Kidney transplants generally improve both the quality of life and longevity of patients with end-stage renal disease (ESRD). By substituting for the costly alternative treatment, dialysis, they also reduce Medicare expenditures over the lifetime of
patients. However, a shortage of kidneys has resulted in a large and growing waiting list for kidney transplants. Potential increases in the number of deceased-donor kidneys are relatively small because the pool of feasible donors is small. Potential increases in the number of live-donor kidneys are large because the pool of feasible donors is very large. Financial incentives, ranging from greater compensation for non-medical expenses to removal of the current ban on sale and purchase, can increase the availability of live-donor kidneys. The transition team recommends that you introduce legislation to establish expanded reimbursement with relative listing, a policy that would increase federal reimbursement for non-medical expenses incurred in making a live donation to the transplant waiting list, allow nonprofit organizations to reimburse non-medical expenses incurred by any living donor, and create a priority on the transplant list for living donors and one relative of their choice.
The National Organ Transplant Act of 1984 currently bans commercial transactions in transplant organs. An unregulated market for live kidneys would eliminate the shortage of transplant kidneys. However, it would have inherent inefficiencies as well as raise ethical concerns about exploitation of the poor, undue advantage for the wealthy, and commodification of the human body. In light of these disadvantages, this analysis considers three other alternatives to current policy that would make live donation either more financially attractive or less financially prohibitive: (1) brokered auctions would impose an intermediary between sellers (vendors) and purchasers (patients); (2) expanded reimbursement with relative listing would offset more of the non-medical costs for living donors and give priority to deceased-donor kidneys to living donors and their designated relatives, if they become patients; and (3) purchase with demand-side chain auctions would allow purchase of vendor kidneys by a chartered entity at an administered price and allocation of kidneys to the transplant centers that can use them to initiate the largest number of transplants.
The transition team assesses these alternatives in terms of five policy goals: (1) protection of human dignity; (2) equity; (3) efficiency; (4) favorable fiscal impact; and (5) political feasibility. Although current policy protects the human dignity of U.S. residents, provides equity in access to transplantation, and is politically feasible, it inefficiently forgoes potential increases in the supply of kidneys and favorable fiscal impacts offered by the other alternatives.
Brokered auctions would substantially increase the availability of kidneys by thousands or even tens of thousands annually and generate very large savings for the federal government. However, these gains in efficiency and favorable fiscal impact come with an increased threat to human dignity through exploitation of the poor, greater inequity in access to transplant organs in terms of wealth, and very poor prospects for adoption.
Expanded reimbursement with relative listing would increase the availability of kidneys by hundreds or perhaps thousands annually and produce savings for the federal government. It would have small impacts on human dignity and equity, and would likely be politically feasible.
Purchase with demand-side auctions would likely increase the availability of kidneys by the tens of thousands, offering the potential for eventually effectively eliminating the kidney transplant waiting list. It would also have favorable fiscal impacts for the federal government and not increase inequity in allocation. However, it does
risk exploitation of the disadvantaged; moreover, as a radical departure from current policy, it would have poor prospects for adoption.
Considering these trade-offs, expanded reimbursement with relative listing offers the best prospects for a desirable and feasible improvement relative to current policy. The transition team recommends that you ask the Congressional Research Service to draft legislation for this alternative.
Policy Problem: Too Few Kidneys for Transplant
End-stage renal disease (ESRD) can currently be treated with either dialysis or transplantation of a replacement kidney. Most ESRD patients prefer a transplant because it generally provides a higher quality of life and greater longevity than dialysis. However, transplantation currently requires available human kidneys, which come from either deceased or living donors. In the United States, the demand for kidney transplants currently far exceeds the supply of donated kidneys. The waiting list for kidney transplants has over 100,000 patients.1
In 2015, available kidneys allowed only 17,821 transplants, with 69 percent coming from deceased donors and 31 percent from live donors. That year, 35,037 new patients entered the waiting list and 4,295 left it because they died. Recent increases in rates of obesity suggest that the demand for kidney transplants will increase faster than population growth in the future, because obesity contributes to diabetes and hypertension which are risk factors for ESRD. Increased prevalence of obesity also reduces the pool of potential donors of healthy kidneys.
The shortage of kidneys has implications for federal expenditures as well as the lives of ESRD patients. Medicare covers much of the cost of dialysis and transplantation not covered by private insurers. Its expenditures pay over 80 percent of the costs of treating ESRD––$30.9 billion in 2013, or about 7.1 percent of total Medicare paid claims.2
Over the expected lives of patients, a transplant involves lower cost to Medicare than does dialysis. A recent study estimates that each kidney transplant saves taxpayers on average about $146,000.3
Increasing the supply of deceased-donor kidneys could reduce, although not eliminate, the shortage. Organ procurement organizations (OPOs) receive authorizations for donations, either post-death from family members or pre-death from donors, for approximately 73 percent of eligible deaths (brain death in a hospital by someone 70 years old or younger and without exclusionary medical conditions).4
If authorizations were received for all the eligible deaths, then approximately another 4,500 kidney transplants could be done each year. Currently, about 15 percent of donations come from those suffering cardiac rather than brain death, although
some transplant centers have increased their rate of use to approximately 30 percent.5
If all centers reached this level of use, then the total availability of kidneys could increase by almost 6,000. Although an increase of this magnitude would be extremely valuable if it actually could be obtained, it would be too small to slow the growth of the kidney transplant waiting list.
Changes in the allocation rules for deceased-donor kidneys implemented in December 2014 by the Organ Procurement and Transplantation Network (OPTN) include provisions that may affect future kidney availability.6
A new classification system for the quality of donated kidneys is likely to reduce refusals by patients to accept kidneys from older or sicker donors. Better matching of expected kidney graft life with expected patient life is likely to reduce the need for second transplants that would otherwise result when patients outlive their grafts. Nonetheless, the new rules are likely to have only a modest impact on the length of the waiting list.
Kidneys donated by living people could substantially reduce or even eliminate the kidney waiting list. Humans are born with two kidneys but only need one kidney to live a healthy life under normal circumstances. Live donation involves a small surgical risk: a 0.03 percent chance of death and less than 1 percent chance of a major complication.7
Although some questions about long-term impacts have been raised by a recent Norwegian study,8
long-term follow-up of living donors in the United States finds neither increased risk of renal disease nor reduced longevity.9
Although living kidney donation poses very small medical risk, it often involves travel and subsistence costs as well as potentially the loss of wages by donors and their caregivers. A recent study found that, although some donors received financial assistance from government or private sources, 89 percent suffered a net financial loss: average costs for donors included direct expenses of $1,157 and lost wages of $1,660, with their caregivers incurring an additional $377 in lost wages.10
The number of living donors peaked at 6,647 in 2004.11
Less than one-third of transplanted kidneys now come from living donors, a decline since the peak. Most
of these donors are relatives or close friends of the ESRD patient. Often people who are willing to donate to a specific person cannot do so because of biological incompatibilities that would result in the patient’s immune system rejecting the donated kidney. Although evidence is accumulating that patients can often be desensitized to increase the range of kidneys feasible for transplantation, outcomes appear less favorable than for compatible kidneys.12
A more common approach to donor incompatibility is the arrangement of paired donations
, which may enable incompatible donors to facilitate transplants for their intended patients by an exchange of donations across pairs: the donor in the first incompatible pair gives to the patient in the second incompatible pair, and the donor in the second incompatible pair donates to the patient in the first incompatible pair. Exchanges can also involve three or more pairs, though they are more difficult to arrange.
A transplantation chain
begins with an altruistically motivated nondirected kidney donation––approximately 180 per year or about 3 percent of all kidney donations in the last five years were nondirected.13
The kidney is transplanted to the patient in an incompatible donor–patient pair. The donor in that pair donates a kidney to the patient in another incompatible pair. The process continues until no patient in an incompatible pair can be found to receive the donation. Instead, the donor in the last pair receiving a kidney donates a kidney to the compatible person on the waiting list with highest priority. By seeding a chain, a single nondirected donation can facilitate multiple transplants that would not otherwise occur. For example, a chain in 2015 involved 34 donors and patients.14
The National Organ Transplant Act of 1984 (PL 98–507) established the legal framework for the regulation of solid organ transplantation in the United States. Section 274c(a) strictly bans the sale of organs: “It shall be unlawful for any person to knowingly acquire, receive, or otherwise transfer any human organ for valuable consideration for use in human transplantation if the transfer affects interstate commerce.” The provision has been interpreted to allow insurers, transplant recipients, states, or others to reimburse living kidney donors for their medical, travel, and subsistence costs. Further, the Organ Donation and Recovery Improvement Act of 2004 (PL 108-216) authorized the Secretary of Health and Human Services to make grants to public or private entities to reimburse live kidney donors and up to two caregivers for their travel, subsistence, and incidental expenses. It also allows reimbursement to those who incur these expenses in good faith but are actually unable to make donations. The grants may fund payments only for costs not covered by state programs, insurers, or org...