The Uninsured Often Donate Organs, but Rarely Receive Them

CHICAGO - People who lack health insurance are about 20 times more likely to donate their liver or a kidney for a lifesaving transplant than to receive one, a new study shows.

A team of Harvard University researchers, writing in the current issue of International Journal of Health Services, reports that a representative sampling of U.S. patients in 2003 shows that at least 16.9 percent of organ donors had no health insurance at the time of their hospitalization. In contrast, only 0.8 percent of the transplant recipients were similarly uninsured; in other words, almost all recipients had some kind of health coverage at the time of their procedure.

Among the transplant recipients, equal proportions (44.2 percent) were covered by private insurance or by Medicare, a public program that serves seniors and some of the disabled (including virtually all patients needing kidney transplants). Medicaid, a government program for the poor, covered another 9 percent. About 2 percent were covered under other programs.

Among organ donors, however, insurance coverage was much less extensive. Private insurance was the most common source of payment for their medical bills (44.8 percent), followed by Medicare (14.6 percent) and Medicaid (2.6 percent). One-fifth of organ donors' insurance status was listed as "other," a designation that may have indicated that their bills were paid by organ procurement organizations. Some of these may have been uninsured for other medical care. Yet even assuming that all of these had coverage, the authors found that 16.9 percent of the organ donors were uninsured. By comparison, only 4.6 percent of other inpatients were uninsured.

The authors analyzed data from the 2003 National Inpatient Sample, a representative sample of hospital stays compiled by the Agency for Healthcare Research and Quality (AHRQ) under the U.S. Department of Health and Human Services. Using AHRQ guidelines, the research team extrapolated their results from the coded hospital records of 1,447 solid organ donors (including donors of kidneys, pancreases, livers, hearts, lungs and corneas) and 4,962 recipients.

The finding that most transplant recipients were insured at the time of their transplant had previously been known. However, "our finding that uninsured patients frequently serve as organ donors is both new and poignant," the authors write. "The U.S. health care system denies adequate care to many of the uninsured during life. Yet, in death, the uninsured often give strangers the ultimate gift."

Strikingly, lack of insurance was a stronger predictor of organ donation than was any hospital characteristic or demographic factor other than age (older people's organs are more often diseased and unsuitable for transplantation).

The authors emphasize that the asymmetry of who donates organs and who receives them does not reflect "the values or intentions" of the medical transplant community, whose members avow a "commitment to equal access for all patients."

They also point out that, because organ transplantation uses a "scarce resource that can only come from fellow human beings," special protocols, including guidelines adopted by Congress, have been developed to improve equity in the transplantation of organs.

The lead author of the study, Dr. Andrew Herring, commented: "If you lack the financial resources to afford a transplant either through insurance or otherwise, few centers will consider you as a candidate. The 1984 National Organ Transplant Act stipulates that transplants should be equally available to all Americans, regardless of their ability to pay. Unfortunately, the health care system is presently not funded adequately to make this a reality." Herring is currently an emergency medicine resident at Highland Hospital in Oakland, California. He performed the study while he was a medical student at Harvard.

Dr. Steffie Woolhandler, a co-author and associate professor of medicine at Harvard, said, "The fact that many organ donors were uninsured dramatically highlights the lack of fairness in the U.S. health care system as a whole. The only way to surmount this problem is to adopt a single-payer national health insurance program, which would guarantee comprehensive and affordable care to everyone without exception."

The lack of health coverage is responsible for at least 18,000 deaths annually, according to the Institute of Medicine. In August, the Census Bureau reported that 45.6 million Americans lacked health insurance in 2007.

"Insurance status of U.S. organ donors and transplant recipients: The uninsured give, but rarely receive," Andrew A. Herring, M.D.; Steffie Woolhandler, M.D.; and David U. Himmelstein, M.D. International Journal of Health Services (New York), Vol. 38, No. 4.

A copy of the study is available at http://www.pnhp.org/organ_donors