Transplanted Kidneys: Metaphors for Vulnerability in Pre and Post Obama Care

My colleague Christine Rizk, JD and I co-authored this article in March of 2012, obviously several months before the Supreme Court’s decision on Obamacare.  At that time, we focused on significant coverage gaps for certain high risk patient populations even within the framework of  the expanded coverage mandated by the Affordable Care Act.  The fate of the ACA of course is now in question as we enter the second half of this election year, but hopefully focus on the known coverage gaps in the current ACA will not be lost in whatever version of the ACA emerges in 2013 and beyond. For an OFFICIAL REPRINT of the article, please contact the AMA Journal of Ethics staff or if you are a colleague, please e-mail me at

Christine and I welcome comments, questions and feedback as always.

American Medical Association Journal of Ethics 

March 2012, Volume 14, Number 3: 250-255. 


Implications of the Affordable Care Act for Kidney Transplantation 

Christine S. Rizk, JD, and Sanjiv N. Singh, MD, JD 

It has been argued that the kidney was the “heart” of antiquity. According to some medical historians, kidneys in the Old Testament symbolized the “core of the person” and thus “the area of greatest vulnerability” [1]. This metaphor of vulnerability is perhaps even more apt in the present day, where the failure of transplanted kidneys symbolizes the core defects of both the existing Medicare system and recent health reform implemented by the Obama administration. This article provides historical perspective on the evolution of coverage for kidney transplant patients and attempts to identify what initiatives would most effectively and efficiently improve their survival. 

The Current State Of Access to Posttransplant Care 


As of January 24, 2012, in the United States, there were 112,767 waitlist candidates on the various national transplant registries [2]. Of those candidates, 90,563 were waiting for kidneys, but in 2011 only 13,430 kidney transplants were performed [3]. The need for kidneys far outweighs the availability of suitable donor organs, and some postulate that the Patient Protection and Affordable Care Act of 2010 (ACA) may worsen the shortage by eliminating barriers to insurance coverage based on preexisting conditions, lifetime coverage caps, and required periods of pretransplant dialysis [4]. 

Even more critical from a clinical, economic, and moral perspective is the fact that the additional end-stage renal disease (ESRD) patients now expected to receive transplants by 2014 will be most vulnerable in the posttransplant phase of care. Coverage for pretransplant dialysis and maintenance drugs for ESRD, but not posttransplant care, receives strong support in Washington from large dialysis and pharmaceutical companies, which derive significant profits from dialysis, ESRD drugs, and dialysis-related services [5]. For ESRD patients, dialysis is covered by Medicare for life [6]. 

For posttransplant care, however, Medicare coverage is limited, providing only 80 percent of the cost of immunosuppressive medications for 36 months after transplantation (for those whose Medicare entitlement is based on ESRD) and no coverage thereafter. Despite the fact that effective and long-term immunosuppression is essential for survival of transplant patients [7], the vast majority are left to fund 20 percent of the cost for the first 3 years of immunosuppressive drugs ($13,000 to $15,000 total cost per year per patient) [8], and, for patients under 65 who are not disabled, all of the cost of immunosuppressive drugs thereafter [9].







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