Editorial A Conflict of Responsibility: No Patient Left Behind Bryan N. Becker Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin In its program END THE WAIT, the National Kidney Foundation (NKF) outlined four comprehensive strategies to achieve the goal that within 10 years, every individual on the US waiting list will receive a transplant within 1 year of listing. Lifetime immunosuppressive coverage is a critical piece of the foundation of this program. Events in 2009 that were dedicated toward achieving a lifetime immunosuppressive benefit were complicated by legislative challenges and a dynamic that placed oral medications in the ESRD bundling proposal in direct conflict with the potential for the lifetime immunosuppressive benefit. In line with its mission, the NKF could not sacrifice one kidney patient constituency for another. Successful patient-centered organizations stay consistent with their mission. The NKF had to weigh the risk of postponing a long-sought goal and its relationships with other organizations with standards of patient safety and equitable and efficient patient care. In a perfect world, we never have to make such choices. In the real world, we can use such choices to forge new ways and dialogue to achieve better health care for all patients affected by kidney disease. Clin J Am Soc Nephrol 5: 744 –745, 2010. doi: 10.2215/CJN.02610310 The Dynamic in Kidney Health Care, Immunosuppression, and the National Kidney Foundation The dynamic in kidney health care that evolved during the recent debate on health care reform was passionate and spir- ited. A large part of that dynamic was ironically driven by the passage of the Medicare Improvement for Providers and Pa- tients Act (MIPPA) in 2008. For the National Kidney Founda- tion (NKF), the MIPPA represented a set of opportunities to advocate for improved patient education and quality kidney health care. During 2009, the MIPPA and the ESRD bundling proposal incorporated within it also became an important point of evaluation for the NKF as a patient-centered organization, especially when choices related to medication coverage defined by Congress suddenly put the NKF into a potential conflict of responsibility. The mission of the NKF is preventing kidney disease, im- proving the health and well-being of individuals and families affected by kidney disease, and increasing the availability of all organs for transplantation. The NKF has been a constant voice supporting ways to increase the availability of organs for trans- plantation and has also been a strong partner and leader in efforts to extend coverage for immunosuppressive medications for a generation. NKF advocacy for immunosuppressive drug coverage under Medicare dates to 1984. The NKF convened a consensus con- ference, “Impact of Cyclosporine on Cadaveric Renal Trans- plantation.” The NKF can be credited with the initiation of 1 year of coverage in 1986 through the Omnibus Budget Recon- ciliation Act of 1986 (Public Law [PL] 99-509). The NKF can also be credited also with gradual extension to 3 years of coverage during the 1990s through the Omnibus Budget Reconciliation Act of 1993 (PL 103-66). The NKF aggressively supported the limited expansion of Medicare coverage in the Balanced Budget Refinement Act of 1999 (PL 106-113) and the elimination of the 3-yr window in the Benefits Improvement and Protection Act of 2000 (for individuals who are not dependent on ESRD status for Medicare coverage). END THE WAIT and a Conflict of Responsibility In its program END THE WAIT, the NKF outlined four comprehensive strategies to achieve the goal that within 10 years, every individual on the US waiting list will receive a transplant within 1 year of listing. Lifetime immunosuppres- sive coverage is a critical piece of the foundation of this pro- gram that recognizes coordinated efforts to improve the out- come of first transplants, increase deceased and living donation, and improve the capacity of the US transplant system to achieve the program’s goal. In pursuing broader immunosuppressive coverage, the NKF, in parallel with other transplant organizations, undertook col- laborative efforts with the staff of Senator Richard Durbin (D-IL) and Representative David Camp (R-MI) throughout the fall of 2008 and most of 2009 to facilitate immunosuppressive medication coverage legislation. This was followed by intro- duction of Senate and House bills to address immunosuppres- sion coverage in March 2009. S.565 was introduced by Senator Durbin on March 10, 2009. H.R. 1458 was introduced by Rep- resentative Camp on March 12, 2009. During 2009, the NKF presented END THE WAIT to the Transplant Roundtable and dialogued as a member of the Immunosuppressive Coalition. This was followed by introduction of Senate and House bills to address immunosuppressive medication coverage in March Published online ahead of print. Publication date available at www.cjasn.org. Correspondence: Dr. Bryan N. Becker, J5/223 CSC 600 Highland Avenue, Mad- ison, WI 53792. Phone: 608-262-9306; Fax: 608-262-6743; E-mail: bnb@medicine.wisc.edu Copyright © 2010 by the American Society of Nephrology ISSN: 1555-9041/505–0744