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 organ donation by implementing presumed consent (where the state presumes a decedent has agreed to be an organ donor unless he has communicated otherwise) and developing the technology to transplant organs from animals, will soon be at hand. While those are both efforts worth pursuing, neither appears to hold promise to increase supply in the short run, so the need to increase living organ donation persists.

It is worth noting the United States has the second-highest rate of cadaveric donation in the world. Its difference with the leading country, Spain, results almost entirely from Spain’s more common use of donors over age 75. This suggests that there are no easy reforms that could dramatically increase cadaveric donation. Moreover, while there may be merit in making the presumption of donation the default for the deceased, European countries that have adopted it have not seen substantial increases in donation, mainly because hospitals inevitably defer to the wishes of the decedent’s family despite the laws explicitly prohibiting them from doing so.

Similarly, xenotransplantation — harvesting organs from pigs genetically modified to produce organs for human transplantation — has shown growing promise in recent years, but it is likely at least a decade away from wide availability. For example, the University of Alabama at Birmingham’s Phase 1 clinical trial of 20 patients has an estimated primary completion date of 2027, and the U.S. Food and Drug Administration traditionally requires multiple trials with far more patients before it authorizes such a new procedure.

Israel’s success / A well-proven and uncontroversial way to increase kidney donations exists in the form of the Israeli donor support system. Since its implementation in 2008, living donation rates in the country have roughly quadrupled. The reforms provide living donors with the following benefits:

  • a three-year exemption from the national health insurance tax (which typically constitutes 3–5% of personal income),
  • five years of reimbursement for private health insurance expenses,
  • five years of reimbursement for life insurance and disability insurance expenses,
  • up to 40 paid days off work,
  • five therapeutic psychiatric sessions within four years of donation,
  • a seven-night recuperative vacation within one year of donation, and
  • reimbursement of approximately $750 in travel expenses.

Such a program in the United States would save approximately 18,000 lives per year if it induced an increase in donations commensurate to Israel’s. Given that per-transplant cost savings to the federal government for no longer having to provide services like dialysis have been estimated at $136,000 by Medicare and $145,000 by outside economists, achieving such an increase would save the government billions of dollars a year, more than offsetting the cost of a program similar to Israel’s.

The Israeli policy has been in effect for over a decade without controversy. That bodes well for the political feasibility of implementing a similar program in the United States. The nation could even offer somewhat more generous benefits. This cost-saving, life-saving measure is worth pursuing post haste.