Death Panels

A Story of Government Intervention in Health Care

Whenever I heard the phrase "Death Panels" in discussions about health care issues, I would think of
my friend Sue from St. Paul. I met Sue at the transplant clinic where her husband had just received a kidney transplant.
The story begins in April of 1974. I was 31 years old and recently admitted to a hospital in Minneapolis with kidney failure. I was receiving dialysis at Hennepin County General Hospital (later renamed Hennepin County Medical Center); without dialysis I would survive two or three weeks. A transplant was possible, but due to high levels of a kidney damaging antibody in my blood, I would need to wait twelve to eighteen months for a new kidney. I had good medical insurance, but there was a lifetime dollar limit. Dialysis and transplantation were very costly then as now. So it might be a year; it might be eighteen months, but I was certain that, without some miracle, I was going to hit that lifetime limit. There was also uncertainty about my ability to work at all or keep my job and whether I would be able to keep my health insurance. My wife Bonnie was working, but her job had no benefits like health insurance.

HR1

While I was in the hospital in Minneapolis, some friends, coworkers and benefactors back in Sioux Falls started a fund drive. As I was talking to a social worker at the hospital, I mentioned the fund drive. The social worker said, "Well you won't need that." She then explained that the miracle I thought I needed had been signed into law by President Nixon in 1972. That miracle was Public Law 92-603, Social Security Amendments of 1972, but commonly known as HR1. On signing the law, President Nixon's statement added "...and it extends Medicare coverage for kidney transplants and renal dialysis--the cost of which is beyond most individuals--to workers under social security, and their dependents."(1)

The God Committee

 How HR1 came to be leads back to my friend Sue. Several years before, Sue had been a member of a health resource allocation committee aka "God Committee", a committee to allocate the scarce resources for kidney failure patients. When there was an opening for a new patient at a dialysis center, the committee would decide which of the waiting patients would be chosen to fill that opening. The committee decisions, at that time, were literally life or death. One could call the committees, as Sarah Palin so succinctly described: a "Death Panel".
To understand the "God committees", we have to go back to 1962 and Dr. Belding Scribner of the University of Washington. Dr. Scribner developed the Scribner shunt, a medical breakthrough making it possible for patients to receive repeated dialysis treatments. Prior to this device a patient in need of acute dialysis could survive for perhaps six weeks before they had exhausted all the possible sites for accessing their blood stream. With the Scribner shunt, dialysis could be a chronic procedure that could last many years. At the time, an estimated 10,000 Americans were dying from renal failure each year.
In January 1962, the Artificial Kidney Center at Swedish Hospital in Seattle opened as the only dialysis center in the country. Three treatment slots were available, an insufficient number for the 60 or so patients in the surrounding area who needed them. Scribner reasoned that choosing among medically eligible candidates was a social concern, not a clinical decision; as such, the burden of choosing should be shared by the public.

In 1962, Seattle's Swedish Hospital established the Admissions and Policy Committee of the Seattle Artificial Kidney Center. It was charged with deciding which terminal patients would get access to the artificial kidneys. The seven committee members, a lawyer, a minister, a housewife, a state government official, a banker, a labor leader, and a surgeon, were unpaid, and anonymous. The criteria they considered were the prospective patient's net worth, nature of occupation, education, marital status, church attendance, potential ability to work, and how many dependents the patient had. 

In November 1962 Life magazine ran a story written by Shana Alexander about the committee. The article, "They Decide Who Lives, Who Dies: Medical miracle puts moral burden on small committee,” drew considerable national attention to the controversy unfolding in Seattle. The exposé sparked a national debate on the allocation of scarce dialysis machine resources. Alexander gave a speech thirty years later titled "Covering the God Committee"; the name stuck from that point on. 

As the dialysis technology was spreading across the country, the need for selection committees continued. The new committees tended to be less explicit about judging human worth than the first Seattle effort. Doctors and hospital administrators had learned from Seattle experience; avoid the perils that come with high visibility in choosing who would receive treatment. The decisions were now usually made by estimating which patients could fulfill the demands of dialysis treatment, including a rigorous diet, careful hygiene, and faithfully meeting dialysis schedules several times a week, in addition to the likelihood of returning to a productive role in society.(2)

At the same time many hospitals struggled with the prospect of gearing up for dialysis or adding dialysis capacity to meet the demand of end stage renal disease (ESRD) patients. Many of these patients would survive long past their ability to pay: while once accepted for treatment, they could not ethically be removed for lack of funds. This scenario was hardly an incentive for increasing the supply of dialysis units.

Between 1962 and 1972, lobbying by physician groups and other advocates were effective in persuading Congress to establish Medicare based universal funding for dialysis. Virtually overnight the supply of dialysis machines and facilities increased. At the same time the agonizing ethical predicaments of allocation disappeared, along with the "God committees" used to remedy them." (2)

What Does Any of This Have to do with Obamacare

Arguments against the Affordable Care Act include that it is a government takeover of health care, it would result in rationing and "Death Panels", that the mandates are unfair and unconstitutional, and that it will be too expensive and bankrupt the country. My experience with the government intervention in end stage renal disease makes me believe that these arguments are fallacious. 

• Government Takeover, in the case of ESRD, no dialysis centers were taken over by government. The majority are now owned by private enterprise, the rest are owned by non-profits. 
• Death Panels, in the case of ESRD, were not created as the result of government intervention; in fact the "God committees" disappeared.
• Rationing, in the case of ESRD, was not intensified; it was alleviated with government intervention.
• Mandates, in the case of ESRD, were effective, constitutional, and universally accepted; in this case the mandate is the payment of Social Security and Medicare contributions in the form of payroll deductions. This week the Supreme Court will announce their decision on constitutionality; fairness should not be in question when everyone is treated the same. 
• Expense, while ESRD programs are expensive (nearly 40 billion dollars per year) America spends more than 2 trillion dollars each year on health care.

The Rest of the Story

As for me I am thankful every day for Medicare and government intervention in health care. After nearly 37 years with a transplanted kidney I should be. Could I have survived the eighteen months before the transplant without the Medicare coverage? I can't say for sure. I do know that HR1 enabled the opening and expansion of dialysis centers across the U.S. including Sioux Falls.
I am also thankful to my sister Kris, who gave me a kidney; to my wife Bonnie, who rescued me from that Sioux Falls hospital and stuck with me through it all; and to the many doctors and nurses.

References

1 Nixon, Richard, 389 - Statement on Signing the Social Security Amendments of 1972. October 30, 1972
 the American Presidency Project, http://www.presidency.ucsb.edu/ws/index.php?pid=3673#ixzz1y5rsJOgp
2. Satel, Sally, M.D., "The God Committee: Should criminals have equal access to scarce medical treatments?" Slate.com 2008, http://www.slate.com/articles/health_and_science/medical_examiner/2008/06/the_god_committee.2.html

Sidebars

In 2008
$2.3 Trillion Spent on Health Care
End-stage Renal Disease (ESRD) Prevalence (2008): 547,982 U.S. residents were under treatment 
382,343 U.S. residents with ESRD received dialysis
Number of kidney transplants performed: 2008: 17,413
Cost for the ESRD program (2008): $39.46 billion in public and private spending
Incidence (2008): 112,476 U.S. residents were new beneficiaries of treatment
Mortality (2008): Among U.S. residents with ESRD, there were 151.7 deaths per 1,000 patient years. There were 88,620 deaths in all patients undergoing ESRD treatment.