Better Incentives, More Kidneys, More Lives

The organ procurement system has long been a miasma of inefficient monopoly providers. In 2024 I quoted some shocking facts from a great Statecraft interview with Jennifer Erickson and Greg Segal:

“Organs are literally lost and damaged in transit every single week. The OPTN contractor is 15 times more likely to lose or damage an organ in transit than an airline is a suitcase.” Organs are not GPS-tracked! “In an era when consumers can precisely monitor a FedEx package or a DoorDash dinner delivery, there are no requirements to track shipments of organs in real time — or to assess how many may be damaged or lost in transit. “If Amazon can figure out when your paper towels and your dog food is going to arrive within 20 to 30 minutes, it certainly should be reasonable that we ought to track lifesaving organs, which are in chronic shortage,” Axelrod said. Here’s one more astounding statistics: “Seventeen percent of kidneys are offered to at least one deceased person before they are transplanted….” Did you get that? The tracking system for patients is so dysfunctional that 17% of kidneys are offered to patients who are already dead–thus creating delays and missed opportunities.

Fortunately, even then there were changes in the works. In 2019 President Trump issued Executive Order 13879 to improve the performance of OPOs with better incentives and to allow living donors to recover more of their costs. The government being what it is, it has taken years to implement some of the new rules and enforcement of the OPO performance measures was deferred to 2026-2027. Nevertheless, there have been improvements. For example, many OPOs now GPS-track kidney transfers. And a new report estimates there have been significant gains from the changes.

• The Advancing American Kidney Health initiative was launched by President Donald Trump via Executive Order 13879 on July 10, 2019. In this Data Point, we estimate the range of increased growth in transplants that might be attributed to the policies launched through the Executive order and the economic value of that increased growth.
• The estimated impacts of the Executive Order (EO) range from a conservative 1,055 additional transplants annually to an upper estimate of 2,110 additional transplants. The range reflects variation in the counterfactuals used to compare with post-2019 transplant growth.
• Under the conservative-case scenario, the policy is estimated to be associated with approximately 23,214 additional kidney transplants between 2019 and 2040, generating about 147,410 life-years gained and 21,821 quality-adjusted life-years (QALYs) gained. Under the optimistic-case scenario, the policy is estimated to be associated with approximately 46,428 additional kidney transplants between 2019 and 2040, generating about 294,819 life-years gained and 43,643 quality-adjusted life-years (QALYs) gained.

The biggest and most consequential change would be to allow payment to living organ donors. The End Kidney Deaths Act, H.R. 2687, proposes a $50,000 refundable tax credit over five years for qualifying nondirected living kidney donors. The act has bipartisan support. Because dialysis is so expensive—and the federal government pays for much of it through Medicare’s special kidney-failure entitlement—the Act could save taxpayers money as well as saving lives.

Hat tip: The indefatigable Elaine Perlman.

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