The United States may not have the Medicare-for-all system Democrats are calling for. But get this: It does have dialysis for all.
And the Trump administration is trying to make the expensive and suboptimal program work a lot better for the half-million Americans who rely on it.
Kidney dialysis — a process in which a machine removes a patient’s blood from their body, cleans it and then returns it to circulation — is the sole medical service Medicare pays for regardless of someone’s age. That’s been the case ever since 1972, when President Richard Nixon signed a bill ensuring the lifesaving process would be made available to anyone who needs it.
So virtually anyone in the United States with end-stage renal disease can get dialysis. That’s a good thing. But it also means dialysis consumes a huge portion of Medicare’s spending — about 20 percent of all services paid under its traditional fee-for-service program.
And because there have been virtually no reforms in 50 years to how Medicare handles patients with kidney disease, far too many receive dialysis in clinics rather than at home, and far too few are able to access kidney transplants, a much cheaper and healthier long-term solution.
President Trump and his top health officials announced yesterday they’re trying to change that with a bucket of initiatives designed to move dialysis patients away from commercial centers and into homes, improve early screening for kidney disease and double the number of kidney transplants performed in the United States.
“Crucially, our new system will ensure that more patients undergoing dialysis can do so from the comfort of their own home,” Trump said in an address at the Ronald Reagan Building, where he signed an executive order laying out the directives.
“And doing this from the home is a dramatic, long-overdue reform — something that people have been asking for many, many years … so many things don’t get done in government, but now we’re getting them done,” he said.
Republican National Committee Chairwoman Ronna McDaniel:
With nearly 100K Americans waiting on kidney transplants, @realDonaldTrump is taking an innovative approach to deliver new treatment options for major diseases.— Ronna McDaniel (@GOPChairwoman) July 10, 2019
Now patients will receive higher quality care at an even lower cost!pic.twitter.com/ftB3jNB2Y9
It’s hard to overstate the toll of kidney disease on health-care spending and on the longevity of Americans, especially those with diabetes, high blood pressure, obesity and heart disease, who are at higher risk. A typical dialysis patient costs Medicare about $89,000 per year, and their average life expectancy is five to 10 years. Kidney disease is the ninth-most-common cause of death in the United States.
And while in-home dialysis is far cheaper and more comfortable, as it can be delivered while patients sleep, just 12 percent of patients receive the procedure in that type of setting. That’s a sharp contrast to other countries, such as in Guatemala, where 56 percent of patients receive it at home, Health and Human Services Secretary Alex Azar noted to reporters. In Hong Kong, he said, 85 percent of dialysis patients use that method.
Politico's Joanne Kenen:
i covered health care for many years before i really understood how awful life on dialysis is – how ill people remain while on it – and how screwed up the incentives for better care were (even bad by screwed up US incentives standards) Will be watching how/if this changes https://t.co/xUu8gpVoKh— Joanne Kenen (@JoanneKenen) July 10, 2019
Senate Finance Chairman Chuck Grassley (R-Iowa):
2day Pres Trump signed a new exec order that will help Americans on dialysis make more kidneys available to ppl who need them most More than 700k Americans need a transplant or dialysis to survive This will help them & their families— ChuckGrassley (@ChuckGrassley) July 10, 2019
Bloomberg White House reporter Jennifer Jacobs:
“The kidney has a very special place in the heart,” Trump says just before signing an executive order on kidney health care. pic.twitter.com/72uaiw6oS3— Jennifer Jacobs (@JenniferJJacobs) July 10, 2019
Craig Garthwaite, director of health care at the Kellogg School of Management at Northwestern University:
I applaud HHS for working to improve U.S. renal care.— Craig Garthwaite (@C_Garthwaite) July 9, 2019
The dialysis space is the clearest example of "the folly of rewarding A, while hoping for B"
We want patients to get early treatment for chronic kidney disease and make informed choices. That's not what we pay for (1/5)
“Right now, the U.S. system creates incentives for clinic-based hemodialysis,” my Washington Post colleagues Lenny Bernstein and Kimberly Kindy report.
“Two companies, Fresenius Medical Care and DaVita, dominate the lucrative market. Physicians generally are reimbursed at higher rates for care of dialysis patients than for treatment of patients with kidney disease who do not yet need dialysis,” they write. “And Americans are not accustomed to taking care of themselves at home, something health care providers often discourage.”
Both companies gave positive but temperate responses. Bill Valle, chief executive of Fresenius Medical Care North America, said the company is “committed to working to achieve the broader goals of expanding access to home dialysis, transplantation and new models of value based care for chronic kidney disease.”
A DaVita spokesman said the new initiatives would support the company’s investments to further kidney disease prevention, encourage home kidney care and improve kidney transplantation rates, my colleagues report.
Andy Slavitt, President Obama's former administrator of the Centers for Medicare and Medicaid Services:
Care of kidney patients has been broken in the US for a long time, plagued with a corporate duopoly & a lower income minority population losing out.— Andy Slavitt (@ASlavitt) July 10, 2019
Other countries do it better. Kudos to @CMSGov, @HHSGov & @AdamCMMi for doing something about this. Announcement coming today. 1/
Today the majority of Americans with kidney disease die on Sunday night.— Andy Slavitt (@ASlavitt) July 10, 2019
The reason why?
Dialysis is traditionally provided on a Monday-Wednesday-Friday schedule. People don’t survive the weekend.
Which is why home dialysis while sleeping is the best standard of care. 3/
There is one law that makes this new change possible.— Andy Slavitt (@ASlavitt) July 10, 2019
The same law that requires people with pre-ex conditions get coverage.
Without it, there is no authority to do this.
Republican lawyers w Trump’s support are arguing in court to strike the entire law down today.
A key to treating kidney disease is discovering it early on. But because patients don’t experience symptoms until late in the game, officials say as many as 40 percent of patients with kidney disease are undiagnosed. It’s an illness doctors rarely prioritize, said Holly Kramer, president of the National Kidney Foundation.
“You really have to lean into those patients and spend a lot of time with them, but there is no financial reimbursement for that extra time you’re spending with those patients,” Kramer told me.
AHH: Our Post colleague Christopher Rowland reports about a woman fighting to get the $2.1 million gene therapy recently approved for her daughter’s spinal muscular atrophy covered by health insurance.
Lauren Sullivan is working on an insurance appeal after UnitedHealthcare said it wouldn’t cover the gene therapy, Zolgensma, that received government approal in May. Sullivan told Christopher: “There’s a lot of screaming into the void around here.”
The questions over who gets treated by a cutting-edge therapy have raised “uncomfortable medical, financial and ethical questions” and “carries deep implications for access to future gene therapies.”
The insurer says Sullivan’s daughter, who has a milder form of spinal muscular atrophy, is not sick enough to be covered for the treatment, an experience that’s “reflective of a partially restrictive approach to coverage by insurance companies in the second month since Zolgensma won approval, according to a financial analysis released last week," as our colleague writes. Some insurance companies are limiting coverage, which Bernstein analyst Ronny Gal said was a signal that payers are frustrated with the high cost of the treatment.
OOF: The White House is pulling away from one of the major elements of the Trump administration’s plan to lower drug prices: It will no longer change how rebates are collected by pharmacy benefit managers, the middleman that negotiates discounts for prescription drugs in a process often derided as opaque.
"Based on careful analysis and thorough consideration, the President has decided to withdraw the rebate rule," White House spokesman Judd Deere told Axios’s Caitlin Owens.
Deere added: “The Trump administration is encouraged by continuing bipartisan conversations about legislation to reduce outrageous drug costs imposed on the American people, and President Trump will consider using any and all tools to ensure that prescription drug costs will continue to decline.”
While critics of the plan said the proposal – which would have banned PBMs from keeping negotiated rebates for themselves in Medicare and Medicaid – would not have forced drug companies to lower prices, the decision not to pursue the plan will put pressure on the pharmaceutical industry that points fingers at the PBMs for high drug costs. The move is also a welcome sign for PBMs, of course, and insurance companies, Caitlin adds.
OUCH: During an emotional hearing before a House Oversight and Government Reform Subcommittee, witnesses pressed lawmakers about the conditions at immigration facilities, and one Guatemalan woman told lawmakers her daughter allegedly died of a viral lung infection as a result of “neglect and mistreatment” in a U.S. immigration jail.
The hearing “reflected the incendiary tensions between Democrats and the White House over the influx of families and unaccompanied minors at the border,” our Post colleague Maria Sacchetti reports. “Among the witnesses were lawyers and advocates who described squalid, cramped conditions at U.S. border facilities. Their reports have stoked outrage among those who believe the Trump administration’s immigration policies have led to children lingering in holding cells that weren’t designed for long-term detention, in the care of border authorities who are ill-equipped to care for minors.”
The discussion also included the types of facilities for children, which can range from air-conditioned cells to vast rural compounds. At the shelters run by the Department of Health and Human Services for unaccompanied minors, some will stay for weeks or months because they must be released to a parent or vetted sponsor.
“Such shelters are not meant to be akin to jails and have typically included educational and recreational opportunities to the children they hold,” Maria writes, noting some of those services were recently cut because of budgetary constraints. The recent passage of a $4.6 billion border bill is meant to improve conditions at facilities by providing funding for food and medical care.
— Meanwhile, Rep. Rosa DeLauro (D-Conn.) is planning to lead a group of lawmakers on a House Appropriations subcommittee to visit a shelter in Florida for unaccompanied immigrant children.
The visit, set for Monday, comes ahead of a planned oversight hearing by the House Appropriations subcommittee on labor, health and human services, and education on the program by the Department of Health and Human Services' Office of Refugee Resettlement that oversees unaccompanied migrant kids.
“Too often, standards of care have been ignored, and children have languished in warehouse-like situations for months without being put into a sponsor’s care,” DeLauro said in a statement. “And many kids recently had their access to education, legal services, and recreational activities cut. That is wrong, and it is not how we should be treating kids in the United States.”
— Disagreements have emerged over a plan from Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) to address surprise medical bills, even though there has been bipartisan support around the issue as well as support from President Trump.
Those rifts could present a hurdle as lawmakers try to pass such a proposal this month, the Wall Street Journal’s Stephanie Armour and Kristina Peterson report. Alexander, chairman of the Senate Health, Education, Labor and Pensions Committee, has reportedly been hoping to get the plan on the Senate floor for a vote this month.
“But fault lines have emerged over the Senate proposal, centered on whether hospitals or doctors should take a financial hit and how to settle disputes. Legal hurdles also are cropping up,” Stephanie and Kristina writes. “The challenges come as hospitals, doctors and other industry groups fiercely defend their turf. Getting a bill to Mr. Trump now appears uncertain despite rare bipartisan agreement on the need for a legislative fix.”
— The House Rules Committee added a provision to a defense spending bill this week to allow all government employees to continue to receive their regular salaries for parental leave or leave for other family-related purposes, our Post colleague Eric Yoder reports.
Currently, federal employees are unpaid for such time away, and some people have used paid vacation or sick time when they’ve needed to take parental leave or for other family reasons.
“The provision essentially changes from unpaid to paid the time available to most federal employees under the Family and Emergency Medical Leave Act,” Eric writes. “That law provides 12 weeks of leave, including for the birth, adoption or foster placement of a child; care for a spouse, child or parent with a serious health condition; or the employee’s own serious health condition.”
The measure will now be part of the defense bill when the full chamber takes a preliminary vote on the bill. Meanwhile, the Senate has approved its own version that does not include federal employee leave policies.
Rep. Carolyn B. Maloney (D-N.Y.), who offered the amendment, said the federal government “should be a model employer, and this bill will help take a big step forward allowing employees to appropriately care for themselves or their families without worrying about job security.”
— And here are a few more good reads:
- The House Oversight and Reform Committee holds a hearing on childhood trauma.
What you need to know about disgraced billionaire Jeffrey Epstein: