Chronic kidney disease affects over 35.5 million Americans, and roughly 800,000 suffer from end-stage renal disease (ESRD), which requires either a kidney transplant or regular dialysis. More than 80% of ESRD patients are unemployed and lack employer-sponsored insurance. Private insurers reimburse dialysis providers at rates well above Medicare, creating an incentive for providers to keep patients on private plans.
The American Kidney Fund (AKF), a nonprofit charity, runs a Health Insurance Premium Program (HIPP) that helps ESRD patients pay insurance premiums regardless of whether they choose public or private coverage. AKF’s largest donors are dialysis giants DaVita and Fresenius Medical Care, which together account for an estimated 80% of AKF’s funding. When HIPP recipients carry private insurance, these providers benefit from higher reimbursement rates.
In 2019, California enacted Assembly Bill 290 to address what the legislature viewed as providers exploiting the Affordable Care Act’s preexisting-condition rules. AB 290 contained five key provisions: a Reimbursement Cap tying provider payments to Medicare rates if the provider donated to a charity like AKF; a Patient Disclosure Requirement forcing AKF to reveal assisted patients’ names to insurers; a Financial Assistance Restriction barring AKF from conditioning aid on treatment eligibility; a Coverage Disclosure Requirement mandating that AKF inform patients of all available insurance options; and a Safe Harbor Provision giving AKF until July 1, 2020, to request an updated federal advisory opinion.
AKF warned it would shut down California operations if AB 290 took effect. AKF, the providers, and individual patients sued.
The United States District Court Central District of California granted partial summary judgment to each side. It struck down the Anti-Steering Provision, the Patient Disclosure Requirement, and the Financial Assistance Restriction as unconstitutional, but upheld the Reimbursement Cap, the Coverage Disclosure Requirement, and the Safe Harbor Provision. The court also found the unconstitutional provisions severable from the rest of the statute.
The panel affirmed in part and reversed in part, ultimately invalidating most of AB 290 in the published case of Fresenius Medical Care Orange County, LLC v. Bonta, Nos. 24-3654, 24-3655, 24-3700 (9th Cir. Apr. 7, 2026)
Reimbursement Cap — Reversed (unconstitutional). The court held that capping reimbursement only for providers who donate to charities like AKF burdens the First Amendment right to expressive association, triggering exacting scrutiny under Americans for Prosperity Foundation v. Bonta, 594 U.S. 595 (2021). California demonstrated a sufficiently important interest in preventing distortion of insurance risk pools, but the Cap failed narrow tailoring. The state could have directly regulated reimbursement rates for ESRD patients without conditioning the cap on charitable donations. The provision was also overbroad, sweeping in any healthcare provider making any donation.
Patient Disclosure Requirement — Affirmed (unconstitutional). Because California’s sole justification for this provision was enforcing the now-unconstitutional Reimbursement Cap, the requirement lacked any surviving governmental interest and violated the First Amendment.
Financial Assistance Restriction — Affirmed (unconstitutional). The court agreed the restriction burdened AKF’s right to choose its own beneficiaries. While California has a substantial interest in protecting vulnerable populations from abusive practices, see Washington v. Glucksberg, 521 U.S. 702, 731 (1997), the restriction’s broad text eliminated AKF’s ability to determine its patient population, far exceeding what narrow tailoring permits.
Coverage Disclosure Requirement — Affirmed as constitutional but not severable. Under Zauderer v. Office of Disciplinary Counsel of the Supreme Court of Ohio, 471 U.S. 626 (1985), the requirement to inform patients of all coverage options compels only factual, uncontroversial information reasonably related to preventing consumer deception. However, the court found this provision failed volitional severability: since 90% of affected patients already carry public insurance, a standalone disclosure mandate — especially without the Anti-Steering Provision — could actually push patients toward private coverage, defeating the legislature’s purpose.
Safe Harbor Provision — Moot. The deadline for AKF to request an updated advisory opinion (July 1, 2020) passed without action, rendering the issue nonjusticiable.
