DaVita/Fresenius duopoly controls 77% of U.S. dialysis clinics

DaVita and Fresenius Medical Care together control 77% of U.S. outpatient dialysis facilities (up from 59% in 2005), with roughly 37% and 38% market share respectively. One-third of the U.S. population lives in markets served by only one of these two chains, and in those monopoly markets, commercial insurance prices are $495 higher per session than in competitive markets. This matters because dialysis patients cannot shop around -- they need treatment 3x/week or they die within days to weeks. So the duopoly can charge whatever it wants to commercial insurers, who pass costs to employers and patients as higher premiums and copays. The structural reason this persists is that the two chains spent over $110 million in California alone (2018) fighting Proposition 8, which would have capped profits at 15% above cost of care. They lobby aggressively against staffing ratio mandates, transparency requirements, and home dialysis expansion because in-center treatment generates significantly more revenue per patient. Senator Blumenthal has pressed the FTC to investigate, but no enforcement action has followed. New entrants cannot compete because building a dialysis center requires massive capital, regulatory approvals, and nephrologist referral relationships that the incumbents have locked up.