There is a quiet crisis unfolding in American healthcare—one measured not in headlines, but in dialysis chairs, waiting lists, and shortened lives. It is a crisis that disproportionately burdens Black Americans, and it raises a troubling question: who benefits when kidney disease becomes big business?
Black Americans are up to four times more likely to suffer kidney failure than other groups. Despite making up just 13% of the U.S. population, black Americans account for more than 35% of dialysis patients. Both biological and sociological factors are in play here. Genetic differences like APOL1 variants increase medical risk while structural inequalities, including access to care, prevention, and early treatment, are contributing factors for kidney problems.
Now, layer on top of that situation a dialysis industry that has become one of the most concentrated sectors in American healthcare.
Two companies, DaVita and Fresenius Medical Care, control nearly 80% of dialysis facilities nationwide. According to a recent academic study published in JAMA Health Forum, dialysis is now the most consolidated healthcare market in the United States. That should alarm anyone who believes competition drives better outcomes and fair pricing.
Instead, consolidation has produced the opposite.
In areas dominated by a single chain, prices for dialysis services are significantly higher, by hundreds of dollars more per treatment, than in competitive markets. Meanwhile, physician ownership and financial entanglements with these corporations have expanded dramatically. The share of facilities with physician owners has nearly tripled, and joint ventures between doctors and corporate chains have surged.
This raises uncomfortable but necessary questions: when doctors have financial stakes in dialysis centers, are patient referrals always guided solely by medical need? Or does the system subtly incentivize more treatments, more patients, and more profit?
Federal law, specifically The Stark Law, generally prohibits physicians from referring patients to entities in which they have a financial interest. Dialysis facilities, however, enjoy a special exemption. That loophole has helped fuel consolidation in the dialysis market and blurred the line between care and commerce.
The consequences are not abstract. They are borne disproportionately by black Americans who are already at a higher risk of kidney disease. When markets lack competition, when prices skyrocket, and when incentives skew toward treatment rather than prevention, vulnerable communities pay the price literally and figuratively.
Recent legal developments deepen the concern. In 2025, a union health plan filed a federal lawsuit accusing DaVita and Fresenius Medical Care of conspiring to inflate prices and carve up regional markets. Both companies deny wrongdoing, but the allegations underscore a broader reality: the dialysis industry is under growing scrutiny for how it operates and whom it serves.
This follows a 2024 settlement in which DaVita agreed to pay $34 million to resolve allegations brought by the U.S. Department of Justice involving improper financial relationships tied to patient referrals. While the company admitted no liability, the case highlights persistent concerns about incentives and integrity in the system.
Dialysis saves lives and the healthcare professionals who perform dialysis are essential, but the system surrounding that care has evolved into something troubling: a highly concentrated, profit-driven marketplace that thrives as more patients become sicker.
That is backwards.
A healthcare system worthy of its name should prioritize prevention, early intervention, and patient well-being, not dependence on lifelong treatment. It should invest in addressing the root causes of kidney disease in black communities, from better hypertension management to expanded access to primary care, and it should ensure that financial incentives align with patient outcomes, not corporate margins.
Policymakers must revisit the dialysis exemption in the Stark Law, regulators must take a harder look at consolidation and pricing practices, and transparency, which is long lacking in the healthcare sector, must become the rule, not the exception.
We have an obligation to ask whether the dialysis industry is serving patients or exploiting them. The answer will define not just the future of kidney care, but the integrity of American healthcare itself.
Ken Blackwell is an adviser to the Family Research Council in Washington, D.C. He has also as U.S. Ambassador to the United Nations Human Rights Commission.
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