The Dialysis Machine: HOW MEDICARE STEERS LOW-INCOME AND MINORITY KIDNEY PATIENTS TOWARD THE HELL OF DIALYSIS--AND KEEPS TWO BIG COMPANIES ROLLING IN PROFITS.

• Author: Kim, Anne

On a sunny August day, an elderly, fragile-looking black man sits slumped in a wheelchair, eyes closed, outside the doors of a DaVita Dialysis center. The business takes up the comer of a run-down strip mall in Southeast D.C., in a heavily black neighborhood across the river from the Capitol. It's next door to a liquor store and steps away from an ACE Cash Express check-cashing outlet, a barbershop, and a takeout place. A big sign on the glass warns visitors that firearms are not allowed inside. A handicapped-accessible public bus waits in the parking lot to take other patients home.

It's midafternoon, but the shopping center is buzzing with knots of people hanging out by the takeout and the barbershop. Everybody seems to know someone on dialysis. One man in a barber's smock out for a cigarette break says he had a friend who died at a dialysis center. He says ambulances are a constant presence at the DaVita clinic. It's not unusual for people to die on dialysis: nationally, about one-fourth of patients die in the first year, and six in ten will be dead within five years.

As many as thirty million Americans have chronic kidney disease. If you're one of them, and you're white, well educated, and middle class or higher, odds are you'll get the kind of medical care that will save your kidneys. You likely have private health insurance and get regular checkups. You probably caught your condition early and are taking medication to slow down the disease's progression.

But if you are poor, less educated, and black, the odds are much greater that your disease will run unchecked and your kidneys will eventually fail. According to the National Institutes of Health, black people are nearly four times as likely to suffer kidney failure as whites. Then you will likely end up on dialysis, spending three days a week, four hours at a time, at a place like this one, as your blood is pumped out of your body, filtered, and pumped back in.

Farther down the sidewalk, waiting for her daughter at the takeout, is Sharon C, a soft-spoken sixty-two-year-old black woman in a sleeveless white dress and Jackie O sunglasses who doesn't want to give her full name. She sits in a wheelchair, her left foot and ankle grotesquely swollen, the result of poor circulation caused by the diabetes she was diagnosed with in 2005.

Sharon goes to a different Da Vita center for dialysis, one near Capitol Hill, where she spends every Tuesday, Thursday, and Saturday. "You can't miss a treatment," she says. "You can't go anywhere." She says she only got on dialysis two months earlier, when her one functioning kidney finally failed. She is not on the wait list for a transplant. "I need to find a donor," she says, echoing what patient advocates say is a common misperception among dialysis patients: that you can't get a transplant unless you find a donor for yourself. "I don't want to be like this."

Of the 661,000 Americans with kidney failure, about 468,000 people--more than a third of whom are black--are on dialysis. In the District of Columbia, where the prevalence of kidney failure is the highest in the nation, according to the Centers for Disease Control, there are twenty-three dialysis centers, mostly in Northeast and Southeast Washington, the predominantly black parts of the city that are also ground zero for diabetes and high blood pressure, the two conditions most linked to kidney disease. Another 100 dialysis centers are within a twenty-five-mile radius of the city, again concentrated in the suburbs with the largest minority and low-income populations. In District Heights, Maryland, a DaVita center dominates the busy intersection of Pennsylvania Avenue and Silver Hill Road. In a strip mall just across the street is a clinic run by U.S. Renal Care.

Like check-cashing outlets and payday lenders, dialysis centers--the vast majority of which are for-profit, like DaVita and U.S. Renal Care--are now fixtures in the urban commercial landscape. "We used to say there's a liquor store on every corner," said Clive Callender, a transplant surgeon and professor of surgery at Howard University. "Now we say there's a dialysis unit on every corner."

The prevalence of dialysis centers in minority neighborhoods is a reflection of policy failures that encourage--indeed institutionalize--class and racial disparities in American health care. These failures include more than just disparate access to the primary and preventive services that could help high-risk patients stave off kidney disease. Public policy effectively steers low-income and minority patients with kidney disease toward dialysis and away from superior options, particularly transplants.

Everyone with kidney failure, also called end-stage renal disease, is covered by Medicare. And Medicare guarantees payment for every dialysis session. As a result, the treatment of kidney failure is a volume-centered business aimed at keeping dialysis centers running. "You fill up a facility with so many stations, you make sure somebody is sitting in each of those chairs around the clock," said Dennis Cotter, president of the Medical Technology and Practice Patterns Institute. "It's the Henry Ford production model."

This system creates an incentive for clinics to keep patients on dialysis until they die.

That's one reason why low-income patients have a tougher time getting transplants, which is the best treatment for kidney failure: their clinicians may not tell them it's an option. And the longer they stay on dialysis, the poorer their health is likely to be, making them less viable as transplant candidates.

Patients may also not be able to afford long-term treatment after surgery. While Medicare pays for the transplant itself, it only pays for three years of immunosuppressant medication to prevent the transplant from being rejected by the body, despite the fact that the one-year cost of these drugs is about a third the cost of keeping someone on dialysis. People running out of coverage ration their medication, lose their transplanted kidneys--and end up back on dialysis. Patients like these are less attractive for transplant centers, which want to keep their success rates high.

This unfair system is also a major driver of U.S. health care costs. While kidney failure patients make up about 1 percent of Medicare beneficiaries, they accounted for 7.2 percent of Medicare spending in 2014 and almost 1 percent of the total federal budget. For each patient on dialysis, the government spent $87,638 in 2014. Much of that money goes to just two companies: Colorado-based DaVita Inc. and the German conglomerate Fresenius Medical Care, which together control the lives of 69 percent of dialysis patients.

As common as dialysis is today--there were 6,757 dialysis units nationwide in 2014, according to federal data--it was once a scarce medical luxury. The story of that transformation is both a triumph and a tragedy for federal policy.

Until the early 1970s, a diagnosis of kidney failure was tantamount to a death sentence. In 1962, the journalist Shana Alexander published a now-classic account in Life magazine on the workings of what she called Seattle's "Life or Death Committee," a group of seven...