What is the Coalition to Modify NOTA proposing? The Coalition to Modify NOTA proposes a ten year pilot program to provide a $10,000 refundable tax credit over five years ($50,000 total) for American non-directed kidney donors who donate their kidney to a stranger at the top of the kidney waitlist. This will greatly increase the supply of living kidney transplants, the gold standard for patients with kidney failure.

How are the estimated savings calculated? 

We estimate that by year ten, the taxpayer will save between $10 billion and $37 billion.

Ike Brannon of the CATO Institute who was Senator John McCain’s Chief Economist calculated that $517,000 is saved by the taxpayer when a kidney failure patients gets a kidney transplant. 

Source: CATO Institute, “Saving Lives While Saving Money” by Ike Brannon

Ike Brannon speculates that the dialysis cost in the table above has significantly increased since he created the table in 2023. The exact amount of that increase is unclear.

Dr. David Axelrod et al. write that the savings would be $174,000 (in 2024 dollars).

We estimate that on average 10,000 Americans will donate to strangers annually over ten years. Because 80% of those on dialysis are on Medicare, taxpayers would save money on 8,000 of the 10,000 transplants.

The left table with Dr. Axelrod’s estimated savings per recipient of $174,000.

The right table if Ike Brannon’s $517,000 saved. 

Savings per recipient ($517K) - tax credit incentive ($50K) multiplied by Number of donors = budget window savings
Calculation: Savings per recipient over 10 years (minus) tax credit incentive (times) additional live transplant recipients = budget window savings

Why are living kidneys better than deceased donor kidneys? Living kidneys last twice as long as deceased donor kidneys. Living kidneys are the gold standard in kidney care.

What is the value of a new kidney? Taxpayers save $517,000 total every time someone on Medicare goes from dialysis to getting a kidney transplant.  The value of a new kidney, in terms of quality of life and future earnings potential, is between $1.1 million and $1.5 million.

What is the American kidney crisis? 1,000 Americans on the waiting list for a kidney transplant die or become too sick to be transplanted each month. That number does not include the many kidney failure patients who are not placed on the waiting list but would have benefited from a kidney transplant if we had no shortage. The total number of patients with kidney failure will grow from 800,000 today to likely one million by 2030. 

Why a “Refundable tax credit for $50,000 over five years?”

  1. Refundable: If donors do not earn enough to take the $10,000 tax deduction, the government will provide them with a check for $10,000 annually for five years.

  2. $50,000: We are aiming to strike a balance between what will provide the government with savings sufficiently compelling to authorize this pilot, which we estimate to be billions over ten years, and an amount which will effectively incentivize someone to donate to a stranger. The $50,000 figure is based on the amount offered in this study published in JAMA Surgery in 2016. 

  3. Five Years: One of the biggest arguments against compensating living kidney donors is that people who are in strained financial circumstances donate out of desperation. All of those who step forward to donate undergo multiple rigorous mental and physical qualifying tests. After being approved and having the surgery, the first of the five payments of $10,000 is received the year after the year of donation; if someone donates in July and files their taxes in February of the following year to receive their check in March, the first check comes 8-9 months post donation, and the next $10,000 the following year. This is not a respite or much of an incentive for someone facing immediate financial hardship.

Why not rely on deceased donor kidneys to end the shortage? A living kidney transplant lasts on average twice as long as a deceased donor kidney. Fewer than 1 in 100 Americans die in a way that their kidneys can be procured. Currently, the 60% of Americans who are registered as deceased donors provide kidneys for 21,000 Americans annually. In the USA, 90,000 Americans are on the kidney waitlist. If we fixed the deceased organ system, we could add at most 2,000 transplantable kidneys annually. A total of 27,000 people are transplanted annually, two-thirds from deceased donors and one-third from living donors. The size of the waitlist has nearly doubled in the past 20 years, while the number of living donors has remained stagnant at around 6,000 for the past 24 years.

What is the extra value that non-directed kidney donors provide? Non-directed kidney donors often launch kidney chains that can result in a multitude of Americans receiving kidneys. Fewer than 5% of all living kidney donations are from non-directed kidney donors who are an excellent source of organs for transplantation because they are healthier than the general population. 

How much does the taxpayer currently spend on dialysis? Kidney transplantation not only saves lives; it also saves money for the taxpayer. The United States government spends nearly $50 billion dollars per year (1% of all $5 trillion collected in annual taxes) to pay for 550,000 Americans to have dialysis, a cost of approximately $100,000 per year per patient, a treatment that is far more expensive than transplantation over the life of a chronic kidney disease patient.

How many more lives will be saved with the refundable tax credit for non-directed donors? The number of non-directed donors increased from 18 in 2000 to around 300-400 each year. After the End Kidney Deaths Act becomes law, we will over time add approximately 6,000 non-directed donor kidneys annually. That is around 60,000 new transplanted Americans by year ten. 

How much tax money will be saved once the End Kidney Deaths Act is passed? The refundable tax credit will greatly increase the number of living donors who generously donate their kidneys to strangers. We estimate that in year ten after the End Kidney Deaths Act is passed, the taxpayers will have saved $25 billion. 

What is a refundable tax credit? A refundable tax credit can be accessed by both those who do and those who do not pay federal taxes. 

What do Americans think about compensating living kidney donors? Most Americans favor compensation for living kidney donors  to increase donation rates. 

Who is able to donate their kidneys?  Donation requires potential organ donors to undergo a comprehensive physical and psychological evaluation, and each transplant center has its own rigorous criteria. Less than 2% of those who pursue evaluation actually end up donating, and only about one-third of Americans are healthy enough to be donors. Providing financial incentives will encourage more Americans to donate their kidneys to help those with kidney failure.

Do kidney donors currently have expenses that result from their donation? The medical costs of donation are covered by the recipients' insurance, but donors are responsible for providing for the costs of their own travel, out-of-pocket expenses, and lost wages. Programs like the federal NLDAC and NKR's Donor Shield can help offset these costs, making donation less expensive.

Is it moral to compensate kidney donors? Compensation for kidney donors can be viewed as a way to address the current kidney shortage and save lives. Americans are compensated for various forms of donation such as sperm, eggs, plasma, and surrogacy, all of which involve giving life. 

How long do we need to compensate living kidney donors? Compensation should continue until a xenotransplant or advanced kidney replacement technology becomes available. In the meantime, it's crucial to prevent further loss of lives due to the shortage.

Will incentivizing donors undermine altruism?  Financial compensation for donors can coexist with altruism. Donors can opt out of the funds from the tax credit or choose to donate those funds to charity. The majority of donors support financial compensation, and relying solely on altruism has led to preventable deaths.

In addition to ending the kidney shortage, what are other benefits of the End Kidney Deaths Act? The End Kidney Deaths Act can help combat the black market for kidneys and reduce human trafficking because we will have an increased number of transplantable kidneys. It can also motivate individuals to become healthier to pass donor screening, potentially further reducing overall healthcare costs.

Why provide non-directed donors with a refundable tax credit of $50,000? The compensation is designed to attract those who are both healthy and willing to donate. Given the commitment, time, pain, stress and effort involved in the donation process, this compensation recognizes the value of those who save lives and taxpayer funds.

When more donors step forward, can transplant centers increase the number of surgeries?  There is considerable unused capacity at most U.S. transplant centers, and increasing the number of donors willlead to more surgeries. The goal is to perform more kidney transplants and reduce the waitlist, benefiting patients in need.

In what way does the End Kidney Deaths Act uphold The Declaration of Istanbul?  The Declaration of Istanbul was aimed at preventing transplant tourism. While the End Kidney Deaths Act deviates from one principle of the Declaration of Istanbul by offering compensation, it aligns with the other ten principles and is expected to standardize compensation and reduce worldwide organ trafficking. 

What about dialysis as an alternative to transplant? Dialysis, while a treatment option, can be a challenging and uncomfortable process for patients. For these reasons, only about 25% are able to work full-time. For those who could have been transplanted if there were no kidney shortage, dialysis can result in needless suffering and an untimely death.

Why not compensate living liver donors? Liver donation is riskier and not as taxpayer cost-reducing as kidney donation. While the End Kidney Deaths Act currently focuses on kidney donors, it's possible that compensation for liver donors could be considered in the future.

What about the argument that providing an incentive to donate will exploit the donors, especially low income donors? 

  1. EKDA will increase donations for low-income people: The abundance of transplantable kidneys after the passage of the End Kidney Deaths Act will disproportionately help low income people who are far more likely to die from the kidney shortage.

  2. Right now, low income people face financial barriers to donate: Most donors are high income due to the high personal costs of donation and their better health in comparison with low income people.

  3. It is morally important to compensate people for difficult work: It’s unjust that donors are unpaid for the stressful, time consuming, and physically uncomfortable experience of being a kidney donor. Because of the value they provide, we compensate people for difficult jobs and surrogacy that are far riskier than kidney donation.

Primarily middle and low income kidney failure patients are dying due to the kidney shortage. The End Kidney Deaths Act will provide thousands more kidneys transplants for those waiting longest on the waitlist that is predominantly middle and low income Americans. This abundance of transplantable kidneys will disproportionately help the people who are far more likely to die from the kidney shortage. Low income people are in worse health than high income earners and are far less likely to qualify as kidney donors. Lower-income populations have lower rates of living kidney donation.

Once kidney donation is no longer unpaid work, people of all income levels will be able to donate. People with lower incomes tend to have social networks with fewer healthy people because health is related to income level. In addition, being placed on a waitlist or finding a willing donor often costs money. Kidney donation also costs money, an estimated 10% of annual income. The refundable tax credit will help low income donors and recipients the most by making donation affordable and increasing the number of kidneys for those waiting the longest on the waitlist, frequently middle and low income Americans. The tax credit will disproportionately help those most affected by the kidney shortage, as poorer and middle-income individuals often bear the brunt of the kidney crisis’s consequences. The End Kidney Deaths Act will level the playing field, making it easier for those at all income levels to receive a life-saving kidney. 


This chart reveals that less educated people are more likely to be on dialysis and less likely to be transplanted in comparison with more educated people. 




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