PREVENT ESRD Act
- Sponsor
- Rep. Wilson, Joe [R-SC-2]
- Committees
- Ways and Means Committee (primary)
- Last action
- Jul 22, 2026
Bottom line
This bill establishes a multipayer demonstration program to incentivize health plans to prevent kidney disease progression to ESRD, aiming to improve patient outcomes and reduce Medicare costs.
What it actually does
The PREVENT ESRD Act directs the Secretary of Health and Human Services to implement a 10-year demonstration program by January 1, 2027. This program aims to increase access to specified kidney care services for individuals with kidney disease to prevent its progression to End-Stage Renal Disease (ESRD). Participating health plans, including commercial, Medicaid, and Medicare Advantage plans, would receive a share of Medicare savings if they successfully reduce ESRD progression rates below a risk-adjusted benchmark, in exchange for providing enhanced preventative kidney care and screening with reduced cost-sharing.
Proponents argue
Supporters argue that the bill addresses a critical public health and financial challenge by shifting the focus from costly ESRD treatment to proactive prevention. They contend that incentivizing early screening, diagnosis, and comprehensive care will improve the quality of life for millions of Americans with kidney disease, significantly reduce the immense financial burden of ESRD on Medicare, and foster innovation in kidney care delivery.
Opponents contend
Critics might argue that the demonstration program introduces new administrative complexities and potential for gaming the system, where plans could subtly avoid high-risk patients to secure shared savings. Concerns could also be raised about the accuracy and reliability of savings calculations and whether the 25% shared savings payment is optimally structured to drive meaningful investment or if it might overcompensate plans for existing care practices.
The bill is moderately complex due to its programmatic details and payment mechanisms, but its structure and language are generally accessible, allowing an informed reader to understand its core provisions within a reasonable timeframe.
Sec. 1(a), Sec. 2
Short Title and Congressional Findings on Kidney Disease Burden
This section establishes the bill's short title as the 'PREVENT ESRD Act' and outlines Congress's findings. It highlights that kidney disease affects 36 million Americans, with many unaware of their condition, and accounts for $126 billion in annual healthcare spending, with Medicare bearing over $50 billion for ESRD treatment. It concludes that a voluntary payment model incentivizing prevention could reduce this burden.
Supporters argue
Supporters argue these findings clearly articulate the urgent need for intervention, demonstrating the significant human and financial costs of kidney disease and the potential for a prevention-focused approach to yield substantial benefits.
Critics contend
No specific opposition is typically raised against factual findings, though some might dispute the emphasis or specific figures if they felt they were misleading or incomplete.
Tradeoffs
None explicitly within the findings themselves, but they set the stage for the tradeoffs in the program design.
Sec. 3
HHS Kidney Disease Listening Session
This provision directs the Secretary of Health and Human Services (HHS) to host a listening session within 180 days of the bill's enactment. The session's purpose is to raise awareness about kidney disease and identify policy solutions for improving screening, diagnosis, and treatment of earlier stages of kidney disease, with the goal of preventing or delaying the onset of ESRD. Participants are mandated to include clinical experts, patients, patient advocates, health plans, and innovators.
Sec. 4, new SSA Sec. 1866H(a)
Implementation of 10-Year Demonstration Program
This section directs the Secretary of HHS to implement a 10-year 'Multipayer Kidney Care Medicare Savings Demonstration Program' by January 1, 2027. The program's overarching goal is to increase access for qualifying kidney disease enrollees to 'specified kidney care services' to prevent the progression of their condition to End-Stage Renal Disease (ESRD).
Sec. 4, new SSA Sec. 1866H(a)(2)
Scope of Preventative Kidney Care Services
This provision defines 'specified kidney care services' as items and services furnished to individuals diagnosed with kidney disease to prevent ESRD progression, including prescription drugs covered under Medicare Part D. The Secretary must specify the exact scope, which must include, at a minimum: various screening measures (e.g., urinalysis, blood tests, genetic testing), all FDA-approved drugs and biologicals indicated for slowing kidney decline, nutrition services and education, comprehensive disease management support (including patient education, genetic counseling, community health workers, and referrals for health-related social needs), and consultations regarding kidney health. Telehealth services are also included if medically appropriate.
Sec. 4, new SSA Sec. 1866H(a)(3)-(5)
Program Eligibility for Health Plans and Patients
This provision defines which entities can participate in the program and which patients are covered. An 'eligible plan' is broadly defined to include group health plans, individual market health insurance plans, State Medicaid programs, Medicaid managed care plans, Medicare Advantage plans (Part C), and any other plan type specified by the Secretary. 'Participating plans' are eligible plans that voluntarily apply and are selected. A 'qualifying kidney disease enrollee' is an individual enrolled in a participating plan with a current kidney disease diagnosis, meeting other Secretary-determined criteria.
Sec. 4, new SSA Sec. 1866H(b)(1)
Obligations of Participating Health Plans
Participating plans must enter into agreements with the Secretary, committing to several key activities. These include implementing measures to ensure access to specified kidney care services, developing a screening plan for all enrollees, and submitting extensive historical and current data (including protected health information) on kidney disease prevalence, progression rates, service utilization, quality of care, and screening rates. Plans must also cover all specified kidney care services with the lowest possible cost-sharing under their benefit design, avoid restrictive utilization management for drugs/biologicals, and provide kidney disease screening without any cost-sharing for all enrollees. In return, plans may be eligible for shared savings if their ESRD progression rates are below a set benchmark.
Sec. 4, new SSA Sec. 1866H(c)
Medicare Shared Savings Mechanism
This provision details the eligibility and calculation for shared savings payments. Participating plans become eligible if they cover specified kidney care services and their risk-adjusted CKD/ESRD progression rates are below a Secretary-established benchmark by a minimum percentage. The benchmark is dynamically set each year based on the plan's historical progression rates, national/regional disease prevalence, enrollee characteristics, and adjustments for increased screening. The Secretary, with certification from the CMS Chief Actuary, determines the Medicare savings (e.g., from individuals not becoming Medicare-eligible for ESRD). Eligible plans receive 25% of these certified Medicare savings, contingent on meeting established quality performance standards.
Sec. 4, new SSA Sec. 1866H(e)
Program Oversight and Congressional Reporting
The Secretary is mandated to continuously monitor and evaluate the Program. This includes conducting intermediate and final evaluations to assess the program's effectiveness in preserving kidney function, delaying ESRD, and reducing Medicare expenditures. These evaluations will involve comparing participating plans to carefully matched control groups from nonparticipating plans. Reports summarizing the intermediate and final evaluations are required to be submitted to Congress 3 and 6 years after the program's implementation date, respectively.
Sec. 4, new SSA Sec. 1866H(f)
Program Funding and Trust Fund Allocations
This provision outlines the funding mechanisms for the program. It allocates $5 million annually for administrative costs for fiscal years 2026 through 2038, transferred from the Federal Hospital Insurance Trust Fund (Medicare Part A) and the Federal Supplementary Medical Insurance Trust Fund (Medicare Part B) to the CMS Program Management Account, with funds available until expended. Additionally, shared savings payments and any optional advance investment payments to participating plans for program years 2027 through 2037 will also be drawn from these same Medicare trust funds. The proportion from each trust fund will reflect the relative actuarial value of the Medicare benefits impacted by the savings or payments.
This provision includes a 'Prohibition on avoidance of at-risk patients,' allowing the Secretary to reduce, recoup, or deny shared savings payments, or terminate a plan, if it takes action to avoid enrolling high-risk kidney disease patients or fails to adhere to program terms. It also introduces an 'Optional advance investment payment,' where the Secretary *may* provide upfront funds to participating plans for each qualifying enrollee, to be used for improving kidney care services. This advance payment would be deducted from any future shared savings received by the plan.
Sec. 4, new SSA Sec. 1866H(c)(4)-(5)
Why it matters:The anti-gaming provision is a standard, but vital, safeguard in value-based payment models, often placed in technical sections. The advance payment is an optional, discretionary tool for the Secretary, making it a secondary detail to the core shared savings mechanism.
Case for: Supporters argue these provisions are crucial for program integrity, preventing plans from cherry-picking healthier patients and ensuring that upfront investments can be made to kickstart preventative initiatives, especially for plans that might lack initial capital.
Case against: Critics might argue that the 'avoidance of at-risk patients' clause could be difficult to enforce objectively and might deter plans from participating if they fear arbitrary penalties. The optional nature of advance payments might also be seen as insufficient to truly support smaller plans or those with significant upfront investment needs.
Estimated impact: High impact on the fairness and equity of the program by mitigating adverse selection, and on the capacity of plans to make initial investments in preventative care.
This provision grants the Secretary broad authority to implement the section by program instruction, agreement, or otherwise, and to waive any requirement of Titles XI or XVIII (Medicare) and specific sections of Title XIX (Medicaid) as necessary to carry out the Program. It also explicitly exempts the program's implementation and administration from the Paperwork Reduction Act (44 U.S.C. 3501 et seq.).
Sec. 4, new SSA Sec. 1866H(g)
Why it matters:Such broad waiver and implementation authority is common in demonstration programs to provide flexibility for adaptation and streamlining. The exemption from the Paperwork Reduction Act is a specific technical detail that reduces administrative burden but also limits public input on data collection.
Case for: Supporters argue this flexibility is essential for the Secretary to adapt the demonstration program as needed, respond to unforeseen challenges, and streamline administrative processes, especially given the innovative and multipayer nature of the model. The PRA exemption can significantly speed up implementation.
Case against: Critics might argue that such broad waiver authority and exemption from the Paperwork Reduction Act could lead to reduced transparency, accountability, and public input in the program's design and implementation, potentially allowing the Secretary to bypass important safeguards and public review processes.
Estimated impact: High impact on the administrative burden for HHS and participating plans, and on the level of public oversight and input into program design and data collection.