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We live in interesting times. In just over 3 decades we have seen the birth of the Medicare End Stage Renal Disease (ESRD) program, which has provided access to lifesaving therapy to over 1.5 million people with chronic kidney disease (CKD) and has given hope to individuals who would otherwise face certain death. The enactment of that program provided a guarantee of federal payment for dialysis and transplantation, and coupled with private insurance coverage that followed, an industry was spawned that has expanded access to renal replacement therapy (RRT) to all those in need. Fixed dialysis reimbursement throughout the history of the program has led to efficiencies in care delivery, technological improvements, industry consolidation, and vertical integration in a number of provider companies and has affected the mix of registered nurses in staffing patterns. Medicare coverage for immunosuppressive drugs was the program’s first foray into coverage of outpatient medications. In the late 1990s, quality was defined through the National Kidney Foundation (NKF) Dialysis Outcomes Quality Initiative (DOQI).