240,000 rural ESRD patients face higher mortality from travel burden

240,000 rural patients with end-stage kidney disease in the United States have worse outcomes than urban counterparts: less access to predialysis nephrology care, higher mortality on dialysis, and lower rates of transplant evaluation. 27% of all dialysis patients lack private transportation, and those relying on Medicaid transport, paratransit, or public transit are 1.25x to 1.70x more likely to die within one year compared to patients with private rides. Missed or shortened treatments increase linearly with travel time -- patients traveling 60+ minutes each way are far more likely to skip sessions. Some rural patients must travel 100-200 miles round trip, three times per week. Each missed treatment causes dangerous fluid overload, potassium buildup, and can trigger cardiac arrest. The structural reason this persists is that dialysis centers cluster in profitable urban/suburban areas where patient density supports the business model. Rural areas cannot sustain a center that needs 20+ chairs running 3 shifts/day. Home dialysis could solve this, but CMS terminated the End-Stage Renal Disease Treatment Choices (ETC) model in December 2025, removing the primary federal incentive pushing providers toward home modalities for rural patients.