program is cited as a landmark—of a policy not wisely calculated from a fiscal perspective and of a disease-specific approach that is inappropriate for the public financing of medical care because it is unfair to those who suffer from other ailments.

It must be understood, however, that the approach of the United States to coverage of population groups for medical care has followed an incremental and sometimes disease-based pattern. For example, in the nineteenth and twentieth centuries, public facilities for treatment of mental illness and mental retardation were made available. Thus, the kidney treatment legislation was within the realm of American policy tradition for health care. Furthermore, this is not the first time that long-term program costs have been underestimated by government. We do it continually, with the overruns on Medicare and Medicaid as even more dramatic examples of our failings.

Thus, a misreading of the traditions of American health policy accounts for one source of criticism of federal funding of kidney disease treatment. But there is another facet that helps explain the place of the kidney legislation as a cautionary tale in the lore of health policy—the ambivalent feelings generated in us by its technological mainstay, the dialysis machine. It is a power that saves and a power that costs; it makes life possible, but that life can be a source of misery. The evocation of such multiple and conflicting images creates ambiguity and perplexity regarding appropriate clinical use and public policy. The dialysis machine has become a metaphor for modern technological medicine, and deciding the right response to this whole new area of treatment continues to elude the makers of policy and holders of political power in the United States.



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