July 10, 2025
On July 4, 2025, President Trump signed the "One Big Beautiful Bill" into law. This legislation will put kidney patients' access to healthcare at risk, cutting federal health spending by $1 trillion over a decade and potentially leaving nearly 12 million more people without insurance by 2034.
A Critical Overview for Kidney Patients
🚨 URGENT: 30% of all ESKD patients nationwide rely on Medicaid for coverage.
Many more chronic kidney disease patients across the country are covered through the Medicaid program or through the Affordable Care Act (ACA) marketplace. Major changes to the healthcare system will roll out over the next five years. As these changes take effect, kidney patients will experience changes to health coverage and access to care.
Many of the changes that will impact kidney patients, like new work requirements for people covered by the Medicaid program, will roll out in 2025 and 2026, depending on where you live. This blog lays out the timeline for changes to the healthcare system and steps you can take to prepare for how these changes might affect you and your care in the coming years.
Why Kidney Patients Are At High Risk
- At least 30% of ESKD patients rely on Medicaid for coverage of dialysis and kidney transplant care.
- Many individuals with kidney disease rely on Medicaid or coverage through the ACA as their primary means of accessing healthcare.
- Although the law does not change Medicare coverage for ESKD, many patients are dual-eligible (both Medicaid and Medicare).
- Many patients rely on Medicaid to help cover costs associated with their dialysis treatments, for example, the 20% coinsurance on Medicare dialysis treatments, transportation, in-home care, and immunosuppressive drugs.
- The law requires states to tie many patients’ ability to get Medicaid coverage to work requirements and to prove eligibility more often. Every state will institute these requirements differently over the next several years.
- If you are in an ACA plan, you will experience a shorter time frame during which you can re-enroll and may face more documentation requirements.
- Many kidney patients rely on rural hospitals. Rural hospitals and other healthcare facilities in rural areas may face financial stress and closure due to Medicaid cuts.
Timeline of Medicaid Changes
2025 and 2026
- States Implement Work Requirements: The law requires states to impose work requirements on able-bodied adults without dependent children. Able-bodied adults will need to consistently show they are working 80 hours a month or provide 80 hours of community service activities to qualify for Medicaid coverage. Some exemptions will apply.
- New Barriers for Immigrants: It may be more challenging to secure Medicaid coverage depending on your immigration status.
- Affordable Care Act Changes: The open enrollment period will be shorter, and some patients may experience challenges getting premium tax credits that help defer the costs of coverage.
- Providers Prepare for Tax Cuts: Hospitals and healthcare facilities prepare to face reduced Medicaid revenue
- Eliminates Access to Planned Parenthood: This creates new barriers for kidney patients receiving care from health centers.
- Transportation Services at Risk: Medicaid-funded medical transport may be reduced
2027-2030
- States Continue to Implement Work Requirements: Many patients will need to prove they are working and show documentation of their work more frequently to access Medicaid benefits.
- New Medicaid Co-Payments: There will be $35 copayments for some services, including for kidney patients earning 100-138% of the poverty level.
- Affordable Care Act: Patients face more significant paperwork barriers to accessing premium tax credits that help with the cost of a marketplace plan.
- Healthcare Providers Face Reduced Funding: Facility closures are possible, especially in rural areas, and access to services may be reduced.
Critical Actions for All Medicaid Recipients
- Prepare for work requirements: Understand exemptions for disability/illness and speak to your social worker about determining if you qualify for disability and how to apply in your state.
- Budget for copayments: Up to $35 per service
- Organize paperwork for frequent renewals: Every 6 months
Kidney Transplant Recipient Actions
- Verify immunosuppressive drug coverage across all your insurance plans. Remember, lifetime immunosuppressive drug coverage is available under Medicare if needed.
- Establish relationships with multiple transplant centers if possible
- Consider living donor options, which have shorter wait times and better outcomes
- Maintain excellent medication compliance, or transplant rejection may be harder to manage
Dialysis Patient Actions
- Ask about home dialysis options: There are two options, peritoneal dialysis or home hemodialysis
- Get evaluated for transplant ASAP: Even if you think you're not ready
- Talk to your social worker about changes that may impact your access to care
- Discuss payment plans if insurance coverage changes
Kidney Disease Patient Actions
- Get a comprehensive kidney evaluation now while coverage is certain
- Establish care with a nephrologist before you need dialysis
- Control diabetes and high blood pressure to prevent or slow kidney disease progression
- Research living donor options early, including family members or paired kidney exchange programs
- Consider a preemptive transplant before needing dialysis
Insurance Backup Plans
- Employer insurance: If possible, maintain a job that provides access to health insurance.
- Medicaid Eligibility: Talk to your social worker about what you need to do to maintain access to Medicaid coverage.
- ACA marketplace: Understand your eligibility to get help purchasing a plan, requirements for verifying your eligibility, and how long you’re able to enroll.
- Kidney-specific programs: Research foundation assistance programs
The Bottom Line
This legislation represents the greatest threat to kidney care access in decades. With patients across the country reliant on Medicaid, the ACA, and hospitals, community health centers, and dialysis facilities that could be impacted, the kidney community must act proactively.
Key Recommendations For All
- Document all coverage and providers
- Prepare for Medicare work requirements and more frequent Medicaid renewals
- Be aware of changes to coverage you get through the Affordable Care Act (ACA)
- Talk to your care team about potential changes to access to care
- Get comprehensive kidney testing
- Consider home dialysis evaluation
- Pursue transplant aggressively
- Talk to your transplant team about potential changes to your coverage and how you may be impacted
- Understand your state's specific risks, as some states will be hit harder
- Join NKF and get our Advocacy Newsletter to stay informed and join our collective action to fight.
The 37 million people in our country with kidney disease cannot afford to wait and see how these changes will play out. Take action to protect yourself now!
