Like most of American healthcare, kidney care has for decades been plagued by red tape. The Trump administration says it wants to change that. On Tuesday, Department of Health and Human Services (HHS) Secretary Robert F. Kennedy Jr. announced his department's Kidney Care National Plan, which promises to introduce more competition, reduce regulatory barriers, expand patient choice, and overhaul America's kidney transplant system.
Much of the plan focuses on barriers to entry in dialysis care, which treats nearly 558,000 Americans. While dialysis can be performed at home, most patients receive treatment at specialized facilities, which must comply with federal certification requirements governing equipment, staffing, water quality, and patient safety in order to participate in Medicare.
Kennedy argues that regulatory barriers have discouraged competition and innovation, leaving patients with fewer dialysis treatment options. "Dialysis technology is an extraordinary technology," said Kennedy at the press conference, but "because of monopolies in the system and the barriers to new entrants, we have not seen any real improvements in that technology."
Of course, the existence of large or even monopolistic companies is not in itself evidence of a problem, but government regulation can often entrench those companies' positions in the market. "I like the fact that they're recognizing that a lot of regulatory…barriers are contributing to the problem, and that's refreshing to hear," says Jeffrey Singer, a practicing general surgeon and senior fellow at Reason Foundation, the nonprofit that publishes Reason. Singer says that removing barriers that prevent new companies from competing with established providers could not only increase choice but also drive down prices.
HHS says that two companies, DaVita and Fresenius Medical Care, control approximately 74 percent of the American dialysis market. As of 2019, roughly a third of Americans lived in areas where the only available dialysis provider was one of those two companies, according to the agency. The administration argues that government regulation has helped entrench this dominance by making it difficult for new providers to enter the market.
To address this, the Kidney Care National Plan suggests a number of reforms, including simplifying certification requirements. HHS also plans to investigate whether dominant dialysis providers have used payment arrangements and legal strategies to secure higher reimbursements without delivering better care.
The 17-page report calls for a review of existing requirements, but it does not specify which regulations will be repealed, nor does it establish a timeline for doing so. It also does not propose any significant reduction in the government's role in financing the distorted market. Instead, the plan largely seeks to make existing government-financed systems such as Medicare more competitive and efficient.
Kennedy has also correctly identified the need for reform regarding kidney donations. Nearly 90,000 people are waiting for a kidney transplant at any given time in America, and 11 people die every day waiting for a kidney. The transplant process is currently managed by Organ Procurement Organizations (OPOs), which are federally certified nonprofits responsible for recovering organs from donors and coordinating their transfer. There are currently just 55 federally designated OPOs operating in the United States, and HHS argues that they behave as "regional monopolies." Since no new OPOs have been approved in the last year, the Kidney Care National Plan suggests fast-tracking certification.
The plan also seeks to make living kidney donation easier by reducing financial barriers. Following the passage of the Honor Our Living Donors Act in February, HHS revised federal reimbursement rules so that a donor's eligibility for financial assistance is no longer determined by the transplant recipient's income. Eligible donors can receive up to $6,000 to cover expenses, including travel, lost wages, and childcare.
However, the reforms proposed stop short of allowing kidney donors to receive direct compensation for the organs themselves, which remains prohibited under federal law. "I can sell my blood. Why can't I sell my kidney?" Singer asks.
Peter Jaworski, director of the Georgetown Blood and Plasma Research Group, feels similarly, arguing that financial incentives are available to nearly everyone involved in kidney transplantation except the donors themselves. "According to this plan, it's OK to use incentives to encourage them to be more productive, to actually do a better job," Jaworski tells Reason, referring to transplant surgeons, hospitals, and organ procurement organizations. "The only exception, once again, is the donor who is offering a kidney."
Better solutions exist, according to Jaworski, who points to the proposed End Kidney Deaths Act. The bill, which was introduced by Rep. Nicole Malliotakis (R–N.Y.) last year, would offer living kidney donors a $50,000 refundable tax credit, distributed over five years. "We have those systems in order to make sure that we can treat patients. That's the point of blood donation. That's the point of plasma donation. That's the point of kidney donation too."
America's plasma market is an excellent example of financial incentives encouraging donation. Unlike many other countries, the U.S. allows plasma donors to be compensated, and despite accounting for just over 4 percent of the world's population, it supplies approximately 68 percent of the plasma collected globally for manufacturing medicines.
"Why do you think America does it? Is it because in America there's way more altruism than in France or Italy or Belgium? No, it's because in the United States you can be paid to donate plasma," argues Jaworski.
The Trump administration appears to recognize that government overreach has stifled competition and restricted patient choice. It also recognizes that living adults donating kidneys will be part of the solution to the long, deadly waiting lists. But its plan leaves the government's outsize role in kidney care largely untouched. For patients facing years on dialysis or waiting for a lifesaving transplant, recognizing the problem is not enough.
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