If I'm reading the article correctly, the kidney foundation and by extension, the dialysis centers, are gaming the system.  If these people are too poor for private insurance, then they must qualify for Quest, right?  But I'm sure Quest  and Medicare reimburse the dialysis centers at a much lower rate.  So the kidney folks pay the premium just so they can get a higher reimbursement from private insurance.  The patients will get their dialysis either way (on Quest, Medicare, or private insurance) but I can see where the motive of the kidney dialysis people are questionable in the desire to get the highest reimbursement possible.