Opinion > Opinions - Healthcare The views expressed by contributors are their own and not the view of The Hill End-stage disease shouldn’t be the entry to care by Dr. Robert Redfield, opinion contributor - 03/03/26 12:30 PM ET by Dr. Robert Redfield, opinion contributor - 03/03/26 12:30 PM ET Share ✕ LinkedIn LinkedIn Email Email FILE – Adrian Perez undergoes dialysis at a DaVita Kidney Care clinic in Sacramento, Calif., on Monday, Sept. 24, 2018. (AP Photo/Rich Pedroncelli, File) I began my medical career on the front lines of the AIDS epidemic. In those early years, too many patients entered care only after the virus had already devastated their immune systems. By the time we saw them, the window for meaningful intervention had often narrowed or closed entirely. It was not because medicine lacked the will to help. It was because policy, stigma and system failures delayed action. We were structured to respond to a crisis rather than prevent decline. Medicine fails when we wait until people are at their sickest before intervening. Today, we are repeating a version of that mistake in kidney care. Chronic kidney disease is a silent epidemic. More than one in seven American adults, roughly 35 million people , are living with it. Tens of millions more are at risk. Like HIV or Alzheimer’s Disease, kidney disease often progresses quietly. Patients may feel well while irreversible damage accumulates. By the time symptoms appear, options have narrowed, and lives have already been shortened. This is not a niche issue. Chronic disease is the central public health challenge of our time, and kidney disease sits squarely at its center. It fuels heart attacks and strokes. It disqualifies patients from certain medications, treatments and life-saving surgical procedures. It costs Medicare hundreds of billions of dollars each year. And yet our system is largely designed to respond at the final stage, putting patients on dialysis where five-year survival rates are below 50 percent. Early treatment saves lives. Whether managing HIV, cancer, diabetes, or hypertension, earlier intervention preserves organ function, reduces complications, and extends life. Once a patient reaches end-stage illness, medicine becomes reactive, expensive, and limited in what it can achieve. Kidney disease is uniquely suited for early intervention. We can identify it through routine lab testing. We understand many of its risk factors. We have therapies that can slow progression and reduce complications. But current government payment policies too often wait until damage is advanced and options are few. Under the Biden administration, the U.S. Centers for Medicare and Medicaid Services doubled down on a bundled payment structure that prioritized cost containment over patients. While framed as promoting efficiency, these models have discouraged use of critical medications and pushed care downstream toward dialysis rather than prevention. When reimbursement is tightly constrained, the pressure to limit therapies increases, even when they are clinically indicated. Consider phosphorus control, a central issue for patients with advanced kidney disease. Elevated phosphorus levels contribute to vascular calcification, heart attacks, strokes, and can even render patients ineligible for transplantation. Medications that help manage phosphorus are not optional add-ons; they are essential components of care. Limiting access to them increases medical risk and undermines long-term outcomes. When payment policy prioritizes accounting over physiology, patients pay the price.  Fortunately, we have an administration that knows we must do better. In 2019, President Trump issued an executive order seeking to fundamentally rethink kidney care. It emphasized prevention, home-based therapies, innovation, and better patient outcomes. It reflected a clear understanding that the status quo was too focused on dialysis as the default endpoint rather than preventing progression in the first place. That momentum has since slowed as policy discussions reverted to reimbursement mechanics and budget neutrality. But public health progress requires continuity and courage. It requires a refusal to accept “this is how it’s always been” as a sufficient justification for maintaining a flawed system. Reforming the bundled payment system for kidney care is an essential step. CMS should recalibrate incentives to support early intervention and evidence-based therapies that slow disease progression. Physicians must have the discretion to treat patients before irreversible decline sets in.  The lesson from the AIDS epidemic is clear. Delay costs lives. Leadership changes outcomes. Once we embraced early testing, early treatment, and sustained investment, we transformed HIV from a near-certain death sentence into a chronic, manageable condition for many patients. Kidney patients should not have to become the sickest version of themselves before