Restricting third-party payments discriminates against patients on dialysis

October 1, 2018

Published by Healio

Kidney disease has a frightening way of leveling the playing field – rich, poor, black or white, no one plans for the eventuality of losing the function of an essential organ. Although we know certain demographic groups are affected more frequently than others, for the most part, CKD and kidney failure are scarily indiscriminate with universal impact. When the kidneys go, no matter the size of one’s bank account, the options are the same if active therapy is the chosen route: a transplant or life-sustaining dialysis care.

Although CKD and ESRD do not discriminate, large U.S. insurers are working hard to create a double standard – one that allows wealthy patients who can pay out-of-pocket the right to obtain private health insurance, while prohibiting less affluent individuals from doing the same. It is an effort that undermines patients’ fundamental right of choice and creates a new pre-existing condition exclusion: being poor.

Available options

Although there are not a great number of choices when it comes to treating kidney failure, since the creation of Medicare’s ESRD benefit in 1972, Americans have been afforded options when it comes to their insurance coverage. For some, Medicare is the best option; but for others, maintaining private insurance through their employer, COBRA or an individual plan is ideal. Private insurance often provides better, more robust coverage than government programs. Some patients have family members who also require coverage – making it logical to retain one private plan, rather than duplicate cost-sharing requirements across different plans. In nearly half of the states, patients who qualify for Medicare because of ESRD may not be able to access Medigap plans and, therefore, wish to rely upon private insurance, which may have more favorable cost-sharing obligations or expanded coverage. Out-of-pocket costs are high even with Medicare coverage and often run more than $7,000 per year; if patients with ESRD and their family members have separate coverage, this number can be more than double.

Regardless of the reason, historically, patients with kidney failure have been given the right to choose what works best for them and their families, but only for a limited duration of up to 30 months under the Medicare Secondary Payer (MSP) statute.

The option for private insurance coverage has always been there, but if some insurers have their way, it will only be available for the wealthy. The MSP statute already restricts this right and caps the duration for which any health plan must provide for coverage. No matter how long these patients have paid for private health care insurance, they cannot keep it. They must transition to Medicare for primary coverage. This results in a substantial taxpayer subsidy for the insurance plan. Yet they want to push as many patients as possible onto government coverage as soon as possible.

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