AS OUR NATION struggles with the painful divide created by President Trump’s foreign policies, let’s not become distracted regarding his domestic programs. During the roll out of his Executive Order on Advancing Kidney Health he said, “The kidneys have a very special place in the heart.”
Obviously, kidneys aren’t “in the heart,” but they do occupy a special place in the Medicare budget, which, since 1973, has funded treatment for kidney failure, including kidney transplantation, regardless of the patient’s age. Those with kidney failure represent 1% of Medicare patients but account for 7% of the Medicare budget.
The estimated six-month billable charges for one kidney transplant are over $400,000, not $35,000 as reported, and this does not include the long-term cost of medications for treatment of complications (e.g., diabetes, infection, CVD, cancer, depression, PTSD), organ rejection, recurring organ failure, returning a patient to dialysis and additional transplants.
Yet, the President plans to deregulate transplantation, already minimally regulated because laissez-faire, free-market principles are the philosophical foundation of the National Organ Transplantation Act (1984.)
Details haven’t been provided about what will be “deregulated,” but in 2018 the President proposed eliminating Medicare rules that penalize transplant centers if too many of their patients die.
Stewardship of public health-care dollars and patient safety require more external oversight and regulation but instead, the President’s aim is to simply increase the number of kidney transplants, in part by increasing the use of living donors, even though living kidney donation doubles the risk of pre-eclampsia, creates oxidative DNA damage and decreases antioxidant activity, leads to a 9-fold increased risk of kidney failure and increases risk for cardiovascular disease and all-cause mortality, and injury from pharmaceuticals, and can cause death by hemorrhage, nerve damage and hernias.
Tellingly, the President has no plan to fund essential long-term care for living donors, only stipends during their surgical period.
Additionally, the boundaries between life and death can be blurred when obtaining organs from “deceased donors.” In 2008, a surgeon was charged with hastening the death of a disabled man in order to retrieve his organs by inappropriately prescribing medications. In 2010, a woman woke up under the operating lights as doctors prepared to remove her organs. Patrick McMahon, a former transplant coordinator, estimated that at his center 1 in 5 patients declared brain dead, and approved as organ donors, showed signs of brain activity.
Significantly, opioid deaths have led to a 24-fold increase in organs for transplant. In 2017, 20% of donor deaths were from overdoses in 11 states (an increase in seven years from 1% to 5.6% among 33 states); there were 8,030 deaths among those waiting for an organ transplant compared to 48,000 opioid deaths.
A transplant surgeon explained, “…the transplant community is to … partially mitigate the tragedy … by maximizing the utilization of organs from ODD” (opioid death donors). Seen in this light, the President’s resistance to Medicaid expansion, needed to fund treatment of opioid use disorder, is alarming.
Variations in health insurance impact many people. Screening for an organ transplant includes a “wallet biopsy”; those unable to afford essential medications when Medicare coverage stops are deemed ineligible for a transplant. Living donors must rely on their recipient’s insurance to fund care for complications, but only if their transplant center is willing to acknowledge the complication.
Many diabetics — with and without health insurance — struggle to pay for insulin, but if they develop diabetic kidney failure, taxpayers fund the exorbitant treatment costs.
In 2012, 44% of those waiting for a kidney transplant had diabetic kidney disease; diabetes is the most common cause of kidney disease worldwide.
In the next decade diabetes is predicted to afflict 54.9 million Americans, with medical and societal costs increasing 53% to $622 billion annually. Social determinants of diabetes include childhood adversity, toxic stress, food insecurity and perfluoroalkyl chemical (PFAS) contamination.
In fact, up to 70% of the determinants of health are outside of individual control, affected by where people are born, live and age, and the distribution of money, power, and resources.
Did the President bypass Congress with his deregulation executive order because too many public health issues would surface if similar legislation were brought before Congress?
Free-market ideology will not lead to rational and equitable health-care policy. Common sense and fairness will. The Medicare End Stage Renal Disease Program should be extended to include all involved patients — those with diabetes, opioid use disorder and living kidney donors — regardless of age. This would be a fair, rational, and a meaningful first step in health-care reform that’s in service of all stakeholders, not just free market, corporate shareholders.