Every day, 33 people — disproportionately people of color — die in the U.S. as they wait for organ transplants. Most of these deaths, and the suffering that precedes it, are preventable. Given that Covid-19 causes organ failure, the problem is only going to get worse.
The majority of people currently waiting for organ transplants need kidneys. As people languish on transplant waiting lists, Medicare now spends $36 billion each year on dialysis, which acts like an external kidney. Not only would more kidney transplants save lives, each transplant would save taxpayers as much as $1.45 million per person through avoided dialysis.
In few areas of health care are the interests of patients and taxpayers so directly aligned. Increasing access to lifesaving organ transplants is not only a win for patients and for cost containment, it’s also a win for health equity, given that the current system systematically disadvantages people of color. The recent Biden-Harris executive order on advancing racial equity offers the perfect opportunity to address this.
In September 2020, the U.S. Department of Health and Human Services (HHS) increased financial reimbursement for individuals willing to make living donations of a kidney or part of the liver to recipients who would die without them. Living-donor expenses such as lost wages and childcare can now be covered by the government as the payer of last resort.
Removing financial disincentives to donation is both the right thing to do and financially prudent — Medicare costs for dialysis dwarf the costs of making donation less expensive for generous living donors.
More can be done to facilitate living donation. Donors may not be compatible with their intended recipients, so kidney exchange has become a standard form of transplantation in the U.S. and some other countries. It allows patient-donor pairs to exchange with one another so each patient gets a compatible kidney from another patient’s intended donor. Many of these transplants come from exchange chains, begun by non-directed living donors, who are essentially generous living donors willing to donate a kidney to a stranger.
Chains involving patient-donor pairs waiting to find compatible exchanges could also begin with deceased donor kidneys, each of which could facilitate multiple transplants instead of just one, with the donor of the last patient in the chain donating a living-donor kidney to a patient on the waiting list for a deceased-donor kidney. (Living-donor kidneys generally last much longer.)
That would require a change in U.S. regulations, because deceased-donor kidneys must currently go directly to patients on the waiting list rather than first passing through a chain of patient-donor pairs. Kidney exchange transplants could also be increased by allowing exchanges between the U.S. and countries such as Canada. Canada has a kidney exchange program much like the U.S.’s, though both Canadian and American regulations would have to be amended to do cross-border Canada kidney exchanges.
In November, HHS followed its announcement about living donors with reforms for organ procurement organizations — the government contractors charged with recovery of transplantable organs from deceased donors. These reforms are projected to save more than 7,000 lives each year, as well as $1 billion saved to taxpayers in foregone dialysis costs.
In December, Congress righted another wrong in organ transplantation: extending the coverage of immunosuppression for kidney transplants, which previously — and nonsensically — stopped after three years, contributing to numerous graft failures each year as some patients could no longer afford their immunosuppressive drugs. Not only will this save lives, it’s projected to save Medicare $400 million over 10 years.
Organ donation reform has met with bipartisan Congressional support, with champions as ideologically diverse as Rep. Karen Bass (D-Calif.), the chair of the Congressional Black Caucus, and Sen. Chuck Grassley (R-Iowa). Both the Senate Finance Committee and the House Committee on Oversight and Reform are also actively engaged in separate investigations into the nation’s organ donation contractors, and leaders from both committees have urged the Biden Administration to undertake swift implementation of organ donation reform.
All of this work raises an even more important question: What is wrong with the U.S. policymaking approach to organ donation that it took decades to enact such commonsense, bipartisan, and popular policies?
We believe the problem has largely been a fracturing of governmental responsibilities, leading to siloed thinking and lack of clear responsibility to develop good policy. Because no single person or agency in government has ownership of the organ donation process, the buck is continually passed, to the detriment of patients and taxpayers.
The Biden-Harris administration has a chance to fix this, and should heed calls to create a dedicated Office of Organ Policy. Such an office could execute a unified vision that puts patients first, rather than falling victim to a bureaucracy that lets problems go unsolved for decades.
Writing in the journal Health Affairs, Ezekiel Emanuel, Bob Kocher, and other experts called for the Biden-Harris administration to focus on “flagship pursuits” as part of its commitments to equity. One such pursuit they highlight is “a focus on end-stage renal disease (ESRD) with goals such as doubling kidney transplant rates.”
That can be accomplished through a combination of expanding support for living kidney donation and transplantation and, as former NAACP president Ben Jealous has called for, accelerating the full implementation of HHS’s reforms of organ procurement organizations, which are currently slated for 2026. In parallel, all five of HHS’s former chief technology officers — spanning both Democratic and Republican administrations — have highlighted the imperative to rebuild outdated organ donation technology.
The first step is creating the governmental platform to act swiftly, intelligently, and purposefully. This is a slow-pitch softball for the new administration, and it should swing hard at it.
Alvin E. Roth is a professor of economics at Stanford University, winner of the 2012 Nobel Prize in Economics, and author of “Who Gets What — and Why: The New Economics of Matchmaking and Market Design” (Houghton Miflin Harcourt, 2015). He reports having an ownership interest in Rejuvenate Healthcare, LLC, which consults on care for patients with end‐stage kidney disease. Greg Segal is the cofounder of Organize, a patient advocacy group that previously served as Innovator in Residence in HHS’s Office of the Secretary during the Obama-Biden administration.