Dialysis is a medical miracle — vastly extending the lives of people with kidney disease. When it was first discovered, Congress rushed to assure that it was covered by Medicare. And then big business got involved. Abdul reflects on the way that American capitalism disembodies healthcare. Then he speaks with Tom Mueller, author of “How to Make a Killing,” about the excesses of dialysis corporations in America.

TRANSCRIPT

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Dr. Abdul El-Sayed, narrating: Cases of COVID 19 continue to spike as new evidence shows that the fall booster has good reactivity to the Pirola variant. A new survey of Gen Z attitudes about health care shows that the vast majority believe health care is a basic human right. A new poll finds that 70% of Americans have favorable impressions of their local health official. This is America Dissected. And for the 200th time, I’m your host, Dr. Abdul El-Sayed. [music break] Imagine there was a universally deadly disease. Literally, you get it, you’re almost guaranteed to die in a matter of months. But now, because of a new technology, you can be almost miraculously cured. However, that technology isn’t available to everyone. It’s limited to a small handful of the vast number of people who need it. What do you think would happen? How do you think patients dying of the disease or their family members might react? How would advocates like you or I respond? Okay, now I want you to hold that thought. I promise we’ll get back to it, though. Today, we’re talking about dialysis, basically the process of providing artificial kidneys for people whose kidneys don’t work. Initially developed as a means to provide a short term bridge for people with acute kidney failure, it’s become a lifeline for those with chronic failure. But with a catch, it means spending several hours a week hooked up to a machine. Remember, the kidneys are your body’s main filter. Beyond removing impurities from the blood, including excess nitrogen that our bodies generate and can make you really, really sick if it gets up to a high enough concentration. They also tightly regulate our blood volume, orchestrating the tight dance between water and salt that keeps us hydrated even when we fail sometimes to keep ourselves hydrated. Think about it. Ever have a super salty meal? Think pizza or burgers and fries to balance all that salt your body demands you drink water. But the real work it’s done by the kidneys, which concentrate your urine, getting as much waste out using as little water as possible. Or think about those days when you do hydrate and your urine is that clear color your doctors want it to be. That’s your kidneys again, working to shed all that extra water from your body after your organs and muscles have had enough to drink. But if your kidneys are shot, that means you can’t even pee because, well, there’s nothing there to make it. You literally can’t get rid of the extra water. Which means that people on dialysis know they need it when they start to feel bloated. Where still all those toxins the kidneys would usually get rid of start to pile on, making them feel extra sick. Dialysis is literally a lifeline. Which brings me back to those questions I started with at the top, because after it was invented post-World War two and developed throughout the 1950s, dialysis became a test case for exactly that scenario I laid out. A life preserving treatment for a disease that had previously been universally deadly. So what happened? Well, Congress acted, imagine that! Recognizing the need to vastly expand dialysis for Americans in 1972, Congress expanded Medicare, which at that point wasn’t even a decade old yet to cover dialysis services for people with end stage renal disease. It’s one of the only disease classes specifically covered by federal health insurance. Remember Medicare is America’s health insurance program developed specifically for seniors. It was basically Medicare for more. Congress acted to assure that nobody who needed dialysis would die because they couldn’t receive it. And that’s a great thing, full stop. But today’s episode is about what happened next. It’s about how corporate greed moved in to exploit the system. It’s about the rise of two monster corporations who ruthlessly crowded out the rest of the market, turning dialysis patients into the human equivalent of hamburgers. Their analogy, not mine. And it’s about how companies that get too big to fail are allowed to write their own set of policies in a democracy that has long needed its own dialysis to purify itself of corporate campaign dollars. I learned about how dialysis became a sad microcosm of corporate greed in American health care when I came across a new book by our guest today. Tom Mueller is an investigative journalist and author of How to Make a Killing, which chronicles the rise of the two dialysis mega giants and how greed came to dominate dialysis and victimized patients and caregivers. Here’s my conversation with Tom Mueller. 

Dr. Abdul El-Sayed: Can you introduce yourself for the tape? 

Tom Mueller: I’m Tom Mueller, I’m an investigative journalist, and I’ve written a book called How to Make a Killing: Blood, Death and Dollars in American Medicine. 

Dr. Abdul El-Sayed: So can I ask you, you know, just to to jump in so much I mean, the entire book and our conversation today is going to be about dialysis. And uh I can give an explanation of what dialysis is. But you’ve written a whole book about dialysis, so uh I’m gonna leave it to you. Can you tell us a little bit about what is dialysis? 

Tom Mueller: Sure, in layman’s terms, if your kidneys fail, you lose a filtration system that is critical to human life. If someone suffers kidney failure and that can happen because of disease or because of a preexisting condition or because of diabetes, hypertension, and obesity, various other factors. Without treatment, you will die within days and the kidneys do a range of different things. They filter out toxic products of our metabolism. They remove fluid that normal kidneys pass through urination. They produce hormones that are important for red blood development and various other things. They are really kind of a Swiss Army knife of of the human organism, largely unappreciated. They’re unsung heroes. You know we talk about people’s brains and their guts and their heart and so on. But they don’t we don’t talk about their renal fortitude, but we do need our kidneys. So when your kidneys fail, you either get a transplant and that takes time, or you go on to dialysis, which is a mechanical kidney that does some of the filtration that your natural kidneys used to do. You attach yourself to the machine or you are attached to the machine by staff in a dialysis clinic typically. The ideal way to do it is at home, but um that’s rarely used. It’s a rarely used model in Americans. And the machine filters your blood for a period of three, four or five hours, removing some of the toxins and some of the liquid that has built up over time and then detach from the machine and go for another couple of days. Ideally, most people are are dialysing every other day. Uh. So that’s in essence what dialysis is.

Dr. Abdul El-Sayed: Yeah. So kidneys are one of those organs that nobody really pays enough attention to because they’re just not as glamorous as lungs or heart or certainly not brain. Uh. And we got two of them. And so, you know, you lose one and be just fine. The challenge, of course, is when you lose them both. And we don’t really appreciate that um, that the work that the kidney does is is about more than making urine. It’s about all of the things that go into uh filtering uh blood so that urine is what urine should be and blood is what blood should be. And if you can’t do that, there is a whole process that we’ve now discovered about how to do it. It’s certainly, you know, decades old now. Um. But I want to ask you, you know, as someone who is not um a physician, not someone who, you know, learned about this in some formalized training. When did you first hear about dialysis? And then why did you decide to write a book about it? 

Tom Mueller: That’s a very, very good question Abdul. Um. I learned about dialysis while writing my previous book on whistleblowing, and each chapter in my whistleblower book took on a set of whistleblowers that have blown the whistle on alleged wrongdoing in various industries and in government agencies. And one of these industries was dialysis. And I had really never I mean I’ve heard the word dialysis, but I never stopped to think what that meant. But the um three of the whistleblowers that I interviewed, their settlements alone totaled almost a billion dollars. And um then I thought, what on earth is this industry? Um. They explained to me that that the industry is dominated by two multinational companies that control almost 80% of the patient population and so on but anyway, I I got into dialysis kind of backed into dialysis, writing about whistleblowing, and I realized very soon that this story is much, much bigger than a chapter in a whistleblower book. It deserves its own book. And at that point, I kind of took the plunge into into dialysis, into this world that really most people don’t even know about unless they happen to have a relative on dialysis. It’s just this sort of a facade and a model that you drive by until um you’re unfortunate enough to have to need it. 

Dr. Abdul El-Sayed: Yeah. And just to appreciate just how big a piece in someone’s life dialysis can be if they need it. Tell us about just the experience of getting dialysis. Like if you’re somebody who is a dialysis patient, you have full blown renal disease and kidney failure. What is your what is your day to day like and where does dialysis fit in or more importantly tell us about dialysis and how the rest of your day to day fits in?

Tom Mueller: Right, exactly. Yeah. I mean, a lot of the patients that I spoke with were getting what many would consider insufficient dialysis. Too short, too fast, you know, abbreviated treatments and in these clinics. And they talked about a life that was pretty much dominated by their dialysis experience. They would have to get themselves psyched up to go in for treatment. Um. They would have really strong and miserable um symptoms while treating. So they have cramps, nausea, vomiting, and so on. And it’d be wiped out by the end of the treatments. They now have to kind of rest before they could even go home. They’d sleep the rest of the day, they get up and start to feel you know decent the next day, but already started to psych themselves up for the following treatments. Obviously this is the worst case kind of scenario for for patients, but it’s something I heard a lot when I was interviewing patients. So and and when dialysis is done short, sharp, fast, as one Australian [?] put it, uh bazooka dialysis, high speed, high throughput, get them on and get them off. It can really create um a crushing set of symptoms that make the dialysis patient’s life very, very [?] very difficult. 

Dr. Abdul El-Sayed: And how often is a dialysis patient being dialyzed? 

Tom Mueller: Uh. You know, each dialysis patient should have their own very specific prescription that takes in their own very specific biology, their own specific health needs. The typical answer to that question is three times a week for three, three plus hours at a treatment. So nine hou– nine hours per week. But there is, there should be a great deal of variation in that. And 3 hours is widely believed not to be a sufficient treatment for most patients. 

Dr. Abdul El-Sayed: Hmm. And what happens if you’re not getting the dialysis you need? What are the symptoms of um of not getting that dialysis uh in time? 

Tom Mueller: If you get insufficient dialysis uh or no dialysis, uh which is sort of two ways of saying the same thing. Um. First of all, there are short term symptoms of weakness, nausea, vomiting, horrible cramps um and dizziness, confusion. Uh they call it dialysis fog or brain fog. Um. In the longer term, there’s organ [?] and other heart and liver and and other organ damage, brain damage that is done because of sudden drops in um blood pressure, quite often due to high ultra filtration rate, high removal, rapid removal of of the liquid from the bloodstream. Um. That should be done gently and slowly and over a period, a longer period of time. If it’s ripped off, as some people have said, some clinic workers have said rip off that liquids um in the in the medium term you’ll cause organ stunting and pretty serious side effects, including coronary arrest. You know, people die from this kind of treatment over the long term. 

Dr. Abdul El-Sayed: Yeah, And I just want to you know comment on that because I want listeners to sort of think through our body is a homeostasis machine. It’s really, really good at accommodating these differences that that happen over time. You know, think about it. You drink too much water and your urine turns clear until you have that water taken off. You don’t drink enough water and your your urine turns ultra yellow until you drink more water and you get really, really thirsty in the process. That’s all your kidneys. Your kidneys are doing all of that. Now, if you don’t have functional kidneys, what happens is that our uh process um for correcting not just water flow, but all of the other um waste that’s sitting there in your blood can do that at a speed that is far quicker than your kidneys would know how to do it. Right? And so our kidneys are really smart about saying, all right, we know how fast we can adjust. But but unfortunately, if you have an economic incentive uh to rip it off fast because you want to free up more seats in the dialysis unit. Right and operate at the maximal efficiency for your dollar flow rather than the maximal safety for a potential patient. You can start to see what the implications can be. And if you adjust those things faster than your body can accommodate them, it can be really, really dangerous. Um. So just to understand how big of a business is dialysis in America? Both in terms of the number of people who are getting dialysis care and in terms of the money that can be made here?

Tom Mueller: Um. There are about 800,000 people currently on dialysis in America. Um. The the more shocking number is that 37 million Americans have some level of kidney disease and nine out of ten don’t even know it. And and the drivers here, as I said earlier, are um typically hypertension, obesity and diabetes, which are epidemics in America. So, you know, a lot of people are moving down that path towards towards kidney failure and towards dialysis that don’t even know it. And and those it’s there’s an expression crashing into dialysis, which kind of captures the way in which one day you’re just walking around, you’re doing your stuff you it’s just normal life. And then and you have a health event, you wake up in the ER or you wake up in the hospital and someone is by your bedside saying, sorry, kidneys failed. From now on, you have to attach yourself to a machine to survive until we can get a transplant if you ever get one. And that’s a real shocking physiological but also psychological shift for many people, this dependency on the machine. Um. And that’s part of the reason why dialysis when it came out in the sixties and became a viable treatment, helped kick start bioethics, because this is the first time that a vital organ was replaced by a machine. Um. There was a huge um demand for it, but very, very few actual dialysis units. So a lot of patients at the beginning were simply not able to be treated and died. So there were actual life and death panels um being organized by hospitals to determine who would live and who would die. Anyway, bioethics got kickstarted by this, um and it’s pretty easy to see why. But um it’s a huge industry. Um. There are two, as I said, major multinationals Fresenius and DaVita, whose market cap combined is something like 40 billion dollars. Um. 

Dr. Abdul El-Sayed: Wow. 

Tom Mueller: They make billions of dollars in profit every year. Um. So it’s a good business to be in from a financial point of view, it’s not a great place to be in from a patient’s point of view. 

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Dr. Abdul El-Sayed: Can you walk us through just the history of dialysis as a as a business? So it opens up in the sixties and now we’re in this, in effect, oligopolistic circumstance. And the other part of of dialysis, which a lot of folks don’t appreciate, is that dialysis is really odd because it’s entirely Medicare funded, unlike so many other pieces of health care. I mean, it really is unique insofar as it’s the only piece of health care that because of what it is, is funded by Medicare. So for most folks, Medicare only kicks in when you’re 65. But if you’re on dialysis, Medicare will pay for your dialysis if you’re 35, 45, 55 or 65. And um and that makes it really unique insofar as it creates this situation where you have this race for this business. Can you first talk about that Medicare policy decision? How did that come about? 

Tom Mueller: Sure, dialysis was born during World War Two um when a collection of different, brilliant MDs but also inspired inventors started cobbling together these machines out of sausage casings and pieces of downed fighter planes and and bicycle pumps and all sorts of other things just to try to tide over uh people who had had kidney failure so their kidneys would restart. Um. They weren’t long term viable cures. In the sixties, two major centers um Seattle on the one hand and Boston on the other with very cutting edge nephrologists. And at a time when nephrology was a new uh specialization, they made it possible for chronic treatment of dialysis. In the past you had this machine that could filter the blood, but each time you attached it to the person, you would destroy a major blood vessel and after a few uh treatments, you’d run out of access points. In Seattle, the um building Scribner, one of the one of the pioneers, invented the Scribner shunt uh a way to attach and detach a patient repeatedly from from the machine. And all of a sudden dialysis became you know uh viable as a treatment. Now, at the same time that the announcement was made, guess what this former death sentence is now treatable. A line began to form outside their door that got longer and longer and longer of people who the day before would have said, well, you know, my number came up. I’m going I’m doomed to die. All of a sudden, there was a possibility, and this is where the the um life and death panels came into play. So you had a number of different centers, but really, Harvard and uh Seattle were two kind of standard [?]. And they had a totally different approach to the business of dialysis, Seattle said nonprofit all the way, fundraising in the local community, getting federal funds as well. Uh and we’re going to treat people um in a nonprofit model. The Harvard uh MDs said, No, we need to roll this up fast and we’re going to get rich doing it. And they started National Medical Care, which was the first dialysis giant for profit, strictly for profit. And in fact, they were back in the sixties these were, you know, heady words. They were the first among the first doctor entrepreneurs. They talked about how it wasn’t a conflict of interest to make money while treating people, it’s actually positive. It made you as an M.D., focus on costs and what’s good for the patients and so on. Uh I think that’s since been debunked. But at the time it sounded great and Reaganomics was coming in and they were they caught that wave and ultimately they won the argument the the Boston model um completely drowned out the nonprofit Seattle model. So it became a major flashpoint for the American conversation around health care. Um. You have this new machine, you can save lives that yesterday would have been impossible to save, but there’s a very limited amount of treatment points and the costs were significant so many people couldn’t afford it and people were dying because they couldn’t afford it. So Congress at a time now remember, we’re talking in the late sixties or early seventies. This is a time when Republicans, Democrats, the AMA, American Medical Association, insurance companies and a bunch of others all had in mind and were pushing hard a plan for comprehensive national health. It’s hard to remember that, but back in the six–, in the late sixties and early seventies, this is the great generation. You know, the carry on from the New Deal. This was this was this was part of the plan that that the U.S. was going to join the rest of the civilized world and in having comprehensive national health and dialysis was considered in 1972 to be the first step towards comprehensive national health. Everyone had expected within a year we would have had a national health plan. So in November of 1972, Richard Nixon signed into law um an adjustment of the Social Security Act that made, as you said, dialysis, a medicare for all condition. But again, with the expectation on everyone’s part that this was just phase one, we’re all going to have national health. And then Watergate, Vietnam consumed Nixon. Uh. We turned from, you know, stagflation and and the OPEC oil embargo caused a reshifting of of priorities from building great generation um you know programs like health care to cost cutting. And Reagan came in and Reaganomics and private does it better. Government is part of the problem. There’s a huge shift and and and dialysis Marxist caesura from from really great generation build a better society to cut costs and private does it better and we’ve never gone back. Um. Dialysis has remained the sort of legacy of Medicare for all. But um there’s never been another moment where there was bipartisan support for, you know, what every other developed country in the world has, that many lesser developed countries, national health care as a as a guaranteed right of all citizens. Um. So it’s hard to look back and think that Richard Nixon signed this. Uh. What would today be by many Republicans be called socialist, uh um a law [?] social sociable society. Those are all good things to me. But hey I’m not a doctor. 

Dr. Abdul El-Sayed: No, I um I really appreciate a lot of the nuggets in terms of the path dependency here. You know, this is it’s hard to imagine this is just after the passing of Medicare itself. So Medicare at this point is a pretty new program. And to your point, right, this is seen as a logical extension of Medicare. We’re going to first provide health care to people over the age of 65. This was also, you know, in the same process that’s how Medicaid was created. So we’re going to provide health care to the lowest income people. And then we’re going to piecemeal add different parts of health care. And this one seems to be an urgent one because we have this new, extremely expensive but incredibly life saving uh piece of health care that is too limited to be offered to everyone. This seems like an obvious step to take to save a whole lot of lives, to provide funding and to grow this program. And then history uh intervenes. And um frankly, here we are. Uh. You know, I wrote a book called Medicare for All. And it is a really interesting um question about what the impact of having one service funded by the government versus an entire health care system funded by by the government can mean. So we have this system now where you have a $40 billion dollar industry dominated by two corporate players uh that are funded almost entirely by the federal government. How do we get from that moment when Nixon signs that law to where we are today, where you just have these two corporate behemoths owning the industry? 

Tom Mueller: Basically, we go from a moment in time when the urgency to rollout clinics was extreme. And in fact, in the ’72 legislation, Congress gave all sorts of [?] built in all sorts of incentives for people to open dialysis clinics. So you got um at first a kind of a widespread range of different facilities being opened up by, you know, individual nephrologists, by nephrologist groups, by hospitals, and then some for profit um concerns like National Medical Care as well. But they were widespread. Many, many non-profits um were popping up here and there. And and and the you know, the saturation point was never reached. But at a certain point, the the as often happens in industries, there’s a process of consolidation. The big ones start beating the little ones. Um. And that process, Pac-Man process, continued um before really uh from the from the late eighties through the mid 2000 teens um where that’s, you know, small mom and pop shops were bought out by larger companies. Those in turn were bought up by regional giants and those in turn were bought up eventually by the Fresenius and the DaVita. Um. There are a couple other players, um but but those are really the two key ones. And I want to stress that consolidation, at least at the beginning, wasn’t always bad. First of all, this was a new field of medicine. You needed benchmarks and you needed a serious attention to detail. Many of the mom and pop shops in the early days were sort of, you know, I’ve heard these horror stories of of of rolling dialysis clinics on campers and various other things that were really not and simply people trying to take advantage of the incentives rather than providing good medicine. So in many cases, at first the consolidation produced better outcomes, better dialysis. But um at a certain point, consolidation has tended to produce a one size fits all model, a fast food model. And in fact, you know, the leaders of the major companies often talk about um the dialysis business as a fast food medicine business, massive scale. So you can have low unit costs and buy very cheaply and you try to standardize the treatments and maximize the throughput. And you know all of this sounds really good from an entrepreneurial point of view. It produces what we’ve seen massively successful corporations, from a health point of view, as you know better than I, if you don’t tailor the treatments to individual physiologies, you can run into some big problems. Some people are not widgets. Uh. I’ve interviewed some some I think originally fairly right wing and maybe still right wing economists who started looking at the dialysis industry saying, yeah, I think the fast food model is going to work here because you know bigger ones are going to do it better and they have better protocols and so on. And they came out the far end and I quote them in my book saying this is an outrage. Um. They are taking they’re doing profits instead of patients. So it’s not like burgers where you produce a pretty good product and it and it’s the same every time. Tailoring treatment is critical to good dialysis as it is to good medical care in general. 

Dr. Abdul El-Sayed: Hmm. If you’re buying a burger or you’re buying a taco or a pizza, you kind of want it to look the same every single time. Because you’re after that same unnecessary but generally enjoyable product. If you’re getting medical care, you decidedly do not want it to look the same every time unless you’re presuming that the nature of the injury has not changed. Which de facto right is not true because humans change. So if you literally take the same exact human being who’s been on dialysis for ten years the day they start and ten years later they are a different patient. They’re ten years older. The nature of the other diseases that probably caused the the renal failure to begin with has progressed, has changed. They’re on different medications that you have to engage with because a lot of medications are either cleared in the liver or cleared by the kidney. And so as those medication doses change, you need to be able to dialyze appropriately. So you’re clearing out all of the metabolites that you need to get out that a kidney would usually clear. And when you have a one size fits all medical model in this respect, you start to appreciate how broken that is. Now, folks will listen to this and say, Yeah, but isn’t that the outcome of a government funded health care program? And it’s a really fascinating thing because this is one of the only pieces of health care that would even lend itself right to that kind of one size fits all thinking where a few corporations can hammer down their operations so efficiently and brutally um to be able to offer this kind of service and then force everyone into it. I want to ask you, what are some of the ways that this kind of fast food ization of of this industry have shown up in the lives of the patients who are brutalized by it? 

Tom Mueller: I just want to insert one thought that um it may not be. I mean, Steffie Woolhandler, who is a distinguished M.D. Ph.D., um public policy thinker, um said to me, well, look, um you know, you have tax dollars that are going into this Medicare for All. You have patients and their caregivers, but in between, you have they have, you know, a major corporation or two have inserted themselves um and they are essentially acting as tollbooths. And she said, you know, you don’t need those corporations, you need the treatment and the patients on the one hand, you need the funding on the other. But in other countries, the funding goes straight through. There is no tollbooth and no one’s you know taking a cut, as it were. So um the model is is is uh is not necessarily the way it’s purported to be. I mean, every other country in the developed world doesn’t have this massive for profit um tollbooth [laugh] between between the patients and the and the funding source. But to come back to your question, um it standardized dialysis treatments. First of all, the whole business of being in center is something that from the beginning, from the debates in Congress in the sixties, it’s clear that home dialysis, wherever possible, is vastly, vastly superior. A, because you can tailor it to your own physical needs, B,  because you have control over your own schedule. C, because as in any chronic condition, a sense of control, a sense of empowerment of agency prevents this sort of feeling of just being at the mercy of your condition. Um. And all of these things um produce better outcome and produced better outcomes. And if you look at places like Australia um and New Zealand, um where home dialysis is is widely practiced, the results are vastly better. In fact, the results are vastly better everywhere else in the developed world than they are in America. So what’s wrong with this picture? Um. But also once you’re in the facility, if you’re being rushed on and rushed off the machine, if they’re cranking up the ultra filtration rate so they’re ripping this liquid off of you. We talked about some of the really onerous um symptoms that are produced, but also some of the physical harms that are produced as a part of this model. I actually I was at the annual dialysis conference in Orlando in 2018, and Allen Collins, a very, very senior um researcher, said, we are creating a disease state with this high pressure dialysis. We are actually creating medical harms with the medical treatment we are providing if we provide it in this manner. So it’s pretty well understood. There are 30 years more or less of of peer reviewed data on why this is a bad way to produce dialysis. Um. But from a financial point of view, it makes a lot of sense. And we are in a society in which a medical corporation can be judged almost exclusively on its financial performance. And and that’s a nonsense to people who come from other countries, and it should be nonsense to us, frankly. I mean, people are not burgers, as we discussed, but um at this current moment, um people can say, hey, you know, we are a extremely successful hospital system. Well, how are your patients doing? Secondary question, right? Look at our– 

Dr. Abdul El-Sayed: Yeah. 

Tom Mueller: You know talk to our Wall Street analysts. They’re overjoyed. Look at our stock price. We’re we’re golden. So, you know, I think we have to kind of fundamentally rethink uh the priorities here between profits and patients. You know, this current system, as it’s configured, um victimizes patients, but also victimizes caregivers from the dialysis techs, who are the sort of the low people on the totem pole to registered nurses straight on up to nephrologists who feel that their autonomy as MDs is severely limited by working for a big company. They’re forced to take part in the uh as one put it, I contribute to the ill health of the people I’m supposed to be caring for. They realize that the model itself, this vast bazooka dialysis model, is actually detrimental to their patients health, the rushing people on, rushing people off, not having time to clean the the units and so on. They realize that they’re not curing or helping their patients. They’re harming them, and there’s nowhere for them to go. 

Dr. Abdul El-Sayed: So the picture that you’ve painted is a situation where public policy allows for the vast scaling of a nearly miraculous life saving treatment at the population level. Two large corporations start to buy up all of the businesses that crop up to provide this service. Installing themselves as you called it or Steffie called it a tollbooth and then forcing individuals into their cookie cutter approach to this service in order to maximize their operational efficiencies and maximize their profit on the back of government tax dollars. In the process creating all kinds of complications for people who are being dialyzed too fast or not being dialyzed enough. And maximizing their chokehold on this service in this country. And you brought up the specter of of other countries where dialysis is done differently, also publicly funded but done differently. How much worse do American dialysis patients do relative to counterparts abroad? 

Tom Mueller: Uh. Vastly worse. Uh you know the mortality rate in American facilities on average um is something on the order of 20%. So one in five people in the room is going to be dead every year. Um. Europe is on the order of 20% better than that. And Japan is 30 to 35% better than that. I mean, um it’s vastly, vastly um inferior treatment for vastly higher um outlays. I mean, the amount of money that is spent on U.S. dialysis is something on the order of 7% of all Medicare goes into dialysis. And that’s just the Medicare piece. 

Dr. Abdul El-Sayed: Wow. 

Tom Mueller: So um we’re talking about a lot of money for ultimately outcomes that don’t measure up to the rest of the industrialized world. There’s something wrong with this picture. 

Dr. Abdul El-Sayed: That is that is insane, um as is so much of our health care system. Um. And I want to ask you, you you tell the story in your book about dialysis as a microcosm of the broader health care system writ large. First, what would it look like to fix the dialysis system? And then second, what does that tell us about what we need to do to fix the American health care system more broadly? 

Tom Mueller: I think this is an excellent question Abdul and my book ends with a number of different vectors, a number of different forces that are moving towards improving dialysis, fixing dialysis, um at least bringing it up to the rest of the world. And I think lessons can be learned that will be applicable to the rest of the health care system. I mean, first of all, several economists that I spoke with, one of them, Thomas Wollmann, wrote a marvelous paper called How to Get Away with Merger, and demonstrated that basically these consolidated extreme consolidation of the dialysis industry has been done kind of under the radar of the FTC. [?] The acquisitions were done at under $5 million uh dollars a pump and therefore they didn’t come up on the radar of the FTC and didn’t trigger an investigation. In his view, according to his published research, um it would have triggered, in many cases, a concern about monopoly duopoly um situation. So another senior economist, Ryan McDevitt, said to me, you know, I think one of the things we need to do is start start talking about breaking up these big companies. These they are too big. They are functionally monopolistic in many regional markets because you have to remember you can’t shop around as a dialysis patient. You need a facility either in your home ideally, but that’s difficult to arrange because of the current model or near your home um and so in many cases um the Fresenius or DaVita has a kind of a stranglehold on the local market. So really there’s only one game in town for you. And these economists have said that’s a step one is making smaller companies that are and there’s and more real competition because in their view and from what I’ve been able to research in my in the process of six years of reporting and research, and um there isn’t a lot of competition between the companies. Um. There are there are is phenomena that kind of suggest that they’re working together in certain ways. For instance, I I chronicle um the process of involuntary discharge from dialysis. And if you just take one moment to pause and think involuntary discharge from life saving dialysis care. You know, that gets your attention, right? Um I it got my attention and I thought it was a one off thing at first. The more people I interviewed, the more I dug into it, the more I talked with regulators and former regulators. It’s it’s a major problem. It’s also a major problem in other areas of health care, um you know um in in hospitals, in in elder care, and in certain hospitals. People are pushed to the curb when their insurance runs out uh or when they cause trouble. But in any case, um people who are in voluntarily discharged, in my experience from my reporting, discharged from facilities are quite often blackballed in in neighboring facilities, even those run by other companies. Which says to me that they are saying, okay, this is a person who was probably not financially very interesting and maybe they are they are perceived as a trouble marker. Whether they’re not or whether they are a troublemaker or not is a very, very different question. And I get into that in my book as well. But um and we’re not going to treat them. But that’s almost, in my view, um acting in concert, um you know, you’re you’re–

Dr. Abdul El-Sayed: Collusion. 

Tom Mueller: –siding. Yeah. Yeah. I mean, it’s a cartel kind of style. I can’t prove it. But all the evidence that I was able to gather suggests that. Um. So there are concerns here, though I think that have to be looked at in terms of just the scale of these of these corporations and whether patients wouldn’t receive much better care, much more tailored care from smaller organizations. 

Dr. Abdul El-Sayed: Mmm. A lot of this, like you talked about, it echoes a certain level of consolidation that’s happening across the country in health care. And it’s happening in ways big and in ways small. But more and more of our health care is being provided by very large systems that dehumanize patients and providers and uh are built to squeeze as much money out of a particular case as possible. And your book talks about how the endgame has almost been reached when it comes to dialysis um in some really, really detrimental ways to people uh who fundamentally need this this care to to survive. Um. And it it is a wake up call to all of us who care about a health care system that is more just, more equitable, more sustainable, uh that does not force people to bear the the insult to the injury of their illness, that is bankruptcy. Um. And we really appreciate you joining us today to share more about your findings. Our guest today is Tom Mueller. He’s an investigative journalist. His latest book is How to Make a Killing. I hope that you all will check it out. Tom, thank you so much for taking the time. 

Tom Mueller: Thank you so much Abdul, I appreciate it. [music break]

Dr. Abdul El-Sayed, narrating: As usual. Here’s what I’m watching right now. Well, it’s fall and– 

[clip of unspecified news reporter] A rising number of COVID cases sparking new concern just as students fill classrooms across the country. 

Dr. Abdul El-Sayed: Yup, COVID feels like it’s everywhere right now. And worse, hospitalizations are up 16% since last month, while COVID deaths are up 10%. Remember, these increases are up from COVID era lows earlier this summer, so they remain quite low relative to the worst of the pandemic. But it should remind us that, well, COVID isn’t over. Importantly, as of Sunday, the FDA and CDC still have yet to announce the new fall booster given the conundrum we find ourselves in, remember, the fall booster was built around maximizing reactivity to XBB, the Omicron sub variant that had been dominant through most of the spring. Since however, two new variants have emerged. The first is Eris, another Omicron sub variant that is currently accounting for most cases. But the other one is Pirola or BA.2.86, which is, if you’ll remember, a vast leap forward from Omicron. Rather than just another Omicron sub variant, Pirola is as far from the original Omicron as the original Omicron is from the original SARS-CoV-2. While Pirola has been discovered in several countries, there have only been a few dozen reported cases, and early laboratory evidence suggests that despite its mutations, it just doesn’t seem very effective at invading cells. And that’s really good news. More importantly, a recent study preprint showed that the fall booster has strong reactivity against Pirola. That suggests to us that we’ll probably be getting the final go ahead for the new boosters any day now. We’ll keep our eyes and ears out for you. Have I ever told you how much I love young people? They just get it. Say what you will about Gen Z. But they’ve grown up in an era where they watched the basic slogans about the American dream, etc., fundamentally fail them. Most of them weren’t even born when 9/11 launched us into two decades of foolhardy wars. They were children when their parents lost homes and saw life savings wiped out during the Great Recession. They were in high school or college when the pandemic derailed their early adulthood, and the vast majority don’t believe they’ll ever be able to afford a house. Which is why it’s not surprising that they understand that it’s absolute trash that we’re the only high income country in the world that doesn’t guarantee health care as a human right. In fact, a recent survey of Zoomers, aged 18 to 24, found that the vast majority believed that health care was a human right and that the government had a responsibility to provide it. 93% of Gen Z Democrats and get this, 76% of Gen Z Republicans three quarters believe that health care is a human right. A whopping 68% of Gen Z Republicans, republicans believe that government had a responsibility to provide health care. When people ask me about the potential for Medicare for All in this country. I’ve always said it hinges on the next generation, one that watched as America struggled to provide a basic response to the pandemic. And now I’ve got the data to prove it. A new poll from the de Beaumont Foundation, one of our sponsors, found that 70% of Americans have favorable impressions of their local health official. As a local health official, I can tell you that I’m really glad to hear it. Thank you. But also, I think that it should serve as a call to action for all of us in public health. Since the pandemic, I think that the public health community has felt a pervasive sense that we’re under attack. But a lot of that has more to do with the ways we get our information than it does with how the vast majority of Americans feel about public health. The very online right, well, they occupy a disproportionate share of our mindspace, making us believe that they speak for everyone. They clearly don’t. And that means that rather than retreat, we need to press on. This is the time to be present and engaged in folks day to day lives fighting on the issues they care about. Whether it’s the way that pollution is choking their kids or distracted drivers are wreaking havoc, or pharmaceutical companies are charging us way too much for insulin or vaping manufacturers are exploiting our kids. It’s time to go on the offensive. We need to earn that trust that folks already have in us every single day. That’s it for today. On your way out. Don’t forget to rate and review. It really does go a long way. Also, if you love the show and want to rep us, I hope you’ll drop by the Crooked store for some America Dissected merch. If you haven’t gotten one of those sick pod bro tanks, I highly recommend it. [music break] America Dissected is a product of Crooked Media. Our producer is Austin Fisher. Our associate producers are Tara Terpstra and Emma Illick-Frank. Vasilis Fotopoulos mixes and masters the show. Production support from Ari Schwartz. Our theme song is about Taka Yasuzawa and Alex Sugiura. Our executive producers are Leo Duran, Sarah, Geismer, Michael Martinez and me, Dr. Abdul El-Sayed, your host. Thanks for listening. [music break] This show is for general information and entertainment purposes only. It’s not intended to provide specific health care or medical advice and should not be construed as providing health care or medical advice. Please consult your physician with any questions related to your own health. The views expressed in this podcast reflect those of the host and guests and do not necessarily represent the view and opinion of Wayne County, Michigan, or its Department of Health, Human and Veterans Services.