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April 10, 1996

The Social Contract and the Treatment of Permanent Kidney Failure

Author Affiliations

From RAND, Washington, DC.

JAMA. 1996;275(14):1123-1126. doi:10.1001/jama.1996.03530380065033

MEDICARE, enacted in 1965 to provide health insurance for the elderly, was extended in 1972 to the disabled under 65 years of age. The disability provision, in turn, became the basis for Medicare coverage of those with end-stage renal disease (ESRD)—regardless of age—who were "deemed to be disabled." Eligibility for this entitlement requires that an individual be diagnosed as having ESRD and be fully or currently insured under Social Security, or be the spouse or dependent child of an insured individual. An estimated 92% to 93% of the US population is thus covered for ESRD treatment. Congress justified this near-universal, disease-specific entitlement partly in the expectation that it would adopt some form of national health insurance in 1973 or 1974.1

Friedman finds Medicare's ESRD a "splendid model" of health care.2 His view of the matter as an international horse race in which "we're No. 1" raises some interesting