President Trump on Wednesday announced an executive order on a topic rather far afield from his usual concerns: improving care for patients with kidney disease.

That might seem like an obscure topic, but it’s a crucial one. A shortage of kidneys for transplant kills about 43,000 people every year. (Compare that to car accidents, which kill 40,000 people a year, or homicide, which kills fewer than 20,000.) Instead of getting replacement organs for everyone whose kidneys have failed, the current US system relies heavily on dialysis, where machines replace kidney function. Dialysis is usually offered three times a week, for four hours at a time. That means no traveling of any real length, since you have to be close to the machine, and holding down a job is extremely difficult due to the time commitment of dialysis and the exhaustion it causes.

It’s an untenable system, and to the administration’s considerable credit, the new executive order appears to go a long way toward fixing it. It would make it easier for living donors to give kidneys and other organs, promote the donation of organs from deceased people, and restructure payment for health care providers to reduce the rate of kidney failure in the first place.

“There hasn’t been presidential action [on kidneys] in 46 years,” a senior administration official involved in the executive order told me. “It’s time to take a comprehensive approach.”

It’s also a change that, as Politico’s Dan Diamond and Rachel Roubein note, reflects the personal histories of key policymakers. Melania Trump was hospitalized for kidney issues last year; Health and Human Services Secretary Alex Azar’s father received a kidney transplant last year; Adam Boehler, the director of the Center for Medicare and Medicaid Innovation, has talked about his aunt’s death from kidney disease.

The result is an under-the-radar policy change that could amount to one of the most significant things the Trump administration does, in terms of total years of life saved. As someone who rarely agrees with the administration and finds most of its conduct actively abhorrent, I am genuinely surprised and impressed at how worthwhile this measure is.

The three components of the executive order

The order has three major parts: one on living kidney donors, one on deceased donors, and one on alternatives to center-based dialysis.

Living donors

The executive order attempts to reform the system for living kidney donors (like me), as well as living liver, lung, and intestine donors, by making sure donors are held financially harmless for donating. While donors don’t have to pay for their medical procedures, they do typically have to cover other expenses like travel to and from the hospital, child and elder care they can’t perform while they’re recovering, lost wages while they’re off from work, and so on. Donors to low-income patients can get travel expenses paid for now, but the executive order would allow people with higher incomes to benefit, and enable reimbursement of more significant costs like lost wages and child care.

That could dramatically increase living donations. Since Israel passed a law in 2008 reimbursing donor expenses and providing other benefits, live donation rates have quadrupled. Josh Morrison, an altruistic kidney donor who runs the advocacy group Waitlist Zero, conservatively estimates that the regulatory change might boost donations in the US by 25 percent. That would mean 1,600 or so additional donors every year, each of whom would enable their recipient to live, on average, nine to 10 years longer.

Deceased donation

The second aspect of the executive order targets deceased donation. In the US, there are 58 agencies with local monopolies over the provision of dead people’s organs, known as organ procurement organizations (OPOs). For some time now, independent analysts and investigative reporters have argued that OPOs are underusing deceased donor organs by the tens of thousands. One report estimated that 28,000 usable organs are abandoned; another put the number at 75,000.

The basic argument is that OPOs face perverse incentives: For instance, they’re often evaluated on the basis of how many organs are recovered per “eligible death,” but “eligible death” is a determination made by the OPOs themselves, making it easy to juke the stats without actually getting more people organs. The result is that tens of thousands of organs go unused.

The executive order scraps the existing evaluation system. The rule-making process is set to instead use two simple, harder-to-game criteria: the number of deceased donors as a share of the total number of deceased people 75 and younger with causes of death compatible with donation (an objective standard determined ahead of time); and the number of organs recovered as a share of that group of deceased people.

“This is a chance for HHS to ensure that OPOs are honoring organ donor wishes,” Jennifer Erickson, an Obama White House staffer who worked on organ donation, says. “This is life or death for tens of thousands of people.”

Better provider care

In an ideal world, everyone in need of a kidney transplant would get one. But even aggressive moves to boost donations like the ones the Trump administration is taking won’t be enough to reach that target. So the administration is also pursuing a series of reforms (including changes to Medicare provider payments, instructions to the Food and Drug Administration, and more) to try to offer alternatives to center-based dialysis.

Currently, the dialysis industry is heavily consolidated, with two providers (DaVita and Fresenius) accounting for 83 percent of the market. Medicare has guaranteed coverage for end-stage kidney disease treatment since 1973, and a huge share of its spending on the disease goes to those two companies, ensuring them an easy profit stream without much competition.

That hasn’t been great for dialysis patients. DaVita and Fresenius are paid per treatment, which deters them from preparing patients for transplant and (to some extent) from offering home-based dialysis, which is easier for patients and cheaper in the long run but has higher upfront costs. More than 80 percent of patients in Hong Kong get home-based care, but only 12 percent of American patients do, suggesting there’s a lot of room to make the treatment more convenient for people.

An antitrust perspective might place the blame here on the lack of competition among dialysis providers. But the Trump administration, perhaps unsurprisingly, argues that “the reason we have seen so little innovation and so little take-up is the government has distorted the space” through Medicare’s dominance, the aforementioned administration official told me.

However, the Affordable Care Act, in one of its lesser-known, cost-focused provisions, set up the Center for Medicare and Medicaid Innovation, which has the authority to pursue cost-saving treatments that improve quality of care. The executive order instructs the centers to experiment with new approaches to provider payment — like rewarding nephrologists for directing their patients toward transplants, and for preventing patients from progressing to kidney failure for as long as possible. It also instructs the Food and Drug Administration to consider early approval of new technologies and treatment methods that allow patients to avoid exhausting center-based care.

These are big enough changes that share prices for DaVita and Fresenius plummeted when Politico broke the news of the administration’s new kidney policy.

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