Fifty Years of a National Program for the Treatment of Kidney Failure

 This JAMA viewpoint tells the story:

Fifty Years of a National Program for the Treatment of Kidney Failure, by Kevin F. Erickson,  Melandrea Worsley, andWolfgang C. Winkelmayer, JAMA. Published online December 19, 2022. doi:10.1001/jama.2022.23873

"Fifty years ago, on October 30, then-President Richard Nixon signed the Social Security Amendments of 1972, which created the End-Stage Renal Disease (ESRD) program. In extending Medicare benefits to people with kidney failure regardless of their age, this landmark legislation availed universal health care coverage for most persons with kidney failure.

...

"In the 1950s kidney transplant had emerged as a treatment option. By the early 1960s, innovations in dialysis machines and vascular access made it possible to treat chronic uremia with dialysis. These technological breakthroughs transformed kidney failure from a terminal illness into a treatable chronic condition. Although the first long-term dialysis center opened in 1962, most patients with kidney failure could not afford dialysis.

...

"For individuals with kidney failure, the ESRD program was transformative. By 1980, there were 58 000 patients receiving lifesaving treatment through the program, with enrollment growth averaging 22% per year. Enrollment growth spanned wide ranges of age, sex, and race, reflecting benefits across broad segments of the US population.4 Currently, more than 700 000 patients with kidney failure have Medicare coverage.

...

" In 2019, Medicare’s fee-for-service program spent $37 billion on the care of patients with kidney failure, accounting for more than 7% of overall Medicare expenditures.

...

"Despite past efforts to maintain quality and limit cost growth, major care gaps remain. Since the ESRD program’s inception, proponents of home dialysis have deplored the underuse of these modalities. Meanwhile, near-universal dialysis coverage may incentivize overtreatment with dialysis. Increasing evidence suggests that some of the sickest patients who start dialysis could instead benefit from active conservative management. A growing body of evidence also suggests that some patients who are new to dialysis may be able to safely undergo a hemodialysis regimen that includes fewer than the standard 3 treatments per week. Near-universal access to kidney failure treatment contrasts sharply with widespread limitations in access to preventive chronic kidney disease (CKD) care. This contrast is particularly poignant as it relates to racial disparities. Black patients face faster rates of CKD progression due, in part, to limited access to CKD care.9 In 2019, 33% of all patients receiving dialysis were Black individuals.

...

"the 2019 Advancing American Kidney Health initiative built on prior efforts to create a dialysis–focused alternative payment model (APM) through 6 new kidney care APMs that encourage home dialysis, kidney transplant, and advanced CKD care. It remains unclear whether dialysis-focused value-based payment initiatives will address outstanding cost and quality gaps. To date, substantial improvements in quality have not been observed.

...

"In summary, during its first 50 years the US ESRD program has provided critical access to lifesaving care for many patients with kidney failure while it has undergone a series of reforms as policy makers aim to control costs and maintain quality. Challenges in balancing cost and quality will persist as the program enters the second half-century of its existence."