The Jordan Harbinger Show - 1336: Dialysis | Skeptical Sunday

Episode Date: May 31, 2026

This Skeptical Sunday, Jessica Wynn explains how dialysis became a $50B industry where under 40% of patients survive five painful years of dependence.Welcome to Skeptical Sunday, a special edition of The Jordan Harbinger Show where Jordan and a guest break down a topic that you may have never thought about, open things up, and debunk common misconceptions. This time around, we’re joined by writer and researcher Jessica Wynn!Full show notes and resources can be found here: jordanharbinger.com/1336On This Week's Skeptical Sunday:Dialysis is a life-sustaining external filtration system for the roughly 800,000 Americans in kidney failure — but it's grueling. Most patients endure three to five hours per session, three times a week, indefinitely, and fewer than 40% survive beyond five years.The financial structure is staggering. Dialysis is a $50 billion-a-year US industry, with Medicare spending about $36 billion annually — roughly 7% of its entire budget for under 1% of the population. Two companies, DaVita and Fresenius, control about 70% of all clinics.The system rewards permanence over cure. Since 1972, Medicare has covered kidney failure for everyone regardless of age, creating guaranteed, indefinite revenue. Transplants and home dialysis are cheaper and better for patients, yet under-incentivized because they cost providers customers.The human and safety toll is severe. Infections cause 36% of dialysis deaths, sepsis mortality runs 100 to 300 times higher than average, and understaffing worsens outcomes. Many patients lose their jobs, mobility, and social lives — some choose to stop treatment entirely.The hopeful part: much kidney disease is preventable or delayable, and you have real power here. Manage diabetes and hypertension aggressively, get your kidneys checked with a simple blood and urine test, and see a nephrologist early — catching it sooner can dramatically slow progression.Connect with Jordan on Twitter, Instagram, and YouTube. If you have something you'd like us to tackle here on Skeptical Sunday, drop Jordan a line at [e-mail] and let him know!Connect with Jessica Wynn at Instagram (and Instagram!), and subscribe to her newsletters: Between the Lines and Where the Shadows Linger!And if you're still game to support us, please leave a review here — even one sentence helps! Sign up for Six-Minute Networking — our free networking and relationship development mini course — at jordanharbinger.com/course!Subscribe to our once-a-week Wee Bit Wiser newsletter today and start filling your Wednesdays with wisdom!Do you even Reddit, bro? Join us at r/JordanHarbinger!This Episode Is Brought To You By Our Fine Sponsors: Lufthansa Allegris: Go to Lufthansa.com and search for "Allegris" to learn moreCookUnity: 50% off first week: cookunity.com/jordan or code JORDANRevolve Man: 15% off: revolve.com/jordan, code JordanMarathon Rewards: Sign up today: marathonrewards.comSee Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

This episode is brought to you by Lufthansa. Lufthansa Allegra is an innovative, elevated travel experience across all classes, focusing on each person with their own individual and situational needs. Look forward to your own feel-good moment above the clouds. Visit Lufthansa.com and search for Allegrais to learn more. Liftonza Allegrais, all it takes is a yes. Welcome to Sceptical Sunday. I'm your host, Jordan Harbinger. Today I'm here with Sceptical Sunday co-host writer and researcher Jessica Wynn.

On the Jordan Harbinger, you know it's funny, Jessica. I was doing comments on Spotify. You can look at people's comments and stuff. And I like to engage there. I like to engage wherever people comment about the show. And people were like, I don't know what it is with Jordan, but he just sucks up to this guest, Jessica.

And I was like, you do? You know, what a weird thing to say about somebody that you work with that you've known for a long time? Like, I would get it if it was like a celebrity, no offense.

I would get it if it's like a celebrity or something like that. Like, oh, look at this guy. And I'm like, is it weird to get along with people that you were? I don't know. That's the age of the internet that we're in right now

where it's actually weird. Right, be mean to me. Yeah. You shut up, Jessica. Who said you could talk on this episode of the show where I pay you to talk? I mean, what am I supposed to do?

Like, I'm supposed to talk down to you and make you look stupid on this show. That's... Yeah, please. That's entertainment, Jordan. It is. Well, that's what passes for entertainment. And the other thing that's weird about it

is it's like, if I were rude to you, I would like to think, I would hope that I would get more comments about how I'm not treating you well. But treating someone too well, I don't know. And people, like someone's like, Like, I agree with Tom or whatever.

Nick, I agree with Nick said that sucks up to it. And I'm just, I was thinking, because of course, me being the neurotic podcast host that I am, I'm like, well, now I have to think about every single thing I've ever said to you and what it might, the vibe of that might be. I don't know. I just thought that was such a funny. I meant to share that with you earlier, but I think it's a funny thing to share with the audience as well, because, I don't know, I guess we're not supposed to get along.

I don't know. Okay, let's be more combative today. Yeah, let's do that, huh? That's a good idea. Finally, you've had a good idea. All right, shut up. Yeah. On the Jordan Harbinger show, we decode the story, secrets, and skills of the world's most

fascinating people and turn their wisdom into practical advice that you can use to impact your own life and those around you. Our mission is to help you become a better informed, more critical thinker. During the week, we have long-form conversations with a variety of amazing folks, spies, CEOs, athletes, authors, thinkers, and performers. On Sundays, though, it's skeptical Sunday. A rotating guest co-host and I will break down a topic you may have never thought about and debunk common misconceptions about that topic, such as recycling, chemtrails, which are not a thing, astrology, which is a thing,

but also not a thing. Well, that's the theme of the show, right? It's a thing, but it's not what you think. Diet supplements, the lottery, reiki, healing, and more. If you're new to the show or you're looking for a handy way to tell your friends about the show, we've got starter packs. They're collections of our favorite episodes on persuasion,

negotiation, psychology, disinformation, junk science, crime and cults, and more. That'll help new listeners get a taste of everything we do here on the show. Just visit Jordan. harbinger.com slash start or search for us in your Spotify app to get started. Today on the show, we're talking about something most people never think about until it becomes everything they think about. Dialysis. It's one of those words that live somewhere in the back of your brain.

You kind of know maybe it's kidney related. You know it sounds serious. You hope you never need to know more than that. And then one day, it's your life on the line or that of somebody you love. And suddenly, that word isn't medical trivia. It's a machine you're hooked up to three times a week. There's something about this that feels very American. Look, we can build a device that keeps you alive and also quietly bankrupt to you. I mean, it's just a miracle of modern science. Here to help us filter the stream of info on dialysis is writer and researcher Jessica Wynn. So quick heads up, by the way, we're going to be discussing some medical stuff that's going to make some people squeamish. So if you're one of those people's

like, I'm listening while I'm eating and if it's going to be gross, you've got to tell me this might be one of those. Jess, dialysis, I'll be honest. I kind of know that it has to do with kidneys and blood cleaning and there's a machine involved in that there's franchises. That's kind of where my knowledge ends, which I think that puts me in with about 99% of Americans. Yeah, definitely. And the invisibility is the whole story. So I didn't know much about dialysis until a good friend's entire life changed after their diagnosis. Wow. Yeah, dialysis operates in this weird space where it's simultaneously a genuine medical miracle and a massive industry, but you don't see it until you're inside it. And by then, you know, you're not in a position to really ask hard questions.

Right. Yeah. I would imagine you are not shopping around or reading reviews online. You're just trying not to die. Right. And that ignorance matters because dialysis affects hundreds of thousands of people. It costs tens of billions of dollars, and it shapes how long and how well people live. Okay, so bring me up to speed. What are we actually talking about here? Okay, so let's start with what kidneys do. You know, they're incredible organs. They're about the size of your fist, and they filter your blood. Every day, they process about 200 quarts of blood to remove waste and extra water, which becomes urine. They balance electrolytes, regulate blood pressure. They even help make red blood cells. So they're basically like your body's water

treatment plant. And they run 24-7 in the background. You know, whenever I learn about organs, I'm always like, this, this is amazing. Every single thing in our body. Yeah. Yeah, first of all, they're busy. They never take breaks, really. They're just, you think like, oh, I'm, I'm so hard on whatever, like my stomach or whatever. Your stomach has it easy. Your stomach's hanging out most of the time. Yeah, you put some food in it. It holds acid. That's not an easy job. But your kidney they're just running a marathon all day, every day in the background. And yeah, making you pee. Right. It's nice to take it for granted. It is nice to take it for granted. And I guess that's why when they fail, you got a big problem. Right. And when they do fail, and that's about 800,000

Americans that are living with kidney failure right now. So your body can't clean itself. Waste builds up, fluid accumulates. And without intervention, you die, usually within weeks. Yeah, I was going to ask how long that took. I'm going to imagine that the last few weeks are really bad. How many days do you need where you're not cleaning the thing that you're usually cleaning 24-7 before you start feeling terrible? It's awful. It's horror movie awful. Yeah. Okay. So this is not like, I don't feel good. I should probably make a doctor's appointment. Okay, it's next week on Wednesday. This is a ticking health time bomb. So, all right, let me slow this down just a little bit more for a second here. When we say dialysis, what are we actually talking about? Well, so dialysis is an external.

version of that filtration system. So the most common type is hemodialysis. You go to a clinic. They stick two needles in your arm, usually in a surgically created like fistula. Okay, that's a really gross word. It's a really gross word. That makes my stomach turn and I don't know what it means. What is that? It sounds like something, oh, God, I don't know. Tell me what that means before I dry heave. So fistula is just the passage between like your organ and the body surface. It's just the name for that hollow, you know, surgically made passage. That sounds way grosser than it is. Okay.

It sounds like postule or something, right? Yeah, like it would be gross and oozy, but it's not. Okay. It's literally the passageway. That makes me feel a little bit better. I think I'm probably not alone there. Okay, that's. So we can say the surgically created passageway.

if you want. You can say fistula. Now that I know what it means, it's not as gross as it was when it was in my head. It was like something out of alien. Right. Okay. So that's where, you know, they've connected an artery to a vein to make it strong enough to handle repeated punctures. And then your blood flows out through one tube, through a machine with a special filter, and back into you through the other tube. How long does this take? How long are you sitting there when you do this? Yeah, it's a long time. Typically three to five. five hours per session. Oh my God. And that's three times a week. Oh, every week, forever. Or until you get a transplant or, you know, you die. Wow. Okay, three to five hours, three times a week. So this is, you're getting a part-time job filtering your blood. Oh my God. So when you say forever, well, you mean forever unless you get a transplant or die, that's not hyperbole because you can't just stop doing this and you, yeah, wow. Yeah. Welcome to dialysis.

Oh, yikes. Yeah, 15 hours a week, and that's minimum, and that's 52 weeks a year. So after a year, that adds up to you've spent a full month of your life sitting in a chair hooked up to a machine. Wow, man, that's a lot of candy crush, or perhaps listening to this podcast, and this is just keeping you alive. You're not curing anything. This is you're treading water when you do this. That's pretty much it. Right.

Your kidneys are still out of commission. So the machine does the kidneys job, but it's not even doing it that well. You know, natural kidneys work continuously and are perfectly calibrated. So dialysis happens three times a week, so you get this sawtooth patterns in your blood chemistry. Oh, yeah, sure. Right after treatment, it's perfect. Then increasingly toxic by day three. So it's like, instead of your heart beating constantly, it just beat really, really hard three times a week.

Yeah, yeah, and by the time it's ready to beat again, your blood is slowed to a crawl slash is not moving. Yeah, this makes sense. Yeah, you're right. I never thought about it. When I'm sleeping, you know, if I get up in the morning, I have to go to the bathroom and I probably have to go to the bathroom even in the middle of the night, right, because I'm well hydrated guy, TMI. But my kidneys are working that whole time. So I don't have to go anywhere and do it because it's working while I'm watching Tehran on my iPad or whatever, right? It's just going while in the sleep. Wow. So this whole go to a place and do it manually sounds profound. profoundly suboptimal. So, I mean, medically, emotionally, existentially, suboptimal. Okay, before we go further, who ends up needing dialysis? Do your kidneys randomly fail because your luck is bad? Who does this happen to? It's absolutely not random. So the two biggest causes are diabetes and hypertension. And together they account for about 70% of kidney failure cases. The rest are caused by a variation of sort of rare conditions or maybe addictions. And here's the really sobering part. Fewer than 40% of dialysis patients survive more than five years. What? Wait a minute. Yeah. That's like a cancer statistic. That's not something people think of

as a routine treatment. Okay. So wow. So by the time you're on dialysis, your health is not good at all. You're not okay. Yeah, you're not okay. I mean, being on dialysis is that serious. Yet, Most people have no idea. So what is actually killing these people? So it's lots of things. You know, it's heart disease. It's a lot of complications from diabetes. But here's the one that really stopped me.

Infections are responsible for 36% of all dialysis deaths. And the most common cause of death after that, withdraw from dialysis. So this isn't the disease and stuff killing them. This is people saying, I can't do this anymore. I don't want to do this anymore. and they just stop doing dialysis and let the illness take its course? Yes. Oh, my God.

About 21% of dialysis patients die after choosing to stop treatment. So it's most common in patients over 60. And to be clear, this usually happens with, you know, doctors and families involved. It's a huge end-of-life decision when the treatment itself has just become too burdensome. Yeah, okay, I see. So, by the way, I misspoke earlier because I said this isn't the disease. killing them. What I meant was this isn't the disease overrides the treatment. They just stop getting treatment. So I should probably clarify that. But it sounds like the treatment can become

harder than the disease, or at least it overrides your will to keep doing this nonsense, right? Every week. Oh, God. Yeah, for a lot of patients, absolutely. I mean, I don't want to romanticize any of this. You know, dialysis keeps people alive, but it can also mean hours in a clinic every week. There's exhaustion afterward, there's serious complications, not to mention the financial burden. And dialysis patients say, you know, I'm not living, I'm just not dying. And that calculation where death feels preferable to the machine, I mean, that tells you something really profound about what people are going through. Okay, you mentioned infections. Break that down for me, because, again, that number is bananas. It's over one third of people who die, die from an infection.

That seems like it shouldn't happen. Yeah, it's horrific, but dialysis requires vascular access. So either a fistula, like we talked about, a graft or a catheter is used. And every time you stick needles in someone or have a catheter line going into their bloodstream, you create an infection risk. And dialysis patients get this three times a week, week after week, year after year. I mean, the statistics are staggering. So sepsis mortality in dialysis patients is one to 300 times higher than in the general population. Wait, wait, wait, 100 to 300 times higher or percent higher?

Percent higher, right? Times higher. Oh, my God, that's horrific. It's hard to comprehend. Yeah. And bloodstream infections from staff bacteria occur 100 times more often in dialysis patients than in adults not on dialysis. You're right.

it's hard to wrap your mind around 300 times higher. That's like, oh my God. Yeah, it's wild. And these aren't freak accidents. These are predictable consequences of the treatment model. And infection rates vary wildly between clinics. So some have excellent protocols and low infection rates. Other clinics are infection factories.

But patients often have no way of knowing, you know, which kind of clinic they're walking into. Yeah. shouldn't there be ratings or something? Like some kind of this place will not kill you scoreboard. Because right now, it feels like dialysis clinics should have those big letter grades in the window, like restaurants in New York. You know, you get an A or a B or a C posted on the door. And like, congratulations, this clinic is a solid B plus of keeping your blood infection free.

Instead of instead of dumplings, it's your bloodstream. I don't know. Just not knowing what you're going to get and being subject to a staff infection that kills you. The dice roll here is crazy. It's just terrible. Yeah, plus you have a lot of other things on your mind. You know, you're putting a lot of trust into these clinics, but there actually are ratings. You know, Medicare gives dialysis clinics star scores based on outcomes and safety measures. And I'm guessing these are not posted on the window next to the inspirational happy kidney smiley face poster.

They're not, but they do exist. They're just not prominently displayed. and the methodology is complicated. So most patients go to the closest clinic because, you know, logistics dictate it. You need treatment three times a week. You can't really shop around. Yeah. If you need dialysis, you need dialysis.

And you're probably not like, you know what, that's it. I'm driving three hours away because it's cheaper and cleaner down and Modesto. Right, exactly. Which brings us to the second type peritoneal dialysis, where you do it at home. So you have a catheter in your abdomen, and you fill your belly with special fluid that draws out waste through the lining of your abdominal cavity. So you drain it out, you refill it, repeat. You know, some people do this manually several times a day. Others hook up to a machine at night that cycles the fluid while they sleep.

Okay, so that sounds better than the clinic, you know, immediately better. But again, it also makes me feel a little bit sick to my stomach. I feel bad saying that because these people have to live with it. And it's like, oh, Jordan's getting queasy hearing about it. But I think hopefully I'm coming across here is sympathetic because honestly, this just seems like such a terrible thing to have to go through. And I feel for anyone who has to deal with this. This is just a terrible way to live. And I'm, I mean, I just, I can't believe that, well, one, the technology is amazing, but I'm also like, how do we not have everybody at home?

I don't know. Maybe we'll talk about that in a bit. Yeah. I mean, it's wild. People just live this way. And so the at-home machines are better for many people. There's more freedom. It's gentler on the body.

And you're not tied to a dialysis chair in one specific clinic every week. So some home dialysis systems are even portable. So people can travel with the equipment or ship supplies to where they're going and continue treatment there. But infection risk is also lower when it's done properly. But for some reason, only 12% of U.S. dialysis patients, use it. Yeah, I don't even think about travel. How do you manage that? So why are only 12% of people using this if it's so much better? Well, now we're getting to the interesting part. So let me ask you something. If you were running a dialysis company, which would you prefer? Patients who

come to your clinic three times a week where you control everything and bill for every visit, or patients who do it themselves at home where you make less money. So home dialysis, particularly peritoneal dialysis is gentler, it's more flexible, and cheaper. And Medicare pays about $60,000 per year for home dialysis, but it pays $90,000 for in-clinic. After 15 straight minutes of kidney horror, even your anxiety needs a snack break. We'll be right back. This episode is sponsored in part by Cook Unity. Jen and I have started doing this thing where we eat at home more often, partly because it saves us a ton of time. By the time you deal with traffic parking, waiting for a table, getting home, the meal's a two-hour event.

We've also kind of exhausted our local restaurant rotation. You just at that point where everything feels repetitive. That's why Cook Unity has been a nice charge for us. It keeps meals interesting without us having to leave the house. The food actually tastes chef-made because it is real chefs, Michelin Star, James Beard Winners, Food Network Stars. They cook in small local kitchens, not mass-produced factory meals. We've been trying all kinds of different stuff.

Korean-inspired dishes, Mediterranean meals, high-protein options, pasta dishes. It genuinely feels like bringing new restaurant experiences home without the hassle or expense of constantly going out. And the biggest thing, it just saves us so much freaking time. Lunch or dinner is ready in minutes. The quality's great. There's no flavor fatigue because there are so many options available. Taste what happens when real award-winning chefs make fresh, small-batched meals just for you. Go to cookunity.com slash Jordan or enter code Jordan before checkout to get 50% off your first order.

That's 50% off your first order by using code Jordan or going to cook, Unity.com slash Jordan. This episode is also sponsored by Revolve Man. One thing I'm trying very hard to avoid is accidentally drifting into full default dad wardrobe territory. You know what I'm talking about. I still want the stuff that feels effortless and comfortable. But I also like wearing pieces that feel a little more unique

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of guessing. I got a big haul from Evolve Man recently, including these really clean on-cloud sneakers that I've been wearing constantly. It's exactly the kind of stuff I like. Comfortable, easy, somehow still makes me look put together without feeling overly styled. That's basically the sweet spot I'm trying to go for here at age 46. And the shipping makes it easy too. Free two-day shipping, easy returns, no hassle. Whether it's a big night out, a wedding, a trip, or just something you need last minute that actually works, Revolve man always has it. Go to Revolve.com slash Jordan to shop and use code Jordan for 15 person off your order. Free two-day shipping, easy returns. It just makes everything easier. That's revolve.com slash Jordan. And use code Jordan for 15 person off your entire order.

Offer end soon. Don't sleep on it. Don't forget about our newsletter, We Bitwiser. It is a gem from a past episode of the show from us to you. It's an under two-minute read comes out every Wednesday. Jordan Harbinger.com slash news is where you can find it. Now, back to Skeptical Sunday. So this is not about what's best for the patients. Color me surprised.

So, okay, are the diseases that lead to kidney failure? Are those predictable? Yeah, very much so. So they cluster in communities with less access to healthy food, preventative care, and safe environments. There's a disproportionate impact on older adults, low-income patients, black and brown communities, and people managing diabetes and hypertension without the resources to manage them well. I know somebody who had to do dialysis, and I remember she had a lot of, she had diabetes

and things like hypertension. I remember even just when I was younger, she had health problems. And then when she got older, she had to do this. So, okay, so by the time the machine shows up, these people had problems for years. the system has failed them in many ways repeatedly, right, if they live in a place where they can't get healthy food or, you know, health care, etc. Yeah, absolutely. And black Americans are three times more likely to develop kidney failure than white Americans. Okay.

Part of that might be genetic variant that's more common in people of West African descent. It's called APOL1. But genetics isn't destiny. So the bigger factors are things like living in food deserts where fresh produce, is scarce, working jobs without health insurance, breathing air near industrial sites, drinking water with lead contamination. You know, by the time someone's on dialysis, they've usually been dealt a bad hand for decades. Jess, I feel like we need to do an episode on food deserts because this is one of those things, and I know I'm going to sound like such a privileged POS right now, but I'm like,

come on, man, like, is that real? You can't get healthy food? They sell chicken everywhere, But I don't know. Like, I'm talking out of my ass, really. I don't know that. There can be many square miles where there's not one regular grocery store. It's just bodegas. You know what? Actually, now that you mention it, when I worked in downtown Detroit, I remember my boss was saying,

you know, a lot of the people in this neighborhood, they do their shopping at the convenience store where they have no business doing all their shopping. And I was like, that's so silly. Why don't they go to the grocery store? And he's like, well, they either walk downstairs and walk into this convenience store and spend an extra $10 buying milk and Cheetos and microwave stuff because that's what they have at the convenience store. Or they take the bus 15 minutes that way,

they go to the grocery store, they get a ton of bags, they get back on the bus with all of those bags. Maybe they have to stand on the way home, and then they walk back up to their place with all the bags of stuff. And I was like, that does sound like a pain in the butt because I was thinking like, oh, you just drive to the store, man. What's the big deal? But like, if you don't have a car.

And you live in a walk up without a mess. elevator and yeah you're doing it little at a time yeah just stuff i never really think about anyway so yeah because my knee jerk reaction is okay eat healthier dummy it's not that hard but it's i guess yeah it's not that simple let the meat cake is what i sound like right now let them go to whole foods yes why don't they just go to air one and buy uh yes an organic bean burrito yeah that's i know i sound for 45 yes that's exactly how i feel saying these things right now but yeah i just because food desert sounds it just sounds fake to me. I can't be alone in that. I can't be the only person who's like food desert. Come on. Of course. But the huge part of the population lives that way. And because you're living

that way, and this is crucial, you know, the consequences don't go away. So let me give you a really typical case drawn from documented patient interviews. So I read about a 62-year-old woman. She worked as a public teacher in Detroit for 30 years. She developed diabetes in her 40s. She struggled to afford her medications. She rationed her insulin a few times when money was tight. Oh, my God. You're not supposed to do that for people who don't know.

Not supposed to do that. And by her mid-50s, guess what? Her kidneys were failing. Because she couldn't afford insulin. That makes me so sad and angry because that sentence should stop all of us cold. Insulin is not even expensive. Well, in most places. Like, it's, it's not. This is one of the cheapest, easiest to obtain medications nowadays. I mean, it's just no one should have to ration it. That is, that's disgusting. Yay, American health care. Yeah, that's terrible. But now she's on dialysis and it's three days a week. She has to take a bus 40 minutes each way to the clinic. She sits in that chair for four hours. By the time she gets home, she's exhausted. You know, she's been interviewed saying, quote, the day. I have dialysis, I don't have a life. I have a treatment. Yeah, geez. Yeah, what else are you going to do

when you take the bus and it's basically an hour to get ready and go and then you sit there for four hours and then you come home. I mean, that's your whole productive day. Plus, you probably feel like crap after doing that. I can't imagine you feel good doing that. Yeah, and here's the thing. Medicare now pays for all of her dialysis, you know, every session. It's one of the only diseases where Medicare covers you regardless of age, the same system that wouldn't reliably help her afford insulin, which, as you've mentioned, is not expensive, now spends about $90,000 a year keeping her on dialysis. I had not thought of that. So we won't pay for the thing that would have prevented this, which is so cheap as to almost not incur cost at all. Right. But we will

pay forever for the extremely expensive treatment. Because I'm going to go out on a limb here and say a public school teacher in Detroit does not make $90,000 a year. So we're actually paying $90,000 for her treatment instead of keeping her working for an extra 20 years for, I mean, the government cost of insulin per year has got to be, I don't know, a couple hundred bucks at most, probably not even. Yeah. That's crazy. Maybe we could pay our teachers more, you know. Or like give them insulin so they don't die. I mean, come on, man. Better health care. Right, exactly. Okay. How much are we talking about here total for the dialysis for everybody in America? It's a lot. You know, dialysis is about a $50 billion a year industry in the United States. Medicare spends about $36 billion a year on it. That's roughly

7% of the entire Medicare budget, and it's going to less than 1% of the population. So on a per-patient basis is the single most expensive condition Medicare covers. For sure. Yeah, I can, I mean, the numbers are staggering. $50 billion every year. That is, that is serious. Yeah. And follow that money. You know, two companies, DeVita and Fresenius, control about 70% of all dialysis clinics in America. Two companies control 70%. That is not much of a market. I'm not going to say that they collude and make the prices higher, but I'm going to go ahead imply that they collude and make the prices higher.

Yeah, you're not wrong. I mean, it's effectively a duopoly. Yeah. So DeVita has about 2,800 clinics. Fresenius has about 2,600. And together, they treat roughly half a million dialysis patients. So this level of concentration is extraordinary, even by American healthcare standards. I want to be clear for legal reasons.

I have absolutely no facts or information whatsoever. And I don't have any reason to believe. believe that they do that other than if I were running a duopoly or half of a duopoly, I would probably be scummy enough to call the other guys and say, hey, you know what we should do, right? Because we'll all make more money. So, yeah, that just means I'm a terrible person. Moving on. How did it happen that there's only two companies? Because if there's this much money in it, how is this not like smoke shops where there's a zillion of these things? Yeah. I mean, it's consolidation over decades. So dialysis requires expensive equipment.

trained staff and regulatory compliance. So small independent clinics, they just, they got bought up. And economics of scale kicked in. And once you're that big, you know, you have enormous power to shape regulation, negotiate with suppliers, and just influence payment rates. And patients, again, can't shop around. You're just trying not to die. And it's so long that you're just going to go to the one that's near you, kind of, right? Yeah, I mean, that's the key. If you need dialysis, you need it three times a week on a schedule. So most people go to the clinic closest to them because, like we said, anything else is logistically impossible. You know, you can't skip treatments to, you know, wait for that better deal. You know, you can't delay. It's not like choosing a gym or whatever. Yes, this is life or death.

Anytime I want to buy electronics, my brother-in-law's like, wait for Black Friday. And it doesn't matter if it's December. Right. He's like, wait for Black Friday. And it's like, no, I kind of just want this thing like in the next 10 months. So I'm going to go ahead and buy it. But yeah, this is, so this is life or death. Yeah, you can't go like, oh, they usually offer a coupon. I'm going to hold off until Monday. Right.

Waiting for that coupon. Right. Doesn't happen. And that lack of choice matters when you look at who controls the industry. So DeVita's market cap is around 11 billion. And their longtime CEO, Kent Theory, who was known internally as mayor, he built this really intense corporate culture. You know, internally, employees called themselves citizens of DeVita Village, and they did these company chance at meetings, all this weird stuff.

Chance, okay, so I'm going to withhold judgment because, I don't know, if you're doing something like this, maybe you need to be cheered up and feel good about it. But I think I saw this guy dressed up as a knight on John Oliver. Is that this guy? You did. Yeah, Defeita Hate. Yeah, yeah, yeah. Yeah, yeah. I can't imagine doing that. But I guess, you know, when you're making $100 million a year. Yeah, right. But it's Davidarte. It's Italian forgiving life.

So there's a right sentiment there, I guess. But managers would lead these synchronized chance with everyone putting their hands in the air. It was meant to build unity and mission. But none of these people are on dialysis. Well, we don't know that. But yeah, that's true. But also, I don't know. And I'm on the fence because a lot of organizations do that.

Sports teams do that. nonprofits do that, the Red Cross could chant and nobody would think twice. And also, I don't know, man, you're probably, it's a little bit depressing because you're seeing these people and they're not well. And then you're like, oh, where's Tom? Oh, I have to cancel Tom's appointment. He passed away. Like, that's sad. I don't know. You probably need a little bit of a morale boost to work in a place like this. I don't know. Yeah, I suppose. It just seems to me when I was reading about the corporate side of this, not what's going on in the clinics, but like what's happening in this corporation, It seemed a little corporate culty to me, I guess.

That's a good point. A lot of these people, they work in a building and they've never seen a dialysis patient in their life. They're not the nurses working. Because I'm always so, I'm so hesitant to crap on a health care worker or a nurse or a medical tech. Like, it's their job is hard enough. That's not exactly who I'm describing. Okay, got it. No, that makes more sense.

Yeah, you're right. When we think of these companies, we're thinking of the nurse who's like, you'll be fine. You know, do you want me to change the channel on the TV? We're not thinking of the person who's like, deny this person. coverage because I'm hungry and in a bad mood. Yeah. The issue, I suppose, is when chanting is happening inside a multi-billion dollar company whose primary customer is Medicare, that's a problem. That's the problem. Because when the rhetoric is about mission and community, you know, the economics are enormous. So theory made more than 17 million in his final year running the

company, which is impressive for a company whose primary customer is Medicare. Yeah, the government. I mean, right, funded by taxpayers. Yes. So our government is cutting enormous, enormous checks to these companies, these two companies. And it's been happening since 1972. That's when Congress passed a law making kidney failure the only disease where Medicare covers everyone, regardless of age. Okay. You're 30 years old with kidney failure.

Medicare pays. You know, it was seen as a moral imperative. We're not going to let people die because they can't afford dialysis. Which in its face, I mean, that sounds great. I want people who have health problems to not die because they can't afford their medicine or their treatment. Right. It sounds great. It was great. But it also created something unique in American health care, guaranteed indefinite payment. So this creates stable, recurring revenue. And financial success becomes tied to keeping patients on dialysis, not necessarily getting them off it. And to be clear, this isn't doctors and nurses wanting people to suffer. I have to go back to my earlier statement that I just, I don't want people to think, like, how

dare you? I work so hard in this dialysis clinic. We're not talking about you. We're talking about the pencil pushers. Of course not. I mean, it's important to remember. Doctors want to help patients, but this system quietly rewards stasis over resolution. So if you're a dialysis company, you have a customer base that cannot leave and a payer that cannot refuse. So you were right. That's not a market, that's a captive revenue stream. So the incentive is to keep people alive, yes, but not necessarily to get them off dialysis. So nobody's saying this out loud, I suppose, but the system works best when people never leave. It's better, I'm not saying this, but in theory, it's better to never get off dialysis. You should not get better. You shouldn't get a transplant. You should just

stay until you die. Like, that's the ideal business. This is the ideal customer for them. Right. That math is undeniable. So a patient on dialysis, dialysis is worth $90,000 a year, every year indefinitely. A patient who gets a kidney transplant costs Medicare, about $110,000 for the surgery. Then they get covered for their immunosuppressant drugs, but they're off dialysis permanently. Huh. Okay. So from a business perspective, once again, transplants are actually bad.

Yeah. From a pure revenue perspective, yes. A transplant means a dialysis provider loses a customer. So dialysis companies aren't actively preventing transplants. It's more subtle than that. The system simply doesn't incentivize them to prioritize getting patients off dialysis. Okay, so how does that play out? What does that look like?

So through the transplant wait list, about 90,000 people are on it. So we discussed it at length in the episode on transplants, which was episode number 1253. Yeah, organ donation, right? Orgon donation, right? The average wait time is three to five years. You know, some people can wait eight, ten years. And during that time, they're on dialysis. Wow, because there aren't enough kidneys to go around to people who need them, right? That's the idea. Right. That's partly it. We do have an organ shortage. About 17,000 kidney transplants happen each year, but demand far exceeds the supply. And here's what's sticky. The referral process to even get on the wait list is complicated.

How was it complicated? Remind me, I don't remember this. Right. So you need a referral from your dialysis clinic. And you need extensive medical evaluations. You have to prove you can afford the anti-rejection drugs. Now that's some bullshit right there. That's some bullshit. That is insane to me. Oh, you're too poor to get this life-saving treatment. I'm sorry. You're just going to have to stay here and do dialysis until you kill yourself. And remember, there's even a stipulation where you have to demonstrate you have social support. Why? That's just part of the requirements to get on the transplant list.

I get it, but I hate that because it's like, you don't have enough friends and family that care about you to live. If you're a loner, sorry. I get it because, I mean, the sad reality is, though, they have to do that because they want to maximize the success of the transplant, right? And the people have more social support have better outcomes, I assume. Correct. Oh, gosh, this is some dystopian-ish, man. So it just ends up that clinics aren't always aggressive about pushing people through that process. Okay. I'm going to say why not, even though I already know the answer, but go ahead. Why not?

There's no financial incentive. Okay. So, in fact, evidence suggests clinics are slower to refer patients for transplants. Color me surprised. Yeah, right? There was a study in the Journal of the American Society of Nephrology, which found patients at for-profit dialysis clinics were 64% less less. to get on the transplant wait list compared to the patients at non-profit clinics. Wow, 64% less likely. That's not subtle. That might not be an accident, Jess. Yeah, right. Even after controlling for patient health, demographics, everything. So the difference was profit motive. It's a system that just makes suffering profitable. So far, the lesson is,

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Bob's in there. There's a lot of great conversation with the crew and a lot of other show fans. So come join us in the Jordan Harbinger subreddit. Now, back to Skeptical Sunday. Yeah, so if you're at a for-profit clinic, they're just quietly not really wanting to help you leave. In a nonprofit clinic, it makes sense, right? We need as many people to get transplants as possible

because then we have a slot open and we can get another person in here because their goal is theoretically helping as many people get through as possible. Whereas a for-profit clinic, they don't really care. If they're full, they're full. It's like a hotel.

They don't really care. Like all guests are kind of created equal, right? Right, right. They're just numbers. Yeah, they're entry in a spreadsheet. This is so, gosh, this is black mirror without like the cool unique technology on screen. Exactly.

Well, I guess it does. Dialysis machine is pretty cool tech. So maybe it's just Black Mirror. It's pretty close. And, you know, these for-profit clinics, they're not blocking you, but they're not exactly shepherding you through either. So remember, these clinics are often understaffed. They're stretched thin.

Social workers who handle transplant referrals are juggling huge caseloads. Clinics are understaffed. And if the company's revenue depends on. keeping chairs filled, you know, what gets prioritized? Yes, the chairs. That's what we were just sort of implying earlier, right? It's the chairs that get prioritized. Of course. You know, there was a whistleblower lawsuit filed in 2015. It was one of several, but where a former DeVita employee alleged the company systematically discouraged transplant referrals. So DeVita denied it and settled, but the allegation was that staff were told not to educate patients too much about transplants.

I'm fuming over here quietly. Don't tell them there's a way out. That's so bleak, man. I can't believe what I'm hearing right now. I know. It's subtle. You know, it's not a written policy. No, because they would be sued into oblivion if it were written down anywhere. Of course. It's about what gets emphasized, what gets resources, you know, what gets rewarded. So if you're a clinic manager and you're bonus depends on build treatments. Are you celebrating when patients leave? Now, but it's, this is psycho, Jessica. This is psycho nonsense. I know it's really hard to swallow, but it's systemic. And here's an even more maddening part. In the U.S. Medicare system, transplants are actually cheaper. You know, Medicare saves about $270,000 over, you know, like 10 years per

transplant patient versus dialysis. Wow. So even if you strip away morality, pure math says transplants win. But since they don't benefit the people currently making money. Correct. Yeah. The savings go to Medicare, meaning taxpayers. The losses go to dialysis companies. So the system is optimized for corporate revenue instead of patient outcomes or, you know, fiscal efficiency. Are nonprofit clinics better? Because it seems to me, right, like I said before, their outcome is like get as many people out of here. Yeah, I mean, they seem to be. They seem to be for sure. So studies show non-profit clinics have lower mortality rates, they have higher transplant rates, and just better patient satisfaction. But they make up a shrinking share of the industry. So for-profit chains have been consolidating dialysis care for years. And nonprofits, they just don't have the capital to expand at the same pace. So the consolidation continues and the profit motive grows. Yeah, so that reinforces why home dialysis isn't pushed, yeah? Right. It makes less money for clinics.

And when patients dialize at home, they're more independent. You're not coming to the clinic three times a week. The company has less control, less opportunity to bill you for add-ons and, you know, and less ability to keep you just in their ecosystem. By the way, you said add-ons? What are add-ons? This should not be add-ons. This is a medical treatment thing.

Don't tell me they're grifting these people in the clinic as well. I mean, why wouldn't they, I guess? There's upselling at the dialysis clinic. Oh, my God, I hate this. This episode is terrible. For medications, they want to sell you vitamin supplements, iron infusions, you know, things like that. And dialysis clinics have gotten very good at finding billable services. For a while, there was a major issue with overprescribing a drug called epigen, which is for anemia.

So since dialysis patients often become anemic, Epigen makes sense, but Medicare used to pay for it separately on top of the dialysis payment. Oh, no. I know where this is going. Oh, gosh. So suddenly, epigen doses, they skyrocketed. It became just a profit center. And these higher doses increased risks of heart attacks and strokes. DeVita and Fresenius were among the biggest purchasers of epigen in the world. And that manufacturer, Amgen, was making billions. This is crazy to me, man. And also the risk of heart attack and stroke, I don't want to sound unkind, but I'm going to go ahead and guess that somebody who's diabetic and on dialysis is already at sky high risk of heart attack and stroke. Yeah, exactly. So giving them a drug that they don't need

that increases that risk is you're killing people doing this, period. I don't even need to know that has happened as a fact to know that that has happened, right? I don't need a documented instance because if you're raising the risk profile of somebody who's high risk, over the course of, you know, 800,000 Americans doing this three times a week, like someone has died from this. Oh, yeah. It's incredibly depressing. So the manufacturers making billions off of selling this drug to these clinics that are upselling it slash giving it out when people don't necessarily need it because they can bill Medicaid for it. Right. Or Medicare for it. So what happened? So Medicare changed how it paid for the drug. So they bundled it into the overall dialysis payment.

So there was no incentive to overprescribe and clinics couldn't bill extra for higher doses. And guess what? Usage dropped immediately. Funny how that works. That's disgusting. Yeah. That's disgusting. And at the same time, the FDA issued safety warnings because studies showed that higher doses

increased the risks of all these health concerns, like the heart attacks, blood clots, and like you said, even death. So when the financial incentive disappeared, suddenly patients didn't need as much of this drug. And both companies have paid massive fraud settlements. Over the past 15 years, DeVita has paid around a billion dollars for various allegations. Wow. Imagine being that general counsel and your job is just to deal with fraud allegations. And you're like, okay, so we definitely did this.

Let's negotiate the fine. Yeah. I'm sure they have a chant for that. Oh, yeah. The legal department is, uh, those guys are busy. A billion dollars in fraud settlements, not wrongful death, not tax fraud. Like this is, you have done, you are a bad actor, you have committed actual fraud. You're getting fined a billion dollars. That is crazy. That is a crazy high settlement. I know. And crazy that they can afford it and stay in business, right? No, cost of doing business is how, that's why they still exist. Otherwise,

this would be, oh my gosh. Yeah, there was a $495 million in just one case for allegedly billing Medicare for drug waste. Oh my God. 34 million just in 2025 last year for illegal kickbacks to nephrologists. Frizenius has been sued for allegedly performing unnecessary vascular access surgeries to generate additional revenue. The lawsuit claimed these surgeries weren't medically necessary, but they were really profitable. Oh my gosh. So they're paying doctors, nephrologist is a kidney doctor. So they're paying doctors, I don't know, probably to refer to a specific clinic or to get some treatment or something. And then they're giving people unnecessary surgeries. Again, not to beat this dead horse, but if you are already high risk for medical

complications and you are, I don't know, diabetic and you have high blood pressure, going into surgery unnecessarily, could and will in some instances definitely kill. Like, again, someone has died from this. Absolutely. Depending on how widespread that fake, or I should say, unnecessary surgery. This is like some Nazi kind of crap. Like, we're just going to do surgery on you because it makes us money. I mean, it's not quite the same thing, but it's up there.

This is, that is up there. It's terrifying. Allegedly. Yeah, allegedly. Sorry. Sorry. Yes. Allegedly.

Allegedly they're doing this. But that case is ongoing. And this is the environment we're talking about. You know, when billing is the business model, pressure to maximize what you can bill for follows. Who's regulating all this? So CMS, the Centers for Medicare and Medicaid Services, they oversee dialysis clinics. And there are standards for water quality, infection control, and staffing. The clinics do get inspected.

But here's the issue. The regulatory burden has exploded. but outcomes haven't improved proportionally. What do you mean? So there's a quality measures manual for dialysis clinics, and it doubled in size from 150 pages in 2016 to 280 pages in 2025. And the patient survey they're required to administer is 62 questions long. And so that's insane and less than 30% of patients even respond to it.

And that doesn't actually help patients. Of course not. because the standards focus on compliance, not outcomes. So a clinic can check every box and still have terrible outcomes. They can meet every technical requirement and still have patients who are miserable or dying at astonishingly high rates. There was an investigation by ProPublica a few years ago that found wide variation in mortality rates between clinics, and some had death rates 50% higher than the national average. Oh my gosh, that's significant. Okay, so how is that possible, though, if they're all regulated?

Because the regulations don't measure quality of life or long-term outcomes very well. They measure things like, is the water clean? Our infections logged, our treatments happening on schedule, you know? Yeah, okay. This almost sounds like soft regulatory capture. Yeah, soft is right. Meaning not like cartoon villain corruption, just regulators maybe slowly over time getting too. cozy with the industry they're supposed to oversee, same language, same incentives. I mean, if there's a duopoly, so there's two companies and it's just this lucrative, there's kind of no way that you don't end up with big problems. And when these two giant companies with enormous resources are running the show, they have sway over how the rules are written. Yeah, that's what I mean, yeah. Yeah. So they submit comments on proposed regulations. They're the ones

funding studies. They hire former CMS officials as consultants. They spend about $2 million each on federal lobbying. And so over time, the regulatory environment just becomes comfortable for them. That is bleak. That is complicated, but bleak. Also, I don't know, side note here, but it is amazing how low that number is. Two million dollars each. It kind of sounds like a lot, but give me a break. You only need two or whatever, $4 million to get the government to let you charge the tax. taxpayers billions of dollars, that is really great ROI. Our Congresspeople are pathetically cheap dates, if that's really what this costs. Yeah, which shouldn't surprise anyone.

I would have thought you had a zero on the end to the amount that they had to lobby to get this stuff. I mean, I guess it's every year, but still, come on. Wow. And so they fund patient advocacy groups, you know, organizations that ostensibly represent patient interests but are financially supported by dialysis companies. So when legislation comes up that might hurt the industry, these groups will oppose it, you know, framed as protecting patient access. Yeah, that's sinister, but it's also super common, so I don't even know if we can act surprised that that's happening. Right, I know. But lower reimbursement could cause some clinics to close, which would hurt access. But the framing is always about protecting the current system, never about

redesigning it. Okay, I need to understand the patient experience more. So let's come back to the human side here. What does this feel like? Do we know what this feels like? I can't imagine you feel great after dialysis, even though it's cleaned you up. Well, people try to describe it. So I'll tell you about another patient. There was this guy I read about named Marcus. He was 54. He worked in construction, and he had kidney failure from untreated hypertension. He described dialysis as, quote, Imagine the worst hangover you've ever had. That's how I feel when I wake up on treatment days because the toxins have built up. Then I sit in a chair for four hours while the machine sucks out my blood, cleans it and pumps it back.

Afterward, I'm wiped out. Not just tired, wiped. Brain fog, nausea, muscle cramps. I go home and sleep. The next day I feel almost human. Then the cycle starts again. Wow, three times a week. Three times a week you go through the same.

that. And here's what people don't realize. You can't travel easily, right? You can't take a spontaneous trip. If you want to go somewhere, you need to arrange dialysis at a clinic near your destination. That's, you know, if they have an open chair. And it has to fit your schedule. So this man, Marcus, he missed his daughter's wedding because they just couldn't arrange dialysis where she lived. Gee, that sucks. I'm sorry to hear that. That's awful. So he misses his daughter's wedding. I don't really know how that's, it seems like that shouldn't happen. I don't know. But I guess if they don't have enough chairs and appointments, like that's it. You just can't go. Right. And I think in his case, there was a lot of optimism. Like, of course, of course this is going to happen for you. And then at

the last minute, it just, it couldn't make it work. Oh, man. You know, and dialysis doesn't just replace your kidney function, right? It reorganizes your entire existence. Your job has to accommodate your schedule, which is what puts people into, yes, Medicare covers it, but people go into financial hardship because you can't really work while you're doing this. Your social life revolves around it. Imagine trying to date while you're on dialysis. You know, who wants to date someone who's exhausted half the week? And big life events become logistical puzzles because clinics or machine rentals are just not available. So you might miss things like walking your daughter down the aisle. I know someone's thinking it, so I'm just going to say it.

I guess if you date somebody who's on dialysis, you should also maybe be on dialysis, right? And then you just sink your appointments up and you, yeah, you go and you say, hey, we want two chairs next to each other. And you bust out the sorry or trouble or some or monopoly or something like that. And you just, you have four hours of uninterrupted. I don't know. I'm joking, but I'm going to guess while you're doing this, maybe you don't feel like having a great time. You might just be sitting there with a slamming headache or something. I don't, I don't know.

I didn't read about what it does to your libido, but it can't be good. Well, yeah, I just, and just like, can you just lay there sort of like on an airplane? You're watching a movie and you feel dehydrated and gross, you know, that's kind of what I'm imagining. Right. It's sad that this is just accepted as normal for these people. This is just their life now. That's depressing. And dialysis is invisible.

I mean, most patients, they don't talk about it because there's a stigma, there's exhaustion. and there's this constant emotional math of gratitude versus suffering. Sure. Like you're supposed to be grateful because the machine is keeping you alive, which it is. But that doesn't mean the system is okay. Right. You can say this keeps people alive and still say, hey, the way we've built this is insane. Exactly.

And that's where criticism gets shut down. Because if you say, hey, the dialysis industry has problems, someone will respond with, oh, so you want people to die? It's like, no, I want people to live well. There is a difference. So what are the clinics like? What is a day of dialysis like in this place? Yeah, so, I mean, it varies. But the typical setup is a large room with maybe, you know, 20 to 30 reclining chairs arranged in rows.

Each chair has a dialysis machine next to it. Patients come in, they get weighed, they get their blood pressure taken, the needles are inserted, and then they sit. for four hours. What do people do? Like I said, you bust out a game or you watch TV. I mean, I don't know. What do you do? Yeah, I mean, they watch TV, they sleep. If you can focus, I guess you could read. Some people bring their laptops. But a lot of patients, they just feel too crappy to concentrate on anything. That's what I'm thinking. Yeah. Yeah. I mean, there is a strange community that forms, and I think this happens with chemo patients too. You know, you see the same people three times a week for years. So some people make friends, others just endure. You know, statistically speaking,

someone is almost certainly listening to this right now while undergoing dialysis. So if that's you, I hope it's going well for you. And we're thinking about you right now. Thinking of you. And we hope you feel better soon. And go find out how to get a transplant if you haven't done that already, because we want you to survive and not have to do this crap anymore. What about staffing at the clinics? So this is a major issue. Nurses and techs are often strapped. thin. In some clinics, one nurse is managing six or seven patients simultaneously, and turnover is high because the work is really hard and the pay isn't great. And when staffing is thin, you know, that's when corners get cut. And patients don't get as much attention. That's when the infection

rates go up. And remember, those infection statistics we talked about, that's 36% of deaths of people on dialysis are from infection. So this is an obstructive. You know, understaffing kills people. So people are dying because clinics save money on labor. I mean, that's the implication. So you maximize profit by minimizing labor costs. And in health care, that means worse outcomes. Yeah, of course.

There's kind of no way around that. I'm curious if you know what happened when COVID hit because that must have just been like a bomb going off in this industry. Oh, my gosh. Yeah, COVID was catastrophic for dialysis patients. So even though dialysis was still available during lockdown, 25% of dialysis patients who got COVID, they died. That's one in four. So it exceeded death rates in the general population by a huge margin.

And there was actually a decline in the U.S. dialysis patient census for the first time because of all these excess deaths. One in four dialysis patients who got COVID died. Wow. Because of their super high risk for exactly this kind of thing and also, oh, man. Yeah. I mean, it was a perfect. storm. So they're immunocompromised. They're in clinics with other sick people three times a week. They can't isolate. The one positive outcome from it was that it accelerated the shift to home dialysis. So suddenly

there was, you know, urgency around getting people out of clinics. So a global pandemic with a lethality of one and four in the target population that we're talking about now had to happen for the system to prioritize the thing that was better and cheaper for patients all along. That. That That's, yeah, okay, if you weren't angry before, you should be now. Yeah, and Medicare started pushing harder for home dialysis, but progress is slow because the financial incentives, they haven't fundamentally changed. Nothing says modern health care, like, we can keep you alive,

but only in the most expensive and depressing way possible. More on that in just a moment. Thank you for listening to and supporting the show. Your support of our sponsors keeps the lights on around here. All of the deals, discount codes, and ways to support the show are searchable and clickable on the website at jordanharbinger.com slash deals. Please consider supporting those who support the show. Now for the rest of Skeptical Sunday.

Tell me about other countries. Does anyone do this better? Denmark probably has a device that fits in the palm of your hand that you can walk around during the day during this, right? It's free. Right. They just have a kidney vending machine. Yeah.

That's Japan. But yeah, go ahead. And the problem is in Japan, it's someone else's kidney. Right. God. But several countries do it better. So in the Netherlands, about 40% of dialysis patients use home dialysis compared to just 12% here. In Hong Kong, it's over 70%.

Wow, 70%. That's incredible. Because they prioritize it. They train patients. They provide support. And they make it the default option unless there's a reason not to. Right. Okay.

And their outcomes are better. They have lower mortality. They have better quality of life. Yeah, because you're at home. with your family chilling watching it's a wonderful life or something with this little thing beeping next to you. You don't have to schlep over someplace with a bunch of strangers and get an infection. Why can't we do that again in America? I don't understand what the, so is it really just, hey, the clinics get, it's got to be incentives, yeah? Yeah, I mean, we could do it, but it

would require changing the incentives. So Medicare could pay more for home dialysis or pay bonuses to clinics that transition patients home. They've started doing this, actually. There's There's a push to increase home dialysis rates, but it's slow because companies are resisting the shift when they see they're going to lose money. What about transplants? Do other countries do that stuff better? I know that's a different episode. Yeah, we talked about that in the organ donation.

And a lot of countries are much better at transplants. So Spain uses that opt-out system. So you're a donor unless you say otherwise. We're in America. We're opt-in. And their transplant rates are among the highest. the world. We have opt-in here, yeah? You have to elect to do it. Right. We have opt-in. And even then, families can override that decision, which is a whole other issue. So we have chronic organ

shortages as well. There are also innovations like paired kidney exchange programs where incompatible donor recipient pairs, they swap kidneys with other pairs to make compatible matches. Okay. There's all kinds of issues. And these are growing, but they're logistically complex and really underfunded. What about artificial kidneys speaking of vending machines, right? Is that science? I mean, this vending machine thing is fake, obviously, but artificial kidneys, is that science fiction still at this point? Or are we, how's that looking? It's actually real, but it's slow. So there are researchers working on implantable artificial kidneys, like some kinds of wearable, devices. They're even talking about bioengineered kidneys that might be possible to grow from

stem cells. The science is promising, but, you know, development is expensive. The path to FDA approval would be really long. We're just not there yet. I see. And the dialysis industry, I'm guessing they're not involved in funding all this research. Right. Why would they? If someone invents a portable artificial kidney that you wear like an insulin pump, that's a the end of the dialysis clinic model, there's no incentive for incumbents to disrupt the system. So innovation is happening despite the industry, not because of it? Mostly, yes. You know, there are some companies exploring new technologies, but the big players are focused on optimizing the current model, not replacing it.

Okay. So because the quietest tragedy in all this is lack of prevention, right? Yeah. I mean, this is the part that makes me angriest, I think. I don't know, a lot of this makes me angry, but chronic kidney disease is often preventable or at least delayable. So if you catch it early, if you manage your diabetes well, control your blood pressure, you can slow progression dramatically. In fact, many people with early stage kidney disease never progressed a kidney failure if it's caught early. But we don't invest in that. We barely invest in that. Nephrologists, the kidney doctors, they're among the lowest.

paid specialists. And there's a shortage of them. So primary care doctors are overworked and often don't catch kidney disease until it's advanced. The screening's really inconsistent. The education's really minimal. You know, we're back to patients like rationing insulin. Because prevention doesn't really make money and you can't bill Medicare for something that never happens. Right. Prevention means nothing dramatic happens. There's no emergency. There's no machine. There's no chair. There's no $90,000 a year treatment. You know, it means someone stays healthy and never enters the system. And there's no billing code for that.

So prevention pays society with fewer sick people and lower costs, but dialysis pays companies. So we have this perverse setup where the most profitable outcome is late intervention, indefinite treatment and no cure. By the way, I want to say real quick, I know someone's going to be like, no, Medicaid also pays for part of I know we're saying Medicare. That is what pays for the bulk of it. And it's just easier than saying both of those things at once. So for people who are ready to fire that off in an email, we know. It's just we're trying to keep it simple. Okay. What would proper prevention look like here? It would just be aggressive screening for high risk populations. You know, better diabetes

management. Access to healthy food would help. Treatment for hypertension. So nephrology consultations for anyone with early stage kidney disease would stop a lot of people from going into dialysis. You know, it's not some exotic idea. We know how to do this. Right, we just don't. Right. We don't fund it. There's no lobby for prevention. But there's a massive lobby for dialysis, spending millions on political campaigns, funding patient groups, shaping the conversation. You've spent a lot of time on this. When you talk to patients, what do they want? And they want their lives back.

You know, that's the consistent theme with people. They're grateful for dialysis. Most of them would be dead without it. But they also don't want to live this way. They want to travel. They want to work full time. They don't want to feel like shit half the week. And they want to feel like the system is trying to get them off dialysis, not keep them on it.

Well, do they feel like the system is trying? Mostly no. They feel like they're in a holding pattern. And here's what's really hard. Many patients blame themselves. You know, they think if I'd just managed my diabetes better, if I'd just gone to the doctor sooner, if I'd eaten better, all of these things you would say to yourself.

And sure, personal choices matter. But these are people who often didn't have good options available to begin with. You know, they couldn't afford medications. They couldn't get doctors appointments or insurance, even if they were working two jobs. Or they lived in neighborhoods where the only, nearby food was fast food. So the system failed them and then they blame themselves. That's right. It's heartbreaking. Yeah. And then the system locks them into these this permanent treatment

while profiting from it. So it's hard not to see it as exploitation. I'm sympathetic to the whole like personal choice thing, but I don't know when you talk about like the food desert thing and the medical thing and then there's also the genetic thing. It's like it's a bad hand like you said earlier in the episode. I suppose somebody could say, hey, you guys are being anti-medicine or you're being extreme, saying it's exploitation. Like, come on, guys. I know, but we don't want to look at it, but the industry hides behind the fact that it's providing necessary care, which it absolutely is.

But the dialysis system, it's not optimal and it's certainly not ethical. So we can acknowledge that dialysis saves lives while also demanding it does better. Okay. And what does better look like? So it looks like this aggressive prevention. so fewer people need the dialysis. It looks like incentivizing home dialysis and transplants. Let's break up this duopoly so there's actual competition. It would look like regulation that focuses on outcomes, not just compliance, better staffing ratios to reduce those horrific infection rates. And it looks like funding research into alternatives, into those portable kidneys, those bioengineered orders, those bioengineered

organs, whatever works. All of which would reduce revenue for the current players. Exactly. So it won't happen without political will. You know, Medicare could change payment structures tomorrow. Congress could fund prevention programs. The FDA could fast track artificial kidney research, but all of that requires overcoming industry resistance. And industry has money and lobbyists and patient groups that they fund. Yeah. Right. And nobody wants to be accused of rationing care, letting people die, so the conversation doesn't happen. We just keep writing checks and the system continues. How do we change that? I mean, honestly, visibility, podcasts like this, you know, most people don't know this is happening. Dialysis is invisible until it's personal. And if people understood the scale of this, that half a million Americans trapped in a system optimized for profit, not outcomes,

where 60% won't survive five years, where infections kill more than a third of the patients, where people are choosing death over continuing treatment. You know, maybe if people realize that, there'd be pressure for reform. But it requires people to care about something that maybe doesn't affect them directly at the moment. I know for now. But kidney disease is growing. Diabetes is growing. Hypertension is growing.

So more people are going to face this. but the system isn't designed for them. You know, it's designed for shareholders. Yeah, that's bleak, man. Yeah, but it's realistic. And here's the thing. It doesn't have to be this way. You know, we built this system through policy choices.

We can unbuild it the same way. So we just need to decide that keeping people alive isn't enough. You know, we should want them to live well. You would think that would be part of the baseline, but I get it. There's numbers involved, but it's like, man, we are really focused on those numbers. Yeah, I mean, you'd think. But when profit is the organizing principle, alive becomes the acceptable outcome. Everything else seems optional.

So what do we tell people? What's the action item here, the takeaway? I mean, you know, if you have diabetes or hypertension, manage it aggressively. Get your kidney checked regularly. It's just a blood test and a urine test. If you have chronic kidney disease, see a nephrologist early. You know, don't wait until you're in crisis. And if someone you care about is on dialysis, support them.

Encourage them to talk with their doctor about transplant eligibility or whether home dialysis might be an option. Sometimes patients just don't realize those conversations are available to them. And politically? I mean, politically, we have to support policies that fund prevention and expand transplant programs. We could demand that Medicare reward outcomes, not just volume. And we have to be skeptical when patient advocacy groups oppose reforms, you know, look at who's funding that and address those infection rates. I mean, 36% of dialysis deaths involving infection. It's unacceptable. Yeah, that's insane to me. And that's where we are. We've built a system that rewards keeping people alive, but not really necessarily helping them live well at all. That's just not, that's an afterthought. Right. I mean, I want to emphasize here, dialysis saves lives. But the business model was built for permanence, not prevention, mobility, or cure. Yeah, that's a strange place for medicine to end up.

Yeah, and it doesn't have to stay this way. The system was built through policy choices. It can be rebuilt the same way. Ethical medicine requires asking how people live, not just whether they live. You know, dialysis isn't a scam. It's not malicious. It's a necessary medical intervention. It's just trapped inside a system that puts profit first.

Thank you, Jess. I feel depressed discovering kidneys have a $50 billion industry built around them or failed kidneys. Yeah, you're welcome. I'm happy to contribute to the existential dread here. But people do need to know about this. And to anyone listening who's on dialysis or loves someone who is, this system is hard, it's complicated. So filter the facts as carefully as your kidneys are supposed to. And if you haven't, maybe go get your kidneys checked by a doctor, hopefully who's not being paid under the table by one of the dialysis companies. maybe get a second opinion. I really feel for you if you're dealing with this. I hope this episode was enlightening for everyone else as well. Jess, this is a really good episode.

Oh, shoot, that's not what I want to say. Jess, terrible work today. Terrible. I'm ashamed of you. I'm sorry to disappoint you. And thank you all so much for listening. Topic suggestions for future episodes of Skeptical Sunday to Me, Jordan at Jordan Harbinger.com. Advertisers, deals, discounts,

ways to support the show, all at Jordan Harbinger. com slash deals. I'm at Jordan Harbinger on Twitter and Instagram. you can also connect with me on LinkedIn. You can find Jessica on her multiple substacks between the lines and where shadows linger. We'll, of course, link to those in the show notes. Her work is also on Instagram at Never Met Jessica's.

That's plural for some reason. This show is created in association with podcast one. My team is Jen Harbinger, Jace Sanderson, Tadasidazkas, Robert Fogarty, Ian Baird, Gabriel Mizrahi in the house as well. Our advice and opinions are our own and yeah, I'm a lawyer, but I'm not your lawyer. Of course, we try to get these as right as we can. Not everything is gospel.

even if it is fact-checked. So consult a qualified professional before applying anything you hear on the show, especially if it's about your health and well-being. Remember, we rise by lifting others. Share the show with those you love. If you found this episode useful, please share it with somebody else

who could use a good dose of the skepticism and knowledge that we doled out today. In the meantime, I hope you apply what you hear on the show so you can live what you learn, and we'll see you next time. You're about to hear a preview about the biggest threats to your health that most people never see coming.

From microplastics in the brain to everyday habits that quietly chip away at your energy, focus, and longevity. I think microplastics are a problem. Most people know generally what they are. I mean, these are like small pieces of plastic that come off larger pieces. And they get into our bodies mostly through what we're ingesting. And they're in the air as well. And so they get smaller and smaller and smaller.

They're called nanoplastics. And the smaller they get, they become more dangerous in a way because we can absorb them easier. It's in our water sources. It's on the plants that we eat. So vegetables and fruits because it's in the soil and they get on the plants. It's in the plants. It's in meat.

It's in every, it's all over the place. Air is a big source of microplastic pollution as well. It's getting everywhere in our organs. But dietary fiber seems to prevent absorption in a couple different ways, particularly soluble fibers, fermentable fiber, prebiotics, right? Those are all sort of interchangeable ways of saying soluble fiber. Fruits. Fruits is a big one, the skins of fruits, some vegetables as well. But you can supplement with it,

like inulin. You know, there's a lot of these prebiotic fibers people take as well. Beta glucans is another one. The point is that if there's something you can do to prevent your body from absorbing it, that's the best. And try to eliminate these microplastics as much as they can. And the number one thing you can do is get a water filter for sure. Air filters in your house, water filters in your house. Those are the two top things that you can do. The reality is, that's microplastics. It's just everywhere. Catch the full conversation with Dr. Rhonda Patrick for the science behind it all and the practical changes that can actually make a difference on episode 1267 of the Jordan Harbinger Show. This episode is sponsored in part by Everything Everywhere Daily.

You've heard the phrase, learn something new every day. Sounds nice, but do you actively do it? That's where Everything Everywhere Daily comes in. This podcast makes it effortless. Just 10 minutes a day, you'll walk away with a fascinating fact, a slice of history, a science gem. It's no wonder the show has climbed up to the top, the number one history podcast. It covers history, science, technology, geography, and stories of remarkable people always in a way that keeps you hooked. Not sure where to jump in? Start with these favorites.

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