President Donald Trump signed an executive order Wednesday aimed at increasing the availability of kidney transplants and reducing the cost of kidney treatment, in an effort to improve care for hundreds of thousands of Americans who have been diagnosed with kidney disease.
Approximately 468,000 Americans are on dialysis, according to the National Institutes of Health, and Medicare spending on dialysis accounts for nearly 1 percent of the federal government’s annual budget.
An estimated 100,000 Americans are currently on the waiting list for a kidney transplant.
“For these patients, their loved ones and all of those impacted by kidney disease, I am here to say we are fighting by your side, and we are determined to get you the best treatment anywhere in the world,” Trump said before signing the executive order.
The president said the order is part of his administration’s broader health care policies, including efforts to reduce prescription drug prices. Some of those efforts, such as requiring drug companies to list prices in TV ads, have been criticized for trying to solve complex problems with oversimplified solutions.
The executive order on kidney disease is being implemented through the Center for Medicare and Medicaid Innovation, which was created through the Affordable Care Act. The Trump administration has taken steps to weaken the Affordable Care Act and has refused to defend the law in court.
Still, Initial reactions to the executive order were largely positive, although some observers cautioned that meaningful change will still take years. Here are some of the steps the order takes:
Reimbursing donors for their costs
A law Congress passed in 1984 made it illegal to pay kidney donors. Lawmakers believed a market for organ donations could lead to people selling their kidneys solely for financial gain, causing lower-income Americans to be exploited.
But donating a kidney can be costly. People often have to travel to a distant hospital that can perform kidney transplants, then miss work while they are recovering from the surgery.
Right now, insurance covers some of those costs, and low-income people can be reimbursed for travel, but higher-income individuals are not.
Trump’s executive order expands who is eligible for reimbursement and allows reimbursements for more costs such as lost wages and childcare.
“We haven’t treated donors very well,” said Alvin Roth, a Nobel Prize-winning economist who developed a system to increase kidney donations. “They do this very generous thing but they have out of pocket expenses they have to pay, which is ungenerous because they save the American medical system so much money.”
Transplants can cost more up front than dialysis — which cost between $50,000 and $90,000 per year– but most patients who receive a transplant must then only pay for anti-suppressant drugs, which cost several thousand dollars a year. Medicare covers the cost of those drugs for up to 36 months after the surgery.
There are also indirect economic benefits of transplants over dialysis. Patients who receive transplants are more likely to have a higher quality of life than people on dialysis. Many can be more productive at work, which means they not only save money but pay more in taxes, Roth said.
The Trump administration also plans to change the requirements for organs that are harvested from deceased people, including the process by which patients are matched to donors, to cut down on inefficiencies.
Allowing more in-home dialysis treatment
Dialysis patients often have to go to a clinic three times a week for hours of treatment. As technology has improved, in-home dialysis has become a more viable option for many patients, but the vast majority of them still go to a clinic. Only 12 percent of Americans on dialysis are treated at home.
That despite the fact that a National Institutes of Health analysis of medical studies found minimal differences in outcomes for patients using in-home versus in-clinic dialysis. Some studies have found higher survival rates for people who choose at-home treatment.
Curtis Warfield, a kidney disease patient and advocate for the National Kidney Foundation, said at-home dialysis allowed him to work normal hours and conduct the treatment at night or overnight.
“I could make my own schedule, instead of dialysis making the schedule for me,” he said.
But making the switch can be difficult for some patients, who must either learn how to work the dialysis machine themselves or pay for a nurse to come to their homes to assist in the treatment. Other patients do not even realize that at-home care is an option.
Trump’s executive order changes the way Medicare pays for the treatment to favor in-home care and preventative measures.
That could shake up a $24 billion dialysis industry that is dominated by two companies, DaVita and Fresenius. After news of the executive order broke Tuesday, both companies’ stocks fell.
But DaVita downplayed any negative effects Trump’s executive order could have on its business. In a statement, the company pointed out that it is the largest provider of home dialysis in the U.S., so the government’s measures will actually support its existing investments in home kidney care and kidney disease prevention.
What still could be done
Even if the Trump administration’s plans work well, advocates still expect to see a shortage of kidneys for the foreseeable future.
But other groups are working to address that by raising awareness about the need for more donations.
Warfield said he was lucky because even though his daughter was not able to donate her own kidney because she was not a biological match, her sorority sister did.
He said Congress should pass laws that ensure people like his daughter are not discriminated against when it comes to buying life insurance policies or long-term care insurance because donors will now live the rest of their life with a single kidney.
In his speech Wednesday, Trump pointed to another possible long-term solution — the creation of an artificial kidney. The Kidney Project, a national research collaborative, received approval in 2015 to expedite its clinical trials. It hopes to complete the first phase of those trials by next year.