Seventeen people die every day in the United States waiting for an organ transplant, and over 100,000 people are currently on waitlists to receive a donated organ. Given these stark numbers, the allocation policies governing who receives donated organs are both critically important and hotly debated. Congress passed the National Organ Transplant Act in 1984 with the goal of eliminating markets for organs and the promise of equitable access to transplants without regard to geography or socioeconomic status. Despite these laudable goals, recent developments in organ allocation policy have led to multiple lawsuits, congressional inquiries, and an exposé in the Washington Post. 

Organ allocation policies developed over the past decade have increasingly mandated broader organ sharing across the country so that organs are less likely to be transplanted into nearby recipients. Analyzing a series of public and restricted-use datasets that include information on all organ donations, transplants, and waitlist registrations, I find consistent empirical evidence that organ allocation policy fails to achieve its goals. First, the metrics used to rank patients by medical urgency have been manipulated, particularly for heart and liver transplant candidates. Next, I find that socioeconomic inequities persist within organ allocation, with the income needed to receive an organ transplant increasing year-over-year (after adjusting for inflation). 

Finally, I find that organ allocation policy has systematically ignored large swaths of the population and thereby impeded access to organ transplants. To estimate the degree to which allocation policy has ignored individuals in need of transplants, I develop a new population-based metric of need for organ transplants — transplant amenable deaths. These deaths include all those that could have potentially been avoided by the timely receipt of a transplant. Analyzing these deaths, I find evidence that parts of the country with the greatest need for transplants are routinely required to export their organs to other wealthier and more urban parts of the country with less need for transplants. 

Transplant amenable deaths also offer an avenue of reform and the chance to achieve equitable access to organ transplants: I propose that new organ allocation policies be cabined by their impact on transplant amenable deaths so that these deaths are evenly spread across the country. Doing so can ensure organs go to areas where they are most needed while also allowing the most urgent patients to receive organs first. Such a distribution would also mitigate socioeconomic disparities.