The Debate Over Medical Costs

The cost of the End-Stage Renal Disease (ESRD) program has attracted much attention in the lay press. The thrust of this coverage has been at the one billion dollars spent to keep 50,000 patients alive. The recent report that more than 40% of ESRD patients are incapable of a level of physical activity beyond that of caring for themselves has brought further public scrutiny to the program.

This issue is a major one and deserves extensive debate. Inimical to such a discussion is the dismal state of most medical reporting. When contemplating medical coverage by the media I am reminded of George Bernard Shaw’s comments about the state of music criticism in late 19th century England. Editors were so unconcerned with the subject that they assigned people with no background in the field to cover it and made no effort to check if their reports were accurate or verified.

Similarly, most medical reporting makes use of information printed in medical journals with no attempt at critical review of the content. Even more serious is the tendency to interview one “expert” and then present his views without either critical review or resort to another source. Such reportorial techniques would never be tolerated by the political or international editor.

If the issue of the cost of the ESRD program is to be understood it must be placed within the entire context of modern medical care. A series of important questions must be answered – as things now stand they have not even been asked.

What do the people most involved think? One has only to look at the outrage that greeted the recent suggestion that the food stamp program be reduced to imagine the reaction to the decision to let poor people with chronic renal disease die while those able to pay for dialysis live. Noteworthy about the study of the quality of life of patients on dialysis is that it was based entirely in physicians’ assessments. No one asked the patients what they thought. My impression is that almost all of them prefer treatment to death.

What about other expensive health programs? ESRD consumes only a small part of the health dollar. Despite incessant propaganda to the contrary, almost no progress has been made towards a cure of cancer. Indeed, Seldin has said “the conquest of cancer is a laudable social goal, but its realization on the basis of present theoretical knowledge would be akin to charging pre-Newtonian physics with the responsibility of designing and fabricating an atom reactor.” The most recent data available from the National Cancer Institute show no decline in cancer deaths over the past 50 yr. I have yet to see anyone suggest that we curtail cancer therapy since it is cost ineffective. One cannot, however, meaningfully discuss the ESRD program without including this issue.

What about coronary artery bypass surgery? Its effectiveness is hotly debated. What about geriatric medicine? Why spend billions of dollars on older people whose likelihood of rehabilitation decreases with every day? Most internists spend a major portion of their time caring for people who have diseases with little hope of rehabilitation. I offer no opinion how these issues should be decided, only the hope that they be debated in the context of the entire problem of dealing with chronic disease in an aging population.

The decision as to whether to curtail funding for the treatment of ESRD should not be an isolated one. It should be made as part of an evaluation of the desirability of spending large sums on the management of all chronic diseases for which there is no cure available. In other words, if no coordinated health planning develops in this country (a development as likely as finding a cure for cancer this year) decisions concerning the allocation of resources for medical treatment will be made the same way those regarding the construction of dams and other pork barrel projects are made. Lobby will be pitted against lobby. A full public debate of health expenditure is mandatory if intelligent decisions are to be made. A future issue of Seminars in Nephrology will examine the ESRD program against this background.


1. Gutman RA, Stead WW, Robinson RR: Physical activity and employment status of patients on maintenance dialysis. N Engl J Med 304:309-313, 1981

2. Seldin DW : Specialization as scientific advancement and overspecialization as social distortion. Clin Res 24:245-248, 1976

3. Ca 31:18-19, 1981

Neil A Kurtzman, MD