The purpose of this paper is to review how and why Congress enacted this historic entitlement, the first (and perhaps the last) designed to cover a particular diagnosis.

A HISTORICAL FOOTNOTE

I was asked to write this paper in the fall of 1989. Because I had previously written about the antecedents to and legislative history of the 1972 Medicare kidney amendments (Rettig, 1976), I was able to suggest the approach that has resulted in this paper. A workshop was held on December 18-19, 1989, at the National Academy of Sciences, with the principals involved in the 1972 legislation.1 The workshop was chaired by Carl W. Gottschalk and supported by Institute of Medicine (IOM) staff. Participants were provided with historical materials before the meeting; several brought additional documents from personal files. The discussion focused on how Congress came to adopt the Medicare kidney disease entitlement. The meeting transcript was used to prepare a draft of this paper. The draft paper was reviewed by all participants and was also discussed at a meeting of the project committee at the National Academy of Sciences Beckman Center in March 1990.

Memories are often unreliable sources of details about events that occurred many years ago. As a result, specific factual claims have been corroborated from documented sources. The workshop basically served as a lengthy interview with a number of key individuals that clarified the major assumptions, underlying processes, and contextual factors that influenced the legislative outcome.

ANTECEDENTS TO THE 1972 LEGISLATION

A brief review of the evolution of federal government policy regarding hemodialysis and kidney transplantation is useful at this point. An extended treatment can be found in the literature (Rettig, 1981, 1982). In 1944, in Nazi-occupied Holland, Willem Kolff first succeeded in prolonging the life of a patient using his primitive artificial kidney machine. (The surviving individual was his seventeenth attempt, all the others having died.) After the war, Kolff sent four of his machines to Europe and the United States, where they provided a basis for successful treatment of acute renal failure in the Korean War.

In 1960, Belding Scribner of the University of Washington in Seattle, working with Wayne Quinton, an engineer, invented a permanent vascular access device and placed his first patient on long-term, continuous, intermittent hemodialysis. That patient, Clyde Shields, lived 11 years. In 1963, when the hemodialysis procedure for treating



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