“Medicare for All” Model Set Back Kidney Care by Stifling Innovation and Access

Published September 11, 2019

If voters want a lesson in how a socialized health care system would work, they should learn how the U.S. health care system treats (or more accurately, mistreats) kidney patients.


Nearly 50 years ago, President Richard Nixon signed a bill that essentially offered government health care to virtually anyone suffering from kidney failure. With the stroke of a pen, the Medicare End-Stage Renal Disease Program (ESRD) was born.


Although government-provided dialysis treatment has saved many lives, innovation in kidney care has either been stagnant or non-existent since the Nixon administration practically nationalized kidney care. Even worse, kidney disease has not budged from being the ninth leading cause of death in the country for those aged 55 and over for the last two decades.  In fact, in 1980, nephritis for that age group was not even ranked as a top 10 killer. In other words, in a country with virtually universal kidney care via the government, kidney disease is getting worse, not better.

Today, the majority of patients with end-stage kidney disease are treated at clinics using hemodialysis machines, which have not changed considerably in 50 years. Hemodialysis attempts to replicate the work of healthy kidneys. The machine removes blood from a patient, filters out the waste, and pumps it back into the body. The process is time consuming and debilitating. Patients typically go to a clinic to sit through three to five-hour sessions, three times a week. Recovery takes time and patients endure any number of health problems, which eventually take their toll. Average life expectancy for a patient  being treated with hemodialysis is five to 10 years.

It sure seems preventing kidney disease as much as possible would be a brilliant idea. Obesity, high blood pressure, and Type 2 diabetes are the leading causes of kidney failure and they are largely preventable through diet and lifestyle change. Since Medicare was expanded to cover patients of any age, the incidence of kidney disease has skyrocketed.  Today, the number of Americans suffering from chronic kidney disease is 37 million, with 726,000 enduring end-stage disease. That is a far cry from the 35,000 patients originally anticipated under the ESRD program.

What drove Americans in 1972 to support Medicare expansion for kidney care was ironically, rationing. Life Magazine profiled the use of “God Committees” when Seattle’s  King County Medical Society in the 1960s appointed a panel of lay persons to determine who would get dialysis because of the limited number of dialysis slots in the area. 

Although “God Committees” no longer exist, the outcomes of kidney care have hardly been universal. A 2017 study found that minorities are disproportionally affected by kidney disease and African American and Hispanic patients, in particular, had a lower likelihood of care before reaching the disease at its end stage.

Today, most dialysis treatment is delivered at clinics dominated by two companies able to manage costs under a single payer system with rising demand. Lack of competition is never good for access and innovation. Unsurprisingly, corruption has run rampant. There have been complaints about lack of quality and ample kickbacks. This year, one company, DaVita Healthcare, agreed to pay $350 million to settle a case for false claims.

Patients can opt for a kidney transplant, which offers double the life expectancy from dialysis. However, there is a 36-month limit on anti-rejection drugs. Transplant patients need these drugs for the rest of their lives. Indeed, patients are going back on dialysis with new kidneys simply because they could not pay for additional drugs.

There is also at-home dialysis, which offers more convenience and perhaps compliance. One  kind of dialysis, peritoneal, cleans blood with a solution through the abdominal cavity. Unfortunately, Medicare payment policies make this difficult (for one, patients must be trained) and providers, for any number of reasons, have not recommended at-home care more broadly.

In advocating his misguided Medicare for All plan, Sen. Bernie Sanders (I-VT) says, “We should be spending money on doctors, nurses, mental health specialists, dentist and other professionals.”  “We” is not “consumers.” “We” is government. And “we” has gotten us to  into the current mess we call kidney care in the United States.

When President Trump announced his long-awaited executive order July 10 on kidney care, he stated it is time to give patients “choice and freedom in health care, ensuring access to the doctors they want, the treatments they need, and the highest standard of medical care anywhere in the world.”

The order involves a three-pronged approach. First, it provides incentives for at-home dialysis and the development of artificial and wearable kidneys. Second, it aims to reduce the incidence of chronic kidney disease with preventative care. Third, it modernizes the organ transplant process. Unlike most organs, kidneys can be procured from live donors, yet there have been obstacles to donors, like insurance coverage for recovery.

The Centers for Medicare and Medicaid Services (CMS) is introducing new payment models to encourage kidney care providers to think outside-of-the-box. Payment incentives and metrics make physicians understandably nervous. Rules and payment systems should not be designed to frighten providers from taking on more complicated cases. Physicians, however, may want to keep an open mind. A shift from decades-old procedures could bring much needed innovation, which doctors would certainly welcome.

The Trump administration has set an ambitious goal for kidney care: reducing the number of Americans with end-stage renal disease by 25 percent by 2030.   

Undoing the “one size fits all” approach is a good first step.