to the committee. His counterpart in the Senate, Jay Constantine, had joined the Senate Finance Committee in as its first professional staff person on Medicare, Medicaid, and welfare.

Irwin Wolkstein, the bureau 's deputy director for policy, had worked on health insurance issues since before the enactment of Medicare and Medicaid. Fullerton had worked for him at SSA, as had Rettig. This report greatly influenced the proposed legislation of , which, although not enacted at that time, was basically adopted in In short, both committees' staff constituted a group of individuals with strong personal and professional ties to each other and with effective working relationships to the executive branch.

Several features characterized the setting in which the legislation was enacted. First, there was a strong commitment among the members of Congress to pass a bill. They had no desire to repeat the experience of when legislation was not passed because the Senate refused to go to conference. Second, the policy debate focused much attention on national health insurance. Senator Edward M.

Kennedy D-Mass. The Nixon. White House responded with legislation of its own. In a message to Congress on February 18, , President Nixon proposed the National Health Insurance Partnership Act of , one of the most important of the many proposals put forward at that time U.

Congress, House, Committee on Ways and Means, b. There is some feeling that Nixon 's action came out of his fear of the possibility of a Kennedy candidacy for the presidency the following year Rettig, Reflecting this interest in national health insurance, the House Ways and Means Committee, after passing H. Congress, House, Committee on Ways and Means, a. In February , the administration submitted extensive amendments to its original proposal U.

Congress, House, Committee on Ways and Means, In the Senate, although Finance Committee Chairman Long did not favor comprehensive health insurance measures, he did advocate insurance against the catastrophic costs of health care, indicating the broad interest in expansion of the existing Medicare and Medicaid programs.

The legislative agenda in and , however, was dominated by H. This legislation, as noted earlier, dealt with social security, Medicare, and welfare reform. Perhaps the bill's most important amendment to Medicare, marking its most significant expansion since , was the extension of Medicare coverage to the disabled. President Lyndon Johnson had proposed such an extension in , two years after Medicare had been enacted, but then it was regarded as too soon to be seriously considered.

In , however, it had been part of the bill that failed enactment for procedural reasons. Its passage in was a foregone conclusion. The Senate Finance Committee first considered H. Congress, Senate, Committee on Finance, These hearings were limited to administration witnesses and focused mainly on the family assistance plan.

Senator Long noted with asperity that two-thirds of the bill consisted of Senate amendments adopted in He noted that the most controversial feature of the legislation was the welfare reform proposal of the administration, as modified by the House. The Senate committee resumed hearings again in January and February , and the opening statements of Long and Ribicoff foreshadowed the welfare reform deadlock mentioned above U.

Congress, Senate, Committee on Finance, a. That deadlock, and the ensuing controversy and behind-the-scenes negotiations, delayed Senate action on the bill until members had returned to Washington from the summer recess. Despite these maneuverings, the facts were that major legislation amending the Social Security Act was proceeding through both the House and the Senate in and , and the Nixon administration was participating in all aspects of the process.

There was no uncertainty about whether there would be legislation. The only question was the kind of bill a Democratic Congress would send to the White House and its acceptability to a Republican president. The formal legislative history of Section I is quite brief. The provision was not considered by the House Ways and Means Committee in hearings or in any executive session on H. The Senate kidney amendment was added to H.

The joint House-Senate conference committee agreed to the Senate amendment barely two weeks later. On October 30, the brief kidney provision was included in the page bill signed by the President.

The informal legislative history, however, is far more complicated. Congress, House, Committee on Ways and Means, c. Glazer made an official statement for NAPH, and then spoke about his personal situation:. I am 43 years old, married for 20 years, with two children ages 14 and I was a salesman until a couple of months ago until it became necessary for me to supplement my income to pay for the dialysis supplies.

I tried to sell a non-competitive line, was found out, and was fired. Gentlemen, what should I do? End it all and die? Sell my house for which I worked so hard, and go on welfare? Should I go into the hospital under my hospitalization policy, then I cannot work? Please tell me. If your kidneys failed tomorrow, wouldn't you want the opportunity to live? Wouldn't you want to see your children grow up? The most dramatic moment of the hearing, however, came when Glazer was briefly dialyzed before the committee.

This event was widely publicized afterwards and was believed by many to have been decisive in the decision of Congress to enact the kidney disease entitlement. Martin, who consulted William Fullerton, the committee staff person for health.

Neither was enthusiastic; indeed, Martin was afraid of what might happen if Glazer died in front of the committee. Nor did the other members or their staff think it was especially appropriate. Plante remembers that the senior staff aide to Barber Conable R-N. Schreiner and Plante had been lobbying Congress assiduously, seeking support for kidney treatment programs from all sources—the tax committees, the health legislative committees, and the appropriations committees.

They feared that an accident would cancel all the progress they had made, and Schreiner stressed this possibility when he tried to dissuade Glazer from dialyzing before the committee. Given these activities, Schreiner's incredulity was all the greater when he received a telephone call at home on the evening before the hearing. Glazer had arrived in Washington, D.

Barred from attending the hearing by the National Kidney Foundation, which did not wish him to lend its prestige to the event, he sent a Georgetown nephrology fellow, James Carey, to act as attending physician. If any untoward event occurred, Carey was instructed by Schreiner to clamp the blood lines, turn off the machine, and declare that the dialysis session was over.

Several years later, Carey disclosed to Schreiner that Glazer had gone into ventricular tachycardia during the dialysis session before. Carey had immediately clamped the lines.

Indeed, Fullerton recalls that a parent of a child with hemophilia made a far greater impression on the committee. The national press, on the other hand, had been handed a dramatic story and publicized it widely. The myth that Glazer's treatment had been decisive in the decision by Congress to enact Section I had been established. On November 11, one week later, Schreiner and William J.

Congress, House, Committee on Ways and Means, d. Flanigan cited the disparity between the few patients with end-stage renal failure who were actually being treated and the many who could benefit, adding the following:.

Just over two decades ago we did not have the artificial kidney machine, and kidney transplant became a technique just one decade ago. Today we have both therapies because of research, both with and without Government support. These life saving procedures cost money and they save lives. It seems to those of us who each day work in the field of kidney disease that too many years have already gone by without a national program of catastrophic insurance or a National Health Insurance Act with provisions for catastrophic coverage.

The events of the previous week were neither mentioned by the National Kidney Foundation representatives nor raised in the perfunctory questioning after the testimony. The testimony simply added one more statement to the hearing record in behalf of national health insurance.

It was noteworthy, then, when Mills introduced a personal bill, H. Fullerton remembers modeling the bill after Title V, which applies to maternal and child health. This proposed bill, far more than the amendment enacted in late , reveals Mills's thinking about this issue.

What was going on? There were probably at least two things operating. First, Mills, who practically never submitted a personal bill, was signaling his sympathy for action on kidney disease. The degree of his commitment to the precise language of H. Mills had heard from Arkansas constituents and individuals across the country, however, and recognized a genuine problem that needed attention.

Fullerton recalls that the chairman began to get calls during this time from people about to die who needed help. Mills's administrative assistant, Gene Goff, handled the Arkansas constituents and took a personal interest in the issue; Fullerton dealt with the others. It bothered Mills, as it did Fullerton, that the congressman had to get involved with life-and-death matters Institute of Medicine, Second, it was about this time that Mills decided to seek the Democratic presidential nomination, a decision he announced a few months later.

Coincidentally, perhaps, substantial legislation emerged from the Committee on Ways and Means during and —expansion of Medicare to include the disabled and general revenue sharing—flowing from a congressional consensus that Mills was powerful in shaping. The Senate Finance Committee held hearings on H. During this time, the supplemental security income benefit was developed on the Senate side.

Congress, Senate, Committee on Finance, b. In the intervening period, discussions went forward on all aspects of the proposed legislation. Although neither the House nor the Senate version of H.

For example, the Republican Party platform included a plank on the coverage of kidney failure treatment. Unbeknownst to the foundation, Bryce Harlow at the Nixon White House apparently had been responsible for this plank provision on behalf of Mamie Eisenhower, then a member of the Kidney Foundation board.

Following a February visit, E. Lovell Becker, then president of the National Kidney Foundation, wrote to thank Long for meeting with him, Plante, and another Kidney Foundation physician. On February 22, Hartke introduced S. Congressional Record, a. Hartke 's action foreshadowed the events of September, although S.

Plante maintained regular contact with Constantine and Mongan on the Senate subcommittee staff and with Fullerton on Ways and Means during the spring and summer of Although no kidney provision was formally under consideration, it was being discussed as part of a much larger, more comprehensive package of Medicare amendments.

The key discussions at the Senate Finance Committee staff level occurred during this period. Constantine was inclined against a kidney disease amendment. Why favor this treatment, he asked, over the long-term treatment of cancer? Mongan, the physician, counseled against opposing a kidney provision. It was the one situation, he argued, where. He suggested that it be looked at as a pilot for catastrophic health insurance. Constantine yielded; he would not recommend against such a provision if it were offered.

Notwithstanding Hartke's earlier expression of interest, there was little indication by late summer that he might offer a kidney disease amendment to H.

When that possibility arose in early September, Schreiner went to Long, concerned that Long—not Hartke—should receive credit. Let Hartke do it; we may need him for something else. The Senate Finance Committee report of September 26 revealed the complexity of legislation that dealt, among other things, with old age, survivors, and disability insurance, Medicare, Medicaid, maternal and child health, social security benefits, supplemental security income, jobs for families, child care, aid to families with dependent children, and general revenue sharing; the document was nearly 1, pages long.

Listed first among the health-related provisions of the House bill that were basically adopted without change by the Senate was the extension of Medicare coverage to disability beneficiaries U.

In this provision, the committee was responding to the obvious needs of the disabled, who used medical services at greater rates than those who were not disabled but who were also much less well off financially. On the other hand, by requiring that an individual be disabled for 24 months before Medicare eligibility began, the provision regulated the share of the costs to be borne by Medicare.

The Finance Committee added 49 provisions to the House bill. The two most prominent were professional standards review organizations and coverage of maintenance drugs by Medicare. The former would be enacted; the latter would be rejected.

There was no provision for kidney disease included in the bill reported out by the committee. In what must be the most tragic irony of the twentieth century, people are dying because they cannot get access to proper medical care. More than 8, Americans will die this year from kidney disease who could have been saved if they had been able to afford an artificial kidney machine or transplantation.

These will be needless deaths —deaths which should shock our conscience and shame our sensibilities. We have the opportunity now to begin a national program of kidney disease treatment assistance administered through the Social Security Administration, and I propose that we take that opportunity so that more lives are not lost needlessly. The last sentence clearly anticipated the events that would follow in swift succession.

The National Kidney Foundation representatives—Schreiner, Plante, and Lovell Becker, the current president—had no reason to expect that a kidney provision would be included in the Senate bill as the Finance Committee took it to the Senate floor in the final week of September. They flew off to San Francisco on Friday, September 29, to attend a major conference on kidney transplantation organized by Samuel Kountz, the transplant surgeon at the University of California, San Francisco.

Before leaving, they made a precautionary check and were assured that nothing was likely to happen. On their arrival in San Francisco, however, the foundation representatives received a telephone call from Washington indicating that Long had agreed to let Hartke offer a kidney entitlement amendment the following morning, Saturday, September 30, and their presence was requested.

Schreiner, who was already committed to a dinner at Norman Shumway 's, the Stanford heart transplant surgeon, and scheduled to deliver a paper at the transplant meeting, remained in San Francisco. He also discussed with Mongan the precise wording of the amendment, which had not been entirely worked out. The Senate, after perhaps 30 minutes of floor debate, voted 52 to 3 in favor of the Hartke amendment, with 45 senators absent and not voting Rettig, Was the Senate action capricious or a considered step of the world 's greatest deliberative body?

From the discussion at the Institute of Medicine's December workshop, several factors stand out. First, the extension of Medicare coverage to the disabled was an essential prerequisite for a kidney disease amendment. Without it, a special provision for kidney disease would have violated basic equity. Given the disability framework, however, chronic kidney failure could be viewed as a disabling, life-threatening condition.

Second, Russell Long's long-standing interest in insuring people against the costs of catastrophic health problems made him responsive to the financial implications of kidney disease, especially for working individuals. Of the staff, Mongan was pivotal. Do you currently have medical coverage. Although an ESRD diagnosis. What your insurance company does not. Carriers do not routinely include ambulance transports for beneficiaries with.

However, this does not influence our. Dec 16, Aug 6, Apr 18, These figures do not include additional costs for copayments and. Jan 19, Dec 11, Medicare Part B covers medical expenses like doctor. Jan 8, The rest of the year, agents are available Monday-Friday from 8 a. Download and print this frequently-asked-questions sheet.

You may want to keep it handy when you talk with an educator. Several resources are available to help you understand your insurance options and enroll in a plan. Disclaimers: This resource is intended to provide DaVita patients with information about some of the available third party resources for comparing and enrolling in Medicare Advantage plans.

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Download Now. Medicare Options for Dialysis Patients. Talk to an Educator. Talk to an Educator Need help understanding plan options and coverage differences? Medicare Advantage What is Medicare Advantage? What is Original Medicare? What is Medicare Advantage? Extra Benefits. Regardless of the model used, these strategies have promise for improving quality and reducing costs by changing the way physicians and their practices care for their patients. Over the past 40 years, Federal administrators have focused more attention on the Medicare Program than on Medicaid.

Nonetheless, Medicaid today is a far different—and dramatically larger—program than it was in its early years, and, as its enrollment has expanded, eligibility is no longer as tightly connected to welfare status as it was at Medicaid's start. The unique nature of the Federal-State partnership for Medicaid has led to substantial diversity in program operations, including eligibility levels and delivery systems, across the States.

The local infrastructure and efficiency of a State-based program remains attractive, but translation of innovation from one State to the next has been slow. Moreover, although a few States have used Medicaid expansions to reduce significantly their rates of uninsurance, most States have lacked the financial capacity and political will to follow their lead.

In its role overseeing the State programs, CMS should continue to push the States to expand coverage and improve quality in Medicaid, although the financing challenges will be substantial. Additionally, rapid availability of State Medicaid data, similar to the planned rapid availability of Medicare data, will facilitate cross-State comparisons.

We see great opportunities for expanding the role of Medicaid in working to improve quality of clinical care across the Nation. CMS also will need to consider its role as a convener of private industry to advance data use to improve medical care. In this area, data aggregation and analysis should expand to include data from Medicaid and private insurance companies. Providers of medical care in America answer to a large number of different payers that all collect data on patients.

Those data are rarely aggregated to inform public policy or individual clinical care. CMS can take a leadership role to expand health information systems and the use of data in routine clinical care.

CMS will need to work with the Agency for Healthcare Research and Quality and private insurance companies to accomplish this goal. Private and public health insurance financing emerged in an era in which most of medicine was focused on care for acute illnesses. Largely because of the successes in acute care and resultant rises in longevity, a large share of the current health care dollar is now spent on patients with chronic illnesses.

The optimal care for chronic illness requires a comprehensive approach that includes self-management support, community resources, decision support, information systems, and a redesigned delivery system Wagner, Such a model of care requires creative financing strategies to motivate high quality care. For example, ensuring access to self-management support education, telephone, and E-mail consultation will require a different financing structure Spann, Current demonstrations in chronic disease management and pay-for-performance are a start, but our health care system has a long way to go before incentives are aligned to support chronic illness care.

CMS policy has tremendous influence on clinical medicine. Although the initial statutes declared otherwise, it did not take long to show that regulation was a key component for ensuring and promoting quality.

CMS policy has evolved over the years to now focus on quality improvement and partnerships across governmental agencies and private industry. CMS should continue to pursue its responsibility for providing access to needed care and ensuring quality. As such, we expect CMS will continue to provide further incentives for high quality care and to invest resources toward improving substandard care.

By pursuing this agenda, we believe that CMS can apply appropriate tools to implement the MMA, devote more attention to Medicaid, work with private industry to develop the data infrastructure to move medical care forward, and change the paradigm in financing to support chronic illness care. We would like to thank John Spiegel and Kathleen Lohr for helpful comments on a draft of this manuscript.

Reprint Requests: Darren A. DeWalt, M. E-mail: ude. National Center for Biotechnology Information , U. Health Care Financ Rev. Darren A. DeWalt , M. Carey , M. Roper , M. Copyright and License information Disclaimer. Copyright notice. Abstract The legislation that established Medicare and Medicaid declared that the Federal Government would not interfere in clinical medicine. Introduction Notwithstanding what Congress wrote in , the Medicare and Medicaid Programs have enormous influence over the practice of medicine.

Background Organized medicine staunchly opposed the passage of Medicare, in part to keep government out of clinical medicine. Quality Improvement Organizations and Effectiveness Initiative In light of skyrocketing costs in Medicare and Medicaid, as well as concerns over fraud and abuse, Congress decided by the early s that closer oversight of the medical care system was necessary.

Unique Role of Medicaid Programs On the Federal level, Medicare has received much more attention than Medicaid over the past 40 years, a consequence of Medicaid's decentralized administrative structure that gives States primary responsibility for its operations. Implications of Involvement in Clinical Medicine We have outlined selected examples of how Medicare and Medicaid have influenced clinical medicine.

Conclusion CMS policy has tremendous influence on clinical medicine. Acknowledgments We would like to thank John Spiegel and Kathleen Lohr for helpful comments on a draft of this manuscript. Hemodialysis International. Health Care Financing Review. Health Services Research.

Open Access in Primary Care. Disease Management and the Organization of Physician Practice. Journal of the American Medical Association. American Journal of Kidney Diseases.

Weighing the Evidence for Expanding Physician Supply. Annals of Internal Medicine. The American Journal of Medicine.

American Journal of Medicine. Erythropoietin: The Promise and the Facts. Kidney International Supplement. Once Health Regulators, Now Partners. Washington Post. Health Affairs.