Profit and power in the U.S. dialysis system: The unhealthy truth

Exposing the profit-driven sickness in American health care 

December 2025

Institute on Race, Power and Political Economy Senior Fellow Tom Mueller is an investigative journalist focused on uncovering fraud, corruption, and graft. His first book, Extra Virginity, examined malfeasance in the olive oil industry. His second, Crisis of Conscience, tackled the corporate corruption fueling whistleblowers. In his latest, How to Make a Killing (W.W. Norton, 2023), Mueller trains his eye on America’s profit-driven kidney dialysis industry. He recently sat down to discuss the problems he unearthed — and possibilities for reform. 

Your latest book takes the profit-driven healthcare system to task. Why is it at odds with patient care today?

The U.S. healthcare system, like much of the corporate world, is riddled with financial conflicts of interest, which all too often put the business of earning money in medicine in direct conflict with providing good patient care. Obviously, there are plenty of expert, highly ethical doctors, nurses, and nurse practitioners. But even they are frequently trapped in a broken system, and in many cases fighting against their own employer to provide high-quality care. 

Take the concept of “leakage,” which occurs when a patient seeks care outside their own network. For a hospital, that’s a financial loss — a “leak”— and is strongly discouraged by the finance people who often run that organization. But what if a patient needs a rare procedure that can only be done by a specialist outside that hospital? It’s financially beneficial for the hospital to keep that patient within its system, but medically beneficial for the patient to seek care elsewhere. It’s one of many cases where medical decisions are made based on profit, not patient care.

What other examples illustrate the conflict between profit and patient care? 

Over five-plus years of researching and reporting on the dialysis industry, I repeatedly heard two diametrically opposed examples from patients, nephrologists, and registered nurses. The first involves involuntary discharge from dialysis facilities, and the second is unnecessary dialysis. 

Dialysis is a perfect microcosm of American health because it preys on the most vulnerable patients.

Again and again, I spoke with people who were discharged from their dialysis facility and cut off from lifesaving care, sometimes with immediate effect. Often, these were patients who had questioned the quality of their care or had an issue with someone in the facility. Or, they were simply not profitable.

I also spoke with patients and nephrologists who witnessed the systemic pulling of patients into dialysis using misleading and simplistic diagnoses, when dialysis was probably not necessary. As one nephrologist told me, a dialysis facility is “like an airplane. They always want to fly with every seat occupied.” 

In your book, you use dialysis as a microcosm of larger issues in health care. Why? 

Dialysis represents the extreme case of an industry that’s been captured by two major corporations: Fresenius Medical Care and DaVita, Inc. Between them, they own nearly 80 percent of the dialysis centers in America1. Fresenius also builds dialysis machines, which they sell to DaVita. It’s a vertically integrated duopoly. 

It’s also a highly financialized industry, and Wall Street is all over it. Warren Buffett owns more than 40 percent of DaVita stock2. It’s a growth industry, too. Kidney failure is skyrocketing on the back of skyrocketing diabetes, hypertension, and obesity. 

In the U.S., kidney care is a massive, $100-billion-a-year business3, and dialysis is the only kind of medical care that is universally covered by Medicare4. Since 1972 to this day, if your kidneys fail, the U.S. government promises to pay for your care, whether that be via transplant or dialysis. And patients need treatment three times a week for the rest of their lives. In a sense, they’re the ultimate “loyal customer,” and very good for cash flow.

How does the for-profit model of care perpetuate racial and economic inequalities?

Dialysis is a perfect microcosm of American health because it preys on the most vulnerable patients: those who need this care to survive, and those from disadvantaged neighborhoods, for whom no one is speaking up. The systemic unnecessary dialysis cases I mentioned earlier all targeted young Black males in inner cities.

If you’re Black in America, you’re four times more likely to go on dialysis5. If you’re Hispanic, you’re two to three times more likely.6 There’s a small genetic component in certain Black populations, but mostly it has to do with life conditions, food deserts,7 and the environmental drain on people who live in these marginalized conditions.8 There’s also a deeply ingrained mistrust9 of the healthcare system, or outright lack of access to primary care.

What policy changes or systematic reforms do you believe are needed in this industry?

We need to pay doctors to do preventative medicine. We need people who have some level of kidney disease to use new kidney health drugs — Ozempic, Wegovy, and the other GLP-1 and SGLT-2 drugs. These aren’t just weight loss drugs, but are also miraculous for kidney health.

We must do better screening and treatment of early stage kidney disease, so that patients never actually reach kidney failure. We need to work on making transplants better — right now an estimated 13 people a day die while waiting for a donor kidney.10

That’s the encouraging thing about this huge, massive, scary problem: It can be fixed, and the fixes are pretty straightforward.

Finally, we need to improve competition in the dialysis industry, which is currently dominated by two huge corporations. Fantastic new dialysis machines are basically being excluded from the market because of this duopoly. The people receiving treatment today, all across the nation, are being treated on machines that haven’t advanced much since the 1980s.

What are you working on with The Institute to help solve these problems? 

After writing my book, I couldn’t walk away. I had to find some way to address the terrible inequities and injustices I’d discovered. So I teamed up with The Institute’s Darrick Hamilton, Mara Heneghan, and Dr. Victor Roy under a Robert Wood Johnson Foundation (RWJF) grant. We’re examining disadvantaged communities with a large intergenerational prevalence of dialysis to figure out how to remedy the situation. 

East Los Angeles and south Chicago both have high dialysis rates and very segregated communities. The difference in life expectancy between certain neighborhoods in north and south Chicago is 30.1 years.11

This partnership with the RWJF and The Institute is magical for me. It allows me to actually address the problems I encountered during my reporting. Most journalists — myself included until now — just move on to their next project, leaving the disasters they’ve discovered unchanged.

In your book you suggest some policy changes. Who can make them? Congress, state governments, people within the system?

Ultimately, it’s the Department of Health and Human Services (HHS), and the Centers for Medicare & Medicaid Services (CMS), the organization within HHS that provides Medicare and Medicaid and therefore pays for about 90 percent of dialysis. They could enact change tomorrow. For example, they could decide only to fund nonprofit dialysis, or they could demand comprehensive metrics about the efficacy of dialysis treatment, and really crack down on providers of bad dialysis. After all, dialysis patients in America die two to three times faster than anywhere else in the developed world12 — yet it costs way more to treat them. CMS should be demanding better treatment for our tax dollars.

I’m talking with certain state and city governments right now about how to create oases of good dialysis that can serve as a model for others. It’s not easy, but it’s doable. 

That’s the encouraging thing about this huge, massive, scary problem: It can be fixed, and the fixes are pretty straightforward. We just need the will to put patients first, not corporate profits.

Footnotes

  1. Xuyang Xia; Wanrong Deng; Paul J. Eliason, et al, “Financial Ties, Market Structure, Commercial Prices, and Medical Director Compensation in Dialysis,” JAMA Health Forum, June 18, 2025, https://jamanetwork.com/journals/jama-health-forum/fullarticle/2835489. ↩︎
  2. “Davita shares fall on weak earnings, Berkshire cuts stake further,” Investing.com, October 29, 2025, https://www.investing.com/news/stock-market-news/davita-shares-fall-on-weak-earnings-berkshire-cuts-stake-further-4317761. ↩︎
  3. The United States Renal Data System 2024 Annual Data Report (ADR), 2024, https://usrds-adr.niddk.nih.gov/2024 ↩︎
  4. Wreschnig, Laura A., Medicare Coverage of End-Stage Renal Disease (ESRD), Congress.gov, August 16, 2018, https://www.congress.gov/crs-product/R45290. ↩︎
  5. Roni Caryn Rabin, “A ‘Race-Free’ Approach to Diagnosing Kidney Disease,” The New York Times, September 23, 2021, https://www.nytimes.com/2021/09/23/health/kidney-disease-black-patients.html. ↩︎
  6. National Kidney Foundation, “Kidney Disease in Hispanic/Latino Communities: Causes and Prevention,” October 15, 2024, https://www.kidney.org/news-stories/kidney-disease-hispanic-latino-communities-causes-and-prevention. ↩︎
  7. Kelly Brooks, “Research Shows Food Deserts More Abundant in Minority Neighborhoods,” Johns Hopkins Magazine, Spring 2014, https://hub.jhu.edu/magazine/2014/spring/racial-food-deserts/. ↩︎
  8. “Why Black Men in America Have Worse Health than White Men — and What Needs to Change,” Johns Hopkins Public Health Magazine, 2020, https://magazine.publichealth.jhu.edu/2020/why-black-men-america-have-worse-health-white-men-and-what-needs-change. ↩︎
  9. Cary Funk, “Black Americans and Mistrust of the U.S. Health-Care System and Medical Research,” Pew Research Center, June 15, 2024, https://www.pewresearch.org/race-and-ethnicity/2024/06/15/black-americans-and-mistrust-of-the-u-s-health-care-system-and-medical-research/. ↩︎
  10. U.S. Department of Health & Human Services, “Organ Donation Statistics,” Organdonor.gov, last reviewed May 2025, accessed November 6, 2025, https://www.organdonor.gov/learn/organ-donation-statistics. ↩︎
  11. Julia Carrie Wong, “Life Expectancy in Chicago: Rich-Poor Inequality Hits Hard,” The Guardian, June 23, 2019, https://www.theguardian.com/us-news/2019/jun/23/chicago-latest-news-life-expectancy-rich-poor-inequality. ↩︎
  12. Alan R., Hull, MD, “Dialysis-related mortality in the United States,” Cleveland Clinic Journal of Medicine, September-October 1994, https://www.ccjm.org/content/ccjom/61/5/393.full.pdf. ↩︎