1. What is the End Kidney Deaths Act proposing?

The End Kidney Deaths Act 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 on the kidney waitlist. This will greatly increase the number of living kidney transplants, the gold standard for patients with kidney failure.

2. How are the estimated financial savings calculated?

We estimate that by year ten, the taxpayer will save between $10 billion and $37 billion. Ike Brannon, Senior Fellow at the CATO Institute, and Senator John McCain’s former Chief Economist, calculated that $517,000 is saved by the taxpayer when a kidney failure patient 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. While the exact amount of that increase is unclear, one study in the American Journal of Transplantation (AJT) found 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 roughly 8,000 of the 10,000 transplants.

The left table with the Dr. Axelrod AJT published study estimated savings per recipient of $174,000; the right table is 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

3. Are the majority of Americans in favor of compensating kidney donors?

Yes! Check out these four surveys:

2006 - American Journal of Transplantation: Public Attitudes Toward Incentives for Organ Donation: A National Study of Different Racial/Ethnic and Income Groups
2012 - Reuters Poll: Americans Show Support For Compensation Of Organ Donors
2016 - JAMA Surgery: Most US Voters Approve of Paying Kidney Donors, Survey Finds
2019 - Johns Hopkins Study Most Americans favor compensation for kidney donors if it leads to more saved lives

4. Which surveys demonstrate the support for kidney donor compensation from the American Society of Transplant Surgeons and the American Society of Transplantation?

1. Rodrigue JR, Crist K, Roberts JP, Freeman RB Jr, Merion RM, Reed AI. Stimulus for organ donation: a survey of the American Society of Transplant Surgeons membership. Am J Transplant. 2009 Sep;9(9):2172-6.doi: 10.1111/j.1600-6143.2009.02741.x. Epub 2009 Jul 16. PMID: 19624568. 2014: Joint meeting of the ASTS and AST devoted to this topic,participants concluded “there is ‘no a priori reason not to work … toward a plan for pilot projects in offering incentives”. (Salomon D, et al, AJT 2015) “We believe it important not to conflate the illegal market for organs, which we reject in the strongest possible terms, with the potential in the United States for concerted action to remove all remaining financial disincentives for donors and critically consider testing the impact and acceptability of incentives to increase organ availability in the United States.”

“Overall, there is strong support within the ASTS membership for changes to NOTA that would permit the implementation and careful evaluation of indirect, government-regulated strategies to increase organ donation.”

2. Salomon DR, Langnas AN, Reed AI, Bloom RD, Magee JC, Gaston RS; AST/ASTS Incentives Workshop Group (IWG). AST/ASTS workshop on increasing organ donation in the United States: from removing disincentives to testing incentives. Am J Transplant. 2015 May;15(5):1173-9. Doi: 10.1111/ajt.13233. Epub 2015 Mar 31. PMID: 25833653.

5. Why are living kidneys better than deceased donor kidneys?

Living kidneys last twice as long as deceased donor kidneys because they come from a healthier source and can be better matched to the recipient.

6. 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.

7. What is the American kidney crisis?

Every month, around 1,000 Americans on the waiting list for a kidney transplant die or become too sick to be transplanted. 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.

8. Why a “refundable tax credit for $50,000 over five years?”

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.
$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 encourage someone to donate to a stranger. The $50,000 figure is also informed by this study published in JAMA Surgery in 2016, which finds that $50,000 would help motivate kidney donation.
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 social, psychological, 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 donation. For instance, 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 payment structure helps alleviate concerns that people may donate in order to receive an immediate financial windfall.

9. 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.

10. How much do taxpayers currently spend on dialysis?

Kidney transplantation not only saves lives; it also saves taxpayer money. 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.

11. 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 the year 2000 to around 400 annually currently. After the End Kidney Deaths Act becomes law, we will over time add approximately 10,000 non-directed donor kidneys annually. That is around 100,000 new transplanted Americans by year ten.

12. How much total taxpayer 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 $37 billion.

13. 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.

14. What do Americans think about compensating living kidney donors?

Most Americans favor compensation for living kidney donors to increase donation rates.

15. 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. Providing compensation will encourage more Americans to donate their kidneys to help those with kidney failure.

16. How will a “healthy” donor be determined?

Less than 10% of those who step forward to donate actually donate. Many are disqualified due to health issues. Some drop out because the donation is no longer needed by their loved one. For instance, if four siblings may come forward to donate to their mother, but only one ended up donating. The other three will likely not donate. Some Americans also cannot afford to donate. Kidney donation is complicated, stressful, painful, and time consuming work.

The transplant centers will continue to conduct their excellent scrutiny of potential donors to make sure that they will do no harm by removing a kidney. They do such a good job that kidney donors live longer than the general population.

17. How will the rules be enforced to prevent a “marketplace” from developing (i.e., organ sale to highest bidder)?

The End Kidney Deaths Act team is opposed to organ markets. When people donate kidneys to strangers, their kidneys go to the people on the top of the waitlist, those most likely to die from the kidney shortage. Private payment for kidneys will continue to be illegal.

18. Is it ethical to provide payment for kidney donors?

9,000 Americans are dying annually while waiting for a life-saving kidney transplant. Saving their lives with a kidney transplant from a compensated donor is the ethical choice rather than letting them die from preventable deaths.

Everyone in the entire donation process is paid except for the kidney donor and the recipient whose remaining years of life will be tripled once transplanted.

It's morally important to pay people for difficult work. Until now, we have not paid kidney donors for the time consuming, stressful and painful work of donation. In other situations, we pay people to do difficult work. Paid heroes like police officers and firefighters engage in difficult work that involves risks to save lives. The choice to not pay kidney donors for their generosity and heroism is arbitrary and resulting thousands of preventable deaths.

With the End Kidney Deaths Act, donors will finally be rewarded for their life-saving generosity. The kidney donors who founded the End Kidney Deaths Act campaign understand that donation is time consuming, stressful and painful work that is worthy of a tax credit. The tax credit system exists to encourage people to engage in prosocial behavior. What is more prosocial than having your body opened up and giving a healthy organ so a stranger can survive and thrive for decades?

The 4 principles of ethics are beneficence (The duty to do good and help others achieve their best health.), nonmaleficence (“do no harm”), autonomy (The right of a patient to make their own decisions about their care), and justice (The duty to treat all people equally and fairly, without discrimination). The End Kidney Deaths Act upholds all four principles.

Nearly half of those 90,000 on the kidney waitlist will die waiting. From 2010-2021, 100,000 Americans, the number of people who fit in the largest football stadiums, were healthy enough to receive a kidney when they joined the waitlist, but instead suffered and died due to the long wait. Another 100,000 will certainly die in the next decade without the passage of the End Kidney Deaths Act.

19. How will the tax credit be implemented?

Implementation will be done through the IRS similar to tax credits for people who purchase electric vehicles. Transplant centers will certify that the donation was nondirected.

20. Will compensating 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.

21. 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 underground 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.

The End Kidney Deaths Act will greatly help low income Americans who are only 12% of the population but 34% of new cases of ESRD. Low income Americans receive only 6% of transplants.

22. 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 will lead to more surgeries. The goal is to perform more kidney transplants and reduce the waitlist, benefiting patients in need.

23. Is the End Kidney Deaths Act consistent with 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.

24. How risky is kidney donation?

Kidney donors undergo multiple qualification physical and mental health testing that take up to six months to complete. Only those who are in top health are approved for kidney donation. Most applicants are disqualified. The transplant centers do such an excellent job at selecting healthy donors that living kidney donors live on average longer than the general population.

Here is a chart that reviews the overall risk of kidney donation in comparison with other the annual professions:

25. 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.

26. What is the relationship between covering donors’ expenses and increasing the rate of kidney donation?

Reimbusing donors for costs and lost wages does not increase the rate of living kidney donation.

The majority of donors are fully compensated for their costs and lost wages so that they are financially cost neutral. 22% receive the reimbursement from the federal program NLDAC. 40% are reimbursed through Donor Shield. 23 states offer tax credits and deductions for donors’ expenses. Reimbursing donors is the right thing to do, but has not resulted in an increase in the donation rate for 20 years. The living kidney donation rate hovers around 5,000 or 6,000 annually, never even reaching 7,000.

In Canada, all donors’ expenses and wages are reimbursed for all donors. This has not resulted in an increase of the living kidney donation rates in Canada.

27. 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.

28. What about the argument that providing compensation to donate will exploit the donors, especially low income donors?

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.
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.
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. 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.

Getting evaluated and approved for kidney donation takes up to six months. The surgery and recovery can take six to eight weeks of time devoted to healing from the operation.

The result of not encouraging donors is nearly 1,000 people dying on the kidney waitlist every month. All of them were healthy enough to receive a kidney when they joined the waitlist. The waiting time killed them. Our current system results in so many heartbreaking preventable deaths. This is not ethical.

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, those who so 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.

29. Where is the legislative text?

Please click here to read the legislative text.

Frequently Asked Questions