Since 1984 the United Network for Organ Sharing (UNOS) has operated the organ transplant system in the United States under a monopoly contract with the federal government. The Biden administration proposes to allow competition in the contract bidding process. The Summer 2022 issue of Regulation described the problems with the existing system: “UNOS performs three key functions: policymaking, technology delivery, and network member compliance.…it has convinced the government that no one else can do what it does, but it doesn’t perform its functions particularly well.”

While allowing competition for the contract is an important first step in improving the organ transplant system, the fundamental cause of organ shortages is the prohibition on compensation for organ donation. The justification for this ban was to prevent the exploitation of the poor by wealthy patients in need of organ transplants, but its effect has been to severely curtail the availability of donated organs.

While the public may not support the libertarian ideal of a free market in organ donation, a majority of Americans would support non‐​cash compensation (such as contributions to a retirement account) provided by a public agency. And Israel has quadrupled living organ donation rates by providing donors with reimbursement for health, life, and disability insurance expenses, paid time off from work, therapy, a recuperative vacation, and reimbursement for travel expenses. New York State recently enacted legislation allowing reimbursement up to $10,000 for expenses incurred analogous to the Israeli program. The Spring 2023 issue of Regulation describes the New York State program and provides estimates of the organ donation increases that would occur from varying amounts of compensation.