| Happy Friday, everybody. My wife and I just moved apartments within Washington, DC, which got me thinking about how much I love this city. It has its jerks (though they mostly live in Virginia), but it also contains a really dense population of people quietly working to make government function a tad better, while no one's watching or giving them credit. It can seem like this is an entire city of people angrily arguing at all times, but the topics that dominate news coverage (stimulus talks, wars, Covid-19 response) are only a small, if important, share of what the federal government does. The under-the-radar stuff is important too, and precisely because it's not as closely followed by the public and politicians, it can be easier to make progress on those kinds of topics. Case in point: A couple of weeks ago, the Trump administration finalized a rule on deceased donor organ transplantation that should save about 7,300 lives a year once implemented. I've watched this and related kidney reforms (like a rule finalized in September expanding reimbursement for living donors) go from proposal to implementation, and it's a good example of how a small group of people working on a specific issue can make remarkable progress on a topic of immense importance, in spite of broader administration dysfunction and political turmoil. The activist group most active on this issue is called Organize (get it? Organ-ize?), founded by Greg Segal, who got interested in organ donation after his father had to wait five years to get a heart transplant. The pitch of Segal and his partner-in-activism, former Obama science policy adviser Jennifer Erickson, was simple: The organizations responsible for recovering organs from deceased people, for donation to people in need of transplants, were not doing their jobs as well as they could. They were rejecting perfectly usable organs, and would-be recipients were dying. In the US, there are 58 agencies with local monopolies over the provision of dead people's organs, known as organ procurement organizations (OPOs). For some time now, independent analysts and investigative reporters have argued that OPOs are underusing deceased donor organs by the tens of thousands. One report estimated that 28,000 usable organs are abandoned; another put the number at 75,000. The basic argument is that OPOs face perverse incentives: For instance, they're often evaluated on the basis of how many organs are recovered per "eligible death," but "eligible death" is a determination made by the OPOs themselves, making it easy to juke the stats without actually getting more people organs. The result is that tens of thousands of organs go unused. The newly finalized rule totally rejiggers the evaluation system for OPOs, instead embracing two new criteria that are tougher to game: the number of deceased donors as a share of the total number of deceased people 75 and younger with causes of death compatible with donation (an objective standard determined ahead of time); and the number of organs recovered as a share of that group of deceased people. The latter is important because OPOs sometimes take some but not all organs eligible for donation out of donor bodies; being more efficient could save a lot of lives. You might be asking how an Obama veteran was able to get the Trump administration to push a big new policy like this. The short answer is that a lot of Republicans genuinely thought it was a good idea, in part because of Segal and Erickson's advocacy and in part because this just isn't a hyperpolarized issue the way, say, Obamacare repeal or (infuriatingly) Covid-19 policy is. Solid conservative senators like Chuck Grassley and Todd Young are very vocally in favor of OPO reform, as are former NAACP president Ben Jealous and Rep. Karen Bass are. In the Trump administration, a White House aide named Abe Sutton and an HHS staffer named Nick Uehlecke deserve particular credit for making kidney issues a priority and helping craft Trump's eventual executive order leading to this rule change. This is the part where liberal readers might be wondering if there is a catch. There is not a catch. This is not secretly a bailout for the Koch brothers. It's actually, in an underappreciated way, a big win for racial justice. OPOs are much worse at providing transplants to Black people and other people of color than to white people — white people on the waitlist have a 50 percent chance of getting a transplant, compared to 25 percent for Black people. That's partly because OPOs are less likely to take organs from nonwhite donors (which are somewhat likelier to match nonwhite patients), and less likely to approach families of nonwhite deceased people to ask about donation. Watching Segal, Erickson, Uehlecke, and Sutton shepherd this change through was like watching a bizarro-world version of American politics, where things just kind of work and policymakers change things in response to sound arguments and evidence. They faced a lot of bad-faith pushback from OPOs and their allies that they had to refute — but that didn't kill the effort. HHS moved forward, despite being slammed with Covid work, and the rule will take effect. It's a small win, especially next to the enormity of the administration's failure on Covid-19. But for the 7,300 people a year whose lives it can save, it's a huge deal. —Dylan Matthews, @dylanmatt |
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