Key Takeaways
- •Rep. Vern Buchanan (R, FL-16) led a discussion on modernizing Medicare’s bundled payment system to incentivize innovation and expand home dialysis access for 800,000 Americans with kidney failure.
- •John Butler (President and CEO, Akebia Therapeutics) stated that Medicare’s flat-rate reimbursement model creates an "innovation desert" by making new, life-saving kidney therapies financially unsustainable for providers.
- •Rep. Gregory Murphy (R, NC-3) and Robert Taylor (Chief Medical Officer, Dialysis Clinic, Inc.) highlighted that current Medicare policies financially reward in-center dialysis over less-expensive preventive care.
- •Rep. Lloyd Doggett (D, TX-37) argued that Republican-led Medicaid cuts jeopardize patient access, while Republicans emphasized that Medicare payment reforms are necessary to drive private-sector medical breakthroughs.
- •Congress is evaluating H.R. 6214 to restructure transitional drug payments, aiming to ensure that breakthrough kidney treatments reach patients instead of remaining unused on shelves.
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Hearing Analysis
Overview
The House Ways and Means Subcommittee on Health held a hearing on March 18, 2026, titled "Improving Kidney Health Through Better Prevention and Innovative Treatment." Chaired by Rep. Vern Buchanan (R, FL-16), the hearing addressed the clinical and financial burdens of Chronic Kidney Disease (CKD) and End-Stage Renal Disease (ESRD). Chairman Buchanan noted that while ESRD patients represent only 1 percent of the Medicare population, they account for 7 percent of Medicare spending, totaling over $50 billion annually. The subcommittee sought to explore how Medicare payment policy can be modernized to incentivize early prevention, increase the adoption of home dialysis, and foster the development of innovative therapies.
Key Testimony
The witness testimony provided a multifaceted view of the kidney care landscape. Ashley Littleton, an ESRD patient from Tennessee, shared her journey from a sudden diagnosis at age 27 to finding independence through home hemodialysis. She emphasized that many patients are not adequately educated on home-based options, which allowed her to maintain her career as a preschool teacher. Dr. Suzanne Watnick, a Professor at the University of Washington and physician at the Seattle VA, testified on behalf of the American Society of Nephrology (ASN). She highlighted a staggering lack of innovation, noting that dialysis treatments have remained largely unchanged for 30 years. Dr. Watnick pointed out that the National Institutes of Health (NIH) invests only $19 per patient on kidney research, compared to over $400 for cancer. Dr. Robert Taylor, Chief Medical Officer of Dialysis Clinic, Inc. (DCI), discussed the challenges of providing care in rural areas, citing the closure of a clinic in Missouri due to workforce shortages. Finally, John Butler, President and CEO of Akebia Therapeutics, argued that the current Medicare ESRD prospective payment system (the "bundle") creates an "innovation desert" by failing to provide a sustainable reimbursement path for new drugs once transitional payments expire.
Policy Proposals
Several legislative proposals were central to the discussion. Much of the focus was on H.R. 6214, the Kidney Care Access Protection Act (K-CAPA), introduced by Rep. Carol Miller (R, WV-1) and Rep. Terri Sewell (D-AL). This bill seeks to extend the Transitional Drug Add-on Payment Adjustment (TDAPA) from two to three years and restructure post-TDAPA payments so they are tied to the actual use of a product rather than being "peanut-buttered" across all dialysis sessions. Rep. Lloyd Doggett (D, TX-37) advocated for his "Stop the Wait Act" to eliminate the two-year Medicare waiting period for disabled individuals and the "Close the Medigap Act" to prevent insurance discrimination against ESRD patients under 65. Rep. Mike Kelly (R, PA-16) and Rep. Danny Davis (D, IL-7) highlighted H.R. 2199, the Restore Protections for Dialysis Patients Act (RESTORE Act), which aims to protect the 30-month coordination period during which private employer plans remain the primary payer for dialysis patients.
Overview
The hearing revealed significant industry impacts, particularly for dialysis providers and biotechnology firms. Organizations like DCI and Akebia Therapeutics are directly affected by the ESRD bundle's structure. Mr. Butler noted that Akebia’s anemia drug, Vafseo, faces adoption hurdles because the current payment system does not account for the higher costs of innovative therapies compared to older treatments. The Centers for Medicare & Medicaid Services (CMS) and the Center for Medicare and Medicaid Innovation (CMMI) were frequently referenced regarding their role in managing the ESRD Treatment Choices Model and the Kidney Care Choices Model. Witnesses urged CMS to better incentivize upstream care for stage three and four CKD to prevent the transition to dialysis.
Industry Impact
The discussion involved several key organizations. Dialysis Clinic, Incorporated (DCI) was highlighted as a nonprofit provider maintaining rural access despite financial losses. Akebia Therapeutics was discussed in the context of developing Nobel Prize-winning science for anemia but struggling with Medicare's "payment cliff." The United States Department of Veterans Affairs (VA) was mentioned regarding its transportation programs for rural veterans. The American Society of Nephrology (ASN), National Kidney Foundation (NKF), and American Kidney Fund (AKF) were cited as supporters of increased research funding and the "Transforming Kidney Health Research Initiative." The Congressional Budget Office (CBO) was referenced by Rep. Doggett regarding the impact of research funding cuts on drug development.
Overview
Partisan dynamics were evident in the debate over healthcare funding. Democratic members, including Rep. Mike Thompson (D, CA-4) and Rep. Judy Chu (D, CA-28), criticized Republican-led budget cuts to Medicaid, the NIH, and the Food and Drug Administration (FDA), arguing these cuts undermine the very prevention and innovation the hearing sought to promote. Rep. Thompson engaged the medical witnesses in a series of "yes or no" questions to establish that cutting research funding hinders the search for a cure. Conversely, Republican members focused on market-based solutions, such as protecting private insurance options and fixing the "distorted" incentives of the Medicare bundle that currently make dialysis more profitable for nephrologists than early-stage prevention.
Notable exchanges included Dr. Gregory Murphy (R, NC-3) questioning the witnesses on the limitations of the ESRD bundle, which he characterized as a cautionary example of "Medicare for All" style budgeting. Dr. Taylor’s admission that nephrologists currently "make more money when someone ends up on dialysis" than when managing early-stage disease was a significant moment, highlighting the need for incentive alignment. Rep. Steven Horsford (D, NV-4) brought attention to the intersection of healthcare and infrastructure, detailing how a transportation dispute involving Pahrump Valley Transportation and the Nevada Department of Transportation nearly cut off life-saving care for rural veterans.
The hearing concluded with a consensus on the need for better patient education and increased transplantation rates. Witnesses and members called for the expansion of the Kidney Disease Education benefit to earlier stages of CKD. While no specific deadlines were set, the subcommittee indicated that H.R. 6214 and H.R. 2199 would remain top priorities for legislative action to stabilize the kidney care market and improve patient outcomes.
Transcript
The subcommittee will come to order. Good afternoon. I want to thank our witnesses for being here to discuss an important issue, improving kidney health in America. Chronic kidney disease, end-stage renal disease, are devastating and expensive diseases. 15 percent of American adults live with some form of CKD, and more than 800,000 patients live with ESRD. These patients are very sick, with more than 500,000 of them requiring multiple hours of dialysis each week. Overall, almost 60 percent of patients die within five years of starting dialysis. CKD and ESRD are also very, very expensive. Despite being only one percent of the Medicare population, patients-wise, it makes up seven percent of what's being spent at Medicare. In fact, diabetics and high blood pressure together account for 75 percent of ESRD cases. I'm interested to hear from you what your thoughts are, but 75 percent, when I seen that, was a shocker. I never thought it would be something like that. We must work together to prevent chronic diseases for patients, or else taxpayers will have to pay the bill. That means improving kidney health by supporting payment policies that increase innovation in treatment and care delivery. Additionally, new drugs and medical devices can help patients manage complications with ESRD, but Medicare payment policy must reward also innovation. We must modernize Medicare coverage to better prevent and treat kidney disease, as well as improve patients' outcomes. I look forward to discussing this important topic and solutions with my colleagues today. I now like to recognize the gentleman from Texas and a very good friend, Mr. Doggett. It's all yours.
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