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I. INTRODUCTION Everyone was unhappy with the federally funded program. The dialysis providers felt strangled by the increased costs of the service. The patients were concerned about the reduction in quality. The federal policymakers were upset about the rising costs of the program. The public did not want to pay for the program with increased taxes. Some people in the United States argue that dialysis is exactly the kind of life-sustaining technology that should not be developed. They believe that it has a limited benefit and a high cost. The dialysis community argues that dialysis has been successful in saving thousands of lives. But they point out three areas needing reform: (1) dialysis reimbursement levels, so they will be sufficient to support the costs of excellent patient care; (2) the quality of patient care, so patient illness and death rates will be reduced; and (3) guidelines for starting or stopping dialysis, so only patients who have a good chance of benefiting from it will receive it. II. HISTORICAL BACKGROUND The earliest organ-procurement organizations (OPOs) in the United States were founded around 1970. They were local organizations, responding to the needs of local kidney-transplantation teams for tra