Projected US Government Expenditures for Dialysis Care: 2030-2040

Background: ESKD is one of the fastest-growing and costliest chronic conditions in the United States. We forecasted net spending by the US government through 2040 for persons with prevalent ESKD and Medicare and examined how it could change if person-years treated with hemodialysis were diverted to other treatment modalities, an earlier stage of kidney disease, or no kidney disease. Methods: We conducted a time-series observational analysis of aggregated, secondary data spanning 2002-2022 published by the US Renal Data System (USRDS). The data included all persons with CKD or ESKD with fee-for-service Medicare claims. We examined alternative scenarios in which person-years using hemodialysis are diverted to peritoneal dialysis, a kidney transplant, CKD Stages G4-5, and, in some cases, CKD Stage G3 and no kidney disease. The outcome measure was government spending, which is the sum of Medicare spending and disability benefits, net of federal tax revenue. Results: Based on trends from the last two decades, the model forecasted 9.1 million person-years with ESKD and Medicare coverage during 2030-2040 and government spending for these person-years totaling $783 billion. We found that if person-years treated with hemodialysis were diverted, then government spending could subsequently fall by $13-126 billion over this time depending on the volume of diverted person-years and the extent to which the progression of kidney disease can be slowed. Conclusions: Deliberate, evidence-based investments that shift modalities and slow progression to ESKD could subsequently lower government spending by billions of dollars while improving the lives of people with kidney disease.