Emulate Israel's Program of Covering Donors' Expenses.

• Author: Morrison, Josh

In 2019, President Donald Trump issued Executive Order 13879, "Advancing American Kidney Health," which instructed the U.S. Department of Health and Human Services to remove financial barriers to living organ donation. In 2020, the Health Resources and Services Administration (HRSA), the agency within HHS tasked with increasing support for living donors, issued a final ruling that fell pitifully short of the mandate in the executive order.

HRSA's action demonstrates the need for Congress to enact robust policies to ensure that kidney donors receive adequate compensation for their expenses and are not thwarted by bureaucratic maneuvering. We suggest that such legislation be modeled after a successful and time-tested Israeli policy.

While the Trump administration's primary intent in issuing EO 13879 was to increase kidney donations, HRSA's stated goal, according to the Federal Register, was to implement new guidelines that would reimburse only the bottom 70% of households in the U.S. income distribution for donation-related expenses such as travel, lodging, forgone wages, and child and elder care. To accomplish this, HRSA limited the eligibility for reimbursement to people who earn no more than 350% of the federal poverty level, which in the continental United States in 2022 is $97,125 for a household of four. Not only does this income limitation reduce the efficacy of the order in boosting donations, but it also fails to reach HRSA's own stated goal, as only half of all U.S. households fall under the 350% threshold. A realistic estimate that would cover 70% of U.S. households would be 500% of the poverty level ($138,750 for that household of four), as HRSA's Advisory Committee on Transplantation recommended.

The very notion that wealthier households should be excluded from being compensated for expenses related to organ donation makes no policy sense given that kidney donations save the government money by reducing dialysis costs. Because living donors disproportionately come from wealthier households, many potential donors would not benefit from this policy. That is the main reason the Trump executive order has not meaningfully changed the nation's kidney shortage. HRSA's preoccupation with not compensating well-off donors rendered the resulting rule largely ineffective.

Other solutions? / Some have argued that reforms to promote living donation are, at present, unnecessary because other potential solutions, such as increasing cadaveric...