Kidney care in the United States is highly regulated, reflecting the dominance of Medicare as the primary payer for dialysis since inclusion of the end-stage renal disease (ESRD) benefit into payment policy in 1973. In the ensuing decades, bundled payments have been introduced for dialysis and quality programs have been adopted for both ESRD and nondialysis chronic kidney disease care. In this installment of the Core Curriculum in Nephrology, we review the key laws and regulations affecting kidney care in the United States, the Medicare ESRD program, quality assessment and pay-for-performance programs including the ESRD Quality Incentive Program, incentives and disincentives for specific kidney failure care modalities, and recent landmark initiatives to promote more coordinated kidney care across the spectrum of kidney disease.