Will GOP attack on Obamacare foil good plans to better kidney disease care?

kidneysnatlinstitute-241x300More than 37 million Americans who suffer from chronic kidney disease soon may see big changes in the way their disabling condition gets treated, potentially also reducing the $100 billion that the federal Medicare program pays for care of the body’s crucial blood cleaning organs.

President Trump issued an executive order calling on the federal government to use all means possible to attack kidney disease in three key ways:

  • Reduce the number of patients who suffer from kidney failure;
  • Slash how many Americans undergo burdensome and expensive dialysis treatment at dialysis centers;
  • Increase the availability of kidneys for transplant.

To accomplish what experts are calling ambitious and transformational actions in kidney disease care, the administration will be tackling politically powerful, profit raking, and entrenched special interests, including giant firms that have an iron grip on the industry that has grown up around dialysis treatment and advocacy groups that have a similar lock on the available kidneys for transplants.  Trump and the GOP also may have to overcome their aversion to the Affordable Care Act — under attack again now in the appellate courts — to accomplish their goals.

The president in a speech said his order seeking to revamp kidney disease treatment could allow the nation to be “making crucial progress on [a] core national priority: the fight against kidney disease.”

The first important change, U.S. health officials said, would occur in the support and resources to educate the public about keeping their kidneys healthy and functioning, emphasizing the prevention of organ disease and failure. Chronic kidney disease is the ninth leading cause of death, and it hits black and Latinos hard. Awareness now is too low about screening for the condition, and, by controlling diabetes, blood sugar levels, and high blood pressure in protecting the kidneys. Officials estimate that as many as 40% of Americans with the disease don’t know they have it until it reaches severe levels.

Medicare steps in to cover end-stage renal disease treatment, including dialysis and kidney transplant. But this care can be burdensome and costly.

As the Washington Post reported:

“Kidney dialysis is a grueling regimen endured by about 510,000 of the 726,000 people who suffer from end-stage kidney disease, according to the National Kidney Foundation. In the United States, most people receive hemodialysis, a treatment that requires a device to filter waste and toxins from their blood. Most receive it in clinics or private facilities that serve dozens of people each day. Average life expectancy for a person on dialysis is five to 10 years, though some live much longer. A less expensive and less grueling option is peritoneal dialysis, a treatment that uses a fluid infused through a catheter implanted in the abdomen, often while the patient sleeps. The process is used by only a small percentage of U.S. kidney patients. Right now, the U.S. system creates incentives for clinic-based hemodialysis. 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. And Americans are not accustomed to taking care of themselves at home, something health care providers often discourage.”

Alex Azar, the secretary of the federal Health and Human Services Department, has campaigned to alter this treatment and reimbursement model, notably to slash the tens of billions of dollars Medicare pays for hemodialysis at private centers and other facilities. Peritoneal dialysis is prevalent and a successful means of care around the globe, approaching 80% of similar patients in Hong Kong, and, even in Guatemala, in the developing world, 56% of patients get therapies at home.

Fresenius, DaVita, and other health care giants have begun to consider how public policy changes might affect their profitability and have started to work on improving home kidney disease care. Doctors, patients, and their families may find it important to keep close watch on how the powerful corporations react to administration kidney disease care initiatives to see if their current, wait-and-see and generally optimistic views hold, especially as their revenues may be threatened.

Improving organ donation

Similarly, public and political scrutiny may need to be sharp on “organ procurement organizations,” these are the 58 nonprofits that “collect organs from deceased donors and send them to transplant centers for implantation,” the New York times reported. “Each OPO holds a monopoly over a chunk of U.S. territory and collects and reports its own data on how successful it is. Some poor performers have manipulated the numbers, researchers have shown.”

Although the OPOs have insisted their procedures and policies are clear and transparent and that they are doing solid work in the transplant roles, critics have disagreed, assailing the groups for allowing burgeoning wait lists to build — “close to 100,000 people are on a waiting list for kidneys,” NPR reported. Officials said they hope to raise the OPO standards, and to make groups hew to them, and to be far more accountable and open about their performance, while also altering policies, so that “living donors could receive compensation from the government for lost wages and child care.”

By 2030, Azar said officials hope to double the number of kidneys available for transplant.

In my practice, I see not only the harms that patients suffer while seeking medical services, but also their struggles to access and afford safe, efficient, and excellent medical care. This has become an ordeal due to the skyrocketing cost, complexity, and uncertainty of treatments and prescription medication, too many of which turn out to be dangerous drugs.

Administration officials deserve credit for giving prime consideration to kidney disease patients and their needs, putting this ahead of the interests of big businesses and vested advocacy groups. It makes sense for Uncle Sam to spend big sums, not to incentivize and pay for the number of procedures performed (e.g. dialysis visits or transactions involving potential transplants) and instead for patients’ improvements in their health and well-being. Robust discussion, improvement, and follow up with these plans should follow. It should occur fast, too, as is appropriate.

Will attacks on Obamacare undercut plans to change kidney disease care?

Trump officials, however, may find themselves caught up yet again in their own political conflicts as they advance their kidney disease care proposals. That’s because these approaches may force them to rely on legal mechanisms that reward health care innovations, programs that are an integral part of the Affordable Care Act.

Trump, his administration, and congressional Republicans detest the ACA and have campaigned long and hard to repeal it, including with an advancing court case championed by the U.S. Justice Department and GOP attorneys general. Advocates in this latest Obamacare litigation made their oral arguments before federal appellate judges, with ACA supporters and Democratic attorneys general warning that it will be disastrous for tens of millions of Americans if courts strike down coverage protections on pre-existing conditions, women’s preventive care, and against insurers’ lifetime limits. The appellate judges expressed doubts about the constitutionality of Obamacare.

Will the GOP extremists, though, be the big dog chasing — and finally catching — the truck zooming down the road? Political partisans have failed for a decade to detail their health insurance and health care options, other than returning the nation to policies that didn’t work. Will they create a national crisis with significant harms to make their political argument?

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