UNOS has considered more than 60 reform proposals in the last five years alone—and rejected all of them. It’s been difficult to reach consensus due to familiar geopolitical divisions. Defenders of UNOS’ system, mostly in the relatively organ-abundant Midwest and South, argue that the regional discrepancies are overstated, and accuse hospitals in states like New York and California of doing a poor job of procuring organs. Advocates in poorer states with lesser shortages say they shouldn’t have to ship organs to their richer counterparts. “Organs should stay in their local region,” said Seth Karp, director of the Department of Surgery at Vanderbilt University.
But organs are already going to people outside their regions. They’re just going to transplant tourists instead of the neediest patients.
The transplant era began in 1954, when the first successful kidney transplant was performed in Boston. Livers, hearts, and pancreases followed in the 1960s. In the 1970s, medical breakthroughs in organ preservation and transplant rejection allowed patients to live longer and organs to be shared statewide and even regionally. In 1983, the Food and Drug Administration approved a key anti-rejection drug, cyclosporine, which spurred an increase in transplants. The following year, Congress mandated the creation of a network to “assist organ procurement organizations in the nationwide distribution of organs equitably among transplant patients.” Thus, UNOS and its eleven regions were established.
More than 30 years later, technology has advanced, so that livers and kidneys can now travel by ground, planes and helicopters (and perhaps soon by drone) and remain viable for more than 12 hours. This makes the existing boundaries obsolete. “The regions are useful for administrative purposes, but not for determining organ allocation,” said James Burdick, a surgeon at Johns Hopkins and an UNOS president in the mid-1990s. “We’re still thinking in those old-fashioned terms of sections of the country.” The regional inequalities also contravene federal guidelines mandating “that allocation of scarce organs would be based upon common medical criteria, not accidents of geography.”
In 2014, a proposal to reform UNOS’ policies inspired transplant centers in Georgia, Kansas, Iowa, and Texas to form Keep Transplants Fair, a coalition whose members have spent hundreds of thousands of dollars lobbying Congress to oppose changes to the UNOS system. The following year, hospitals in New York, Baltimore, Massachusetts, and Connecticut formed the Coalition for Organ Distribution Equity, which hired Washington-based lobbying firm Thorn Run Partners to obtain “reforms to the system for distributing organs for transplant.” CODE has spent $260,000 on lobbying Congress and on “public education.”
This summer, UNOS considered a plan to allow patients within 150 nautical miles of a donor hospital to qualify for a transplant, even if the candidate is in another region. This would have provided low-income patients with more options and reduced the incentive for people to travel to other regions, but met stiff resistance from states who benefit from the current system. On October 10, at a meeting in Chicago, UNOS’ liver committee voted unanimously against the proposal. Doctors on the coasts felt it did too little to address discrepancies, while doctors in between thought it went too far. “Financial interests can rule the day in trying to move forward or to block [change],” said California surgeon Ryutaro Hirose, a former chair of UNOS’ liver committee and the co-author of the proposal.