The Fistula First Breakthrough Initiative (FFBI) has improved the awareness of the value of fistula creation in patients with end-stage renal disease (ESRD). The FFBI Health Policy Workgroup has been charged with reviewing the relationship of policy and economic issues to this project. This article reviews the efforts and successes of renal community clinical activities and reemphasizes the economic impact of fistula creation and catheter reduction on the health care system. Major obstacles are discussed, and existing tools and efforts designed to address them are outlined. The FFBI Health Policy Workgroup then identifies less frequently recognized barriers to the achievement of the FFBI goals and suggests solutions to them. It concludes that nephrologists need to assume the leadership role and drive fistula creation and central venous catheter reduction to achieve programmatic success.