American Kidney Care in a New Governance Landscape

Richard LafayetteRichard Lafayette, MD, Editor-in-Chief, ASN Kidney News

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We cannot discuss too much or focus in too much detail on the issues when it comes to the historic transition of power and influence post-election. Much has been said about radically changing the government, and health care has been in the crosshairs throughout the election and in planning for transition. Governance and policy will be all important in 2017. Although there is limited detailed conversation about how change will occur, there surely will be new policy and rules.

The clearest promise has been that the Affordable Care Act (ACA) would be dismantled and fully repealed. Soon after the election, it appeared clear that not all of the ACA would be discarded, with continued coverage for children under their parents’ policies until age 26 and likely extended coverage for preexisting conditions. However, how to ensure access to the millions of Americans covered under present ACA policies has not been clarified.

There have been broad statements about entitlements by the incoming congressional majority. What this will mean to Medicare, its coverage system (at what age, how costly the premiums, and how extensive the benefits will be), and whether Medicare will soon be allowed to negotiate pharmaceutical and device prices remain to be seen. How the federal government administers Medicaid programs will also be up for grabs, with discussions leaning toward allowing states to have even more responsibility and decision-making authority for running the programs for the financially most vulnerable part of our population. Block grants will limit federal exposure to rising costs but will likely limit benefits to those mired in poverty.

There have been few indications about the new administration’s views about support for research and innovation, areas that bear watching in 2017. In a conversation last year, President Trump suggested NIH is a mess, yet he has also voiced his commitment to the nation’s health and vowed to make American health care great again. We will see how this pushes policy toward the budget and priorities of the NIH, its intramural and extramural programs, and toward the support of industry initiatives to advance.

There has been little specific discussion of kidney health. Because ESRD care is mandated by the 1973 Social Security Act as a federal entitlement, it is not beyond the reach of change in the new leadership environment. Those not covered by Medicare often need help from Medicaid. Whether investments will be made to ensure the highest levels of care and to maintain the present focus on high-quality, cost-effective care is yet to be seen. Recent inroads into predialysis care that have blossomed with Medicare support may be revisited. Furthermore, new developments with payments of care through the Quality Payment Program legislated by MACRA may also be on the table for further revisions as the new administration makes its approaches to health care known.

As nephrologists, health care workers, and citizens of this country, we will need to work to stay at the table to let our opinions be known. I hope we can continue to move toward fairness and equity for our profession, for our patients, and for the diverse population that we care for. We must ensure that our nation maintains its commitment to access to health care, prevention of illness, and the most effective, sincere commitment to advancing knowledge in nephrology through continued support of education and research.