Experts say implementation of the One Big Beautiful Bill Act, the budget law that President Donald Trump signed in 2025, could be devastating for kidney patients in the United States.
The budget law changes the way Medicaid is administered, creating new out-of-pocket costs and work requirements for recipients, limiting how much states can impose in taxes on medical providers, and mandating that recipients renew their eligibility twice a year.
All of these changes could lead to poorer health outcomes for the nearly 35.5 million Americans living with kidney disease. Over half a million of those patients are on dialysis, and 300,000 of those are Medicaid recipients.
“I think the worst is yet to come because the bill did not require that these requirements come into effect until Jan. 1, 2027,” Dr. Jesse Roach, a nephrologist and the senior vice president of government relations at the National Kidney Foundation, told the American Independent.
The new Medicaid work requirements in the law mandate that able-bodied recipients between the ages of 18 and 64 without dependents spend 80 hours per month in a work program, school enrollment at least part-time, or volunteering, unless they fall under an exemption category, including a person who is “medically frail or otherwise has special medical needs (as defined by the Secretary [of Health and Human Services]).” While most patients on dialysis would qualify, the new requirements put the onus on the patient to file the needed paperwork consistently.
“I think there are many circumstances where these people could get a waiver and have to be excluded from these requirements, but then that still requires regularly filling out paperwork, which is a burden on somebody that’s dealing with a serious chronic disease,” Roach said.
The health care foundation the Commonwealth Fund explained in a posting in December 2025 that the law reduces the amount of tax on medical providers such as hospitals, managed care organizations, and nursing homes that states can impose from 6% to about 3.5% of a given provider’s net patient revenue. The states use the tax amount to claim matching funds from the federal government for Medicaid funding of health clinics and hospitals. A reduction in the amount a state can claim could severely impact dialysis clinics, chiefly clinics in rural areas, Roach said.
“I think rural is more susceptible to this just because they’re operating at closer margins and have fewer patients. … I think the lower reimbursement is going to hurt some of these rural clinics that are operating on the edge of profitability, and that type of cut is going to make it harder for them to exist,” Roach explained.
NPR recently reported that patients of a hospital in Chadron, Nebraska, were forced to either move closer to a different clinic or drive hours for treatment when the hospital closed its dialysis clinic. Hay Springs resident Mark Pieper told NPR that he’s now forced to drive 200 miles round trip to reach the dialysis clinic closest to him.
For patients on hemodialysis, daily life on average revolves around a structured treatment schedule, usually three times a week, for between three and four hours at a clinic. The Mayo Clinic explains on its website that patients are intravenously connected to a machine that filters waste, salts, and excess fluids from their blood, often leaving them feeling fatigued. On nontreatment days, life can feel more normal, but patients still have to carefully manage medications, diet, and fluid intake.
For patients on peritoneal dialysis, the routine is more flexible but happens every day: Fluid is injected through a tube inserted through the wall of the abdomen and removes waste from blood using a patient’s peritoneum, the lining of the abdomen, as a filter. Although this option allows for more independence, it requires several weeks of training and comes with a high risk of infection.
Karol Franks is the administrator of the “I Hate Dialysis” Facebook page, which has over 67,000 members, and one of three admins of the website Living Donors Online. Her daughter and several of her siblings have been diagnosed with kidney disease; her father died of kidney failure when she was 7.
Franks told the American Independent that the new Medicaid requirements would be a challenge for those on dialysis.
“Can you imagine? If you have low income, you have a family to take care of, you have kidney failure, you can’t work anymore, disability doesn’t pay very much, and then what if you’re faced with having to deal with doing volunteer work or whatever to qualify for Medicaid? I mean, I don’t know who wrote that thing,” she said. “I think it’s nice to think of people who are on Medicaid and are able to work — I’m OK with that, because they’re on Medicaid just because they need some sort of health insurance, and they don’t have the income to pay for it. But for people on dialysis, I think it’s a challenge.”
Franks said her daughter had been on hemodialysis starting at age 18, from 2004 to 2007. She had her first kidney transplant in 2007. That kidney failed, and she began peritoneal dialysis in 2013 and continued until 2017, when she had her second transplant.
For patients who live above the poverty line, the provisions of the law add a $35-per-treatment co-pay for dialysis, which, for a treatment regimen of three times per week, comes to a total of over $5,000 annually.
“So instituting that, again, it’s a money-saving sort of thing, but it really hits people that can barely afford it pretty hard in their wallet,” Roach said. “And I think that what that’s going to mean is that if somebody has to decide between having food and going to the doctor, then a lot of times they’re going to get food for themselves and their family.”
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