Removing disincentives to kidney donation, by McCormick et al. in J.Am.Soc.Nephrology

Here's the latest paper in an illuminating series on the costs and consequences of kidney donation and transplantation:

McCormick F, Held PJ, Chertow G, Peters T, and Roberts J.  Removing Disincentives to Kidney Donation: A Quantitative Analysis.  J Am Soc Nephrol 30: ccc–ccc, 2019. doi: https://doi.org/10.1681/ASN.2019030242 is:

https://jasn.asnjournals.org/content/jnephrol/early/2019/07/23/ASN.2019030242.full.pdf

I'm fortunate to be on McCormick's distribution list for email updates on matters related to kidney transplantation, and here's how he introduced and summarized this paper (the table of cost estimates is at the very bottom):

"Friends,

About two years ago, Economics Nobel Laureate Alvin Roth observed that since no-one in the transplant community seemed to be opposed to removing disincentives to kidney donation, the community should unite behind accomplishing that goal.  Our just-published article -- “Removing Disincentives to Kidney Donation: A Quantitative Analysis” -- lays out the consequences of pursuing that consensus objective.  It identifies seven disincentives facing living kidney donors and a single disincentive facing the families of deceased donors. 

The seven disincentives to living donors are listed in column 1 of the table below.  Columns 2 - 5 show estimates of the magnitudes of some of these disincentives made by earlier researchers.  Column 6 indicates our own best estimates of all of the disincentives, and Column 7 specifies the government actions needed to remove these disincentives without violating the National Organ Transplant Act.

Note that the disincentives to living donors total almost $38,000, which is much larger than generally assumed.  This is a substantial deterrent to kidney donation by living donors and goes a long way toward explaining why, even though about 125,400 patients were diagnosed with kidney failure in the U.S. in 2017, most of whom could have benefited from a kidney transplant, only 5,811 patients (4.6%) received a kidney from a living donor.

It follows that if the government could remove all of these disincentives by compensating donors, it could substantially boost kidney donations.  We estimate total donations from both living and deceased donors would increase by about 12,500 per year (63%).  That would cut the waiting list for transplant kidneys (currently numbering about 93,000 patients) in half in about four years.

We estimate removing all the disincentives would require an initial government outlay of only about $0.5 billion per year.  But this investment would quickly be recovered because (a) the long-run cost of transplantation is much less than for dialysis and (b) the government pays most of the costs of both.  So taxpayers would wind up saving a net $1.3 billion each year.  Much more importantly, society would enjoy a net welfare gain of about $14 billion per year, reflecting the great value of the additional donated kidneys to recipients and the savings from these recipients no longer needing expensive dialysis therapy. 

The timing of this article is fortuitous because there is currently great interest in Washington in proposals to remove disincentives to organ donation.  Indeed, on July 10, President Trump issued an executive order stating: “Within 90 days of the date of this order, the Secretary [of the Department of Health and Human Services] shall propose a regulation to remove financial barriers to living organ donation.”

               

Frank

The URL for the just published article: McCormick F, Held PJ, Chertow G, Peters T, and Roberts J.  Removing Disincentives to Kidney Donation: A Quantitative Analysis.  J Am Soc Nephrol 30: ccc–ccc, 2019. doi: https://doi.org/10.1681/ASN.2019030242 is:

https://jasn.asnjournals.org/content/jnephrol/early/2019/07/23/ASN.2019030242.full.pdf

This is the fourth in a series of articles aimed at reducing the kidney shortage and thereby saving tens of thousands of lives each year.  The previous three were:

1.             Held PJ, McCormick F, Ojo A, Roberts JP.  A cost-benefit analysis of government compensation of kidney donors.  Am J Transplant 16: 877–885, 2016.         

This article laid out in great detail (13 Supplements) all of the costs and benefits of compensating kidney donors, showing it would confer a net benefit on society of about $46 billion per year and would save taxpayers about $12 billion per year.

https://onlinelibrary.wiley.com/doi/full/10.1111/ajt.13490

2.       Held PJ, McCormick F, Chertow GM, Peters TG, Roberts JP.  Would government compensation of living kidney donors exploit the poor? An empirical analysis.  PLOS ONE, November 28, 2018. 

This article presented evidence that the poor would not be exploited by government compensation of kidney donors.  Indeed, the aggregate net benefit to the poor would increase to $12 billion per year from only $1 billion per year currently.

https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0205655&type=printable

 

 

3.       McCormick F, Held PJ, Chertow GM.  The Terrible Toll of the Kidney Shortage.   J Am Soc Nephrol 29: 2775–2776, 2018.

This editorial argued that the shortage of transplant kidneys is causing the needless premature deaths of about 43,000 Americans each year (118 per day), the same death toll as from 85 fully loaded 747s crashing each year.  This is a much larger number than had previously been assumed. 

 https://jasn.asnjournals.org/content/jnephrol/29/12/2775.full.pdf

Table 1 Disincentives to Kidney Donation Facing Living Donors
(1) Disincentive		Estimated Magnitudes of Disincentives (Adjusted to U.S. prices and standard of living in 2017)					(7) Proposed Government Action To Remove  the Disincentive
		(2) Gaston          et al.      (2006)	(3) Becker – Elías  (2007)	(4) Rodrigue  et al.    (2016)	(5) Przech  et al.    (2018)	(6) McCormick – Held  et al.  (this study)
1	Travel to, and lodging near, a transplant center	$4,313	--	$1,945	$1,653	$3,122	Expand current NLDAC program to include donors of all income levels
2	Loss of income while recovering from surgery		$3,631	$5,118	$4,368	$5,118	Expand current NLDAC pilot program to include donors of all income levels, providing donors with a tax credit of $5,000
3	Cost of home/ dependent care	--	--	--	$5,592	$5,592	Include cost of home/ dependent care in NLDAC program, providing donors with a tax credit of $6,000
4	Risk of dying during kidney removal	$2,951	$6,723	--	--	$1,860	Provide donors with a $5 million short-term life insurance policy
5	Pain and discomfort of kidney removal	$6,414	--	--	--	$6,414	Provide donors with a tax credit of $6,500
6	Decrease in the long-term quality of life	$23,250	$10,085	--	--	$7,910	Provide donors with an insurance policy covering death, disability, and long-term health problems due to donation
7	Concern that a relative or close friend may need a kidney in the future	--	--	--	--	$7,728	Promise to provide a kidney in the future for a specific person in exchange for a donation now
Total		$36,928	$20,439	--	--	$37,745

Elephant tusks and pangolin scales

Singapore has just seized a big load of contraband materials from endangered species. I had been aware of the black market in elephant ivory, but pangolin scales are new to me.

Singapore seizes record haul of smuggled elephant ivory

"Singapore has made its largest ever seizure of smuggled ivory, impounding a haul of nearly nine tonnes of contraband tusks from an estimated 300 elephants, according to authorities.

"The illegal cargo, discovered on Sunday in a container from the Democratic Republic of the Congo also included a huge stash of pangolin scales – the third such seizure in as many months.

Officials said both the ivory and pangolin scales were in a container declared to be loaded with timber destined for Vietnam and passing through Singapore, a major transhipment hub for global trade."
...

"Pangolins, also known as scaly anteaters, are critically endangered. They are the world’s most trafficked mammals because of their meat, which is considered a delicacy, and their scales, which some believe to have medicinal qualities.

"Elephant ivory is coveted because it can be fashioned into items like combs, pendants and other exotic jewellery.

"The global trade in elephant ivory, with rare exceptions, has been outlawed since 1989 after the population of the African animals dropped from millions in the mid-20th century to about 600,000 by the end of the 1980s."

Will we learn to handle immigration by the time sea levels rise?

Below is a link to a 3-minute video of an interview (in English with Portuguese subtitles) that I gave some time ago on Portuguese TV, but just saw recently...  We talked about populism, immigration, and how we're going to have to learn from our failures today to prepare for future mass movements of people. (It starts with an advertisement, before the interview begins:(


Nobel da Economia em entrevista à TVI critica populismos e alerta para mais migração - 
Alvin Roth referiu ainda que o fenómeno do aquecimento global vai aumentar a migração
[G-translate: "Nobel la Economía in interview with TVI criticizes populism and alert for more migration
Alvin Roth also noted that the phenomenon of global warming will increase migration."

Black markets in organs in Egypt and Bangladesh

Dr.  Frederike Ambagtsheer  points me to the following papers. She is one of the coordinators of the HOTT project, Combating trafficking in persons for the purpose of organ removal.

Disqualified Bodies: A Sociolegal Analysis of the Organ Trade in Cairo, Egypt,  Law & Society Review, Volume 51, Number 2 (2017), by Seán Columb

Abstract: Legislative and policy interventions in response to the organ trade have centered on the introduction of criminal sanctions in an effort to deter organ sales
and/or “trafficking.” Yet, such measures fail to take account of the social and
political processes that facilitate the exploitation of individuals in organ markets
in different contexts. Informed by empirical data, gathered via a series of
in-depth interviews with Sudanese migrants who have sold a kidney, this
paper examines the link between increased urbanization, migration patterns,
informalization, and the emergence of organ markets in the Egyptian-
Sudanese context. The findings illustrate how processes of legal marginalization
and social exclusion leave people vulnerable to exploitation in organ markets.
The prevailing law enforcement response does not capture or respond
to the empirical reality. Accordingly, this paper shifts the emphasis away from
criminalization toward an analysis of the legal barriers and policy decisions
that shape the poor bargaining position of organ sellers. In doing so, it opens
up discussion of the organ trade onto wider critiques that disrupt boundaries
between formality and informality in labor markets and trouble dominant
modes of criminalization.
**********

EXCAVATING THE ORGAN TRADE: AN EMPIRICAL STUDY OF
ORGAN TRADING NETWORKS IN CAIRO, EGYPT, British Journal of Criminology, 2016, doi:10.1093/bjc/azw068
Seán Columb

Abstract
Legislative action in response to the organ trade has centred on the prohibition of organ sales and the enforcement of criminal sanctions targeting ‘trafficking’ offences. This paper argues that the existing law enforcement response is not only inadequate but harmful. The analysis is based on empirical data gathered in Cairo, Egypt, among members of the Sudanese population who have either sold or arranged for the sale of kidneys. The data suggest that prohibition has pushed the organ trade further underground increasing the role of organ brokers and reducing the bargaining position of organ sellers, leaving them exposed to greater levels of exploitation.
**********

And an opposite conclusion:

Against a Regulated Market in Human Organs: Ethical Arguments and EthnographicInsights from the Organ Trade in Bangladesh, Human Organization, Vol. 77, No. 4, 2018
Monir Moniruzzaman

Abstract: While organ transplantation is often highly successful in saving lives, it has created an illicit, but thriving, trade in human organs, including kidneys, livers, and corneas sourced from living bodies of the desperate poor. Based on challenging ethnographic fieldwork with seventy organ sellers, along with a group of recipients, brokers, and doctors, this article explains how organ trade results in violence, exploitation, and suffering against the vulnerable, who sell their live organs on the black market of Bangladesh. In opposition to allowing a “regulated organ market,” I argue that such a market is not a magic bullet that by itself would eliminate deception, coercion, and corruption that exist in the illegal trade of vital organs, nor would it ensure equity, rights, and justice to organ sellers. Instead, a regulated market would exacerbate, institutionalize, and normalize violence, exploitation, and suffering against impoverished populations. I, therefore, conclude that organ trade needs to be condemned, as there are alternative ways to resolve organ shortages. I suggest that government authorities must enact stringent laws, ensure ethical transparency, and encourage cadaveric donations to combat organ trafficking worldwide
********

Here are the earlier reports of the HOTT project.

Kidney exchange needs to be conducted at scale, in the AER by Agarwal, Ashlagi, Azevedo, Featherstone and Karaduman

Market Failure in Kidney Exchange

• Nikhil Agarwal
• Itai Ashlagi
• Eduardo Azevedo
• Clayton R. Featherstone
• Ömer Karaduman


AMERICAN ECONOMIC REVIEW (FORTHCOMING)


Abstract
We show that kidney exchange markets suffer from market failures whose remedy could increase transplants by 30%–63%. First, we document that the market is fragmented and inefficient: most transplants are arranged by hospitals instead of national platforms. Second, we propose a model to show two sources of inefficiency: hospitals only partly internalize their patients' benefits from exchange, and current platforms suboptimally reward hospitals for submitting patients and donors. Third, we calibrate a production function and show that individual hospitals operate below efficient scale. Eliminating this inefficiency requires either a mandate or a combination of new mechanisms and reimbursement reforms.
Forthcoming Article Downloads
• Preview (AEA members only) (966.12 KB)

Celebrating Christos Papadimitriou at 70 at Columbia: September 6-8, 2019.

Christos Papadimitriou, the computer scientist who intersects with market design trhough his big contributions to algorithmic game theory, is being celebrated at Columbia in September:
70 Years Papadimitriou. 
A beautiful journey to the Theory of Computation.

Whiskey production is a warehouse business

When we think of whiskey we think of distillers. But aging requires barrels, and barrels take up space for a long time.  A recent fire brings this to mind.  The Washington Post has the story:

A Jim Beam warehouse caught fire, destroying 45,000 barrels of bourbon

"A standard barrel contains about 53 gallons of bourbon, which is aged for years to achieve its desired color and flavor. The bourbon gives the flames ample material to burn, Chandler said. Generally, any alcohol that’s at least 80 proof — like most bourbon — is flammable.
...
"The company operates 126 barrel warehouses, which collectively hold 3.3 million barrels, in the state. The warehouse that was destroyed contained relatively young whiskey, Beam Suntory said, the loss of which will not impact availability.
...
"In the past year, bourbon distillers have also had to contend with the economic consequences of President Trump’s trade war. U.S. whiskey exports slowed during the second half of 2018, after trading partners including the European Union enacted retaliatory tariffs of up to 25 percent, raising the cost of American-made whiskey and bourbon. Sales fell by 11 percent from July to December last year, compared with the same period in 2017, according to data compiled by the Distilled Spirits Council."

Privacy and dating apps

As internet and app-driven dating becomes increasingly common, so has the tension between dating and privacy, i.e. between indicating to potential partners who you are and what you want, and keeping some privacy about these things in the rest of your life.  The NY Times has an article by NY Law School prof Ari Ezra Waldman that focuses on the design of dating apps with respect to privacy:

 Queer Dating Apps Are Unsafe by Design
Privacy is particularly important for L.G.B.T.Q. people. By Ari Ezra Waldman.

"Pete Buttigieg met his husband on a dating app called Hinge. And although that’s unique among presidential candidates, it’s not unique for Mr. Buttigieg’s generation — he’s 37 — or other members of the L.G.B.T.Q. community.

In 2016, the Pew Research Center found that use of online dating apps among young adults had tripled in three years, and nearly six in 10 adults of all ages thought apps were a good way to meet someone. The rates are higher among queer people, many of whom turn to digital spaces when stigma, discrimination and long distances make face-to-face interaction difficult. One study reported that in 2013 more than one million gay and bisexual men logged in to a dating app every day and sent more than seven million messages and two million photos over all.

...

"But for queer people, privacy is uniquely important. Because employers in 29 states can fire workers simply for being gay or transgender, privacy with respect to our sexual orientations and gender identities protects our livelihoods. 

...

"All digital dating platforms require significant disclosure. Selfies and other personal information are the currencies on which someone decides whether to swipe right or left, or click a heart, or send a message. 

...

" Hinge made a commitment to privacy by designing in automatic deletion of all communications the moment users delete their accounts. Scruff, another gay-oriented app, makes it easy to flag offending accounts within the app and claims to respond to all complaints within 24 hours. Grindr, on the other hand, ignored 100 complaints from Mr. Herrick about his harassment. If, as scholars have argued, Section 230 had a good-faith threshold, broad immunity would be granted only to those digital platforms that deserve it.

Privacy isn’t anathematic to online dating. Users want it, and they try hard to maintain it. The problem isn’t sharing intimate selfies, no matter what victim-blamers would have us believe. The problem is the law permits the development of apps that are unsafe by design."

Laws about gay sex in Africa

While many countries have legalized same sex marriages, including South Africa, in the rest of Africa the question is whether engaging in same-sex sex will be legalized.  The Guardian has the story of one step forward and maybe back again in Botswana:

Botswana government to appeal against law legalising gay sex
Attorney general says high court was mistaken in its ruling decriminalising homosexuality

"Botswana’s government will appeal against a high court ruling that decriminalised homosexuality, potentially resuscitating a law that punished gay sex by up to seven years in prison.

"The court’s ruling in June, which was praised by international organisations and activists, meant Botswana joined a handful of African countries that have legalised same-sex relationships.
...
"Same-sex relationships are illegal in more than 70 countries worldwide; almost half of them in Africa, where homosexuality is broadly taboo and persecution is rife.

"Botswana’s ruling came after Kenya’s high court upheld its law banning gay sex, keeping same-sex relations punishable by 14 years in jail, drawing strong criticism from the United Nations and rights activists.

...
Botswana is the latest country in Africa to decriminalise same-sex relations, with Amnesty saying it follows Angola in January, the Seychelles in June 2016, Mozambique in June 2015, and São Tomé and Principe, and Lesotho, in 2012.

South Africa is the only African nation to have legalised gay marriage."

Transplantation in China: update

I returned Sunday from a busy and potentially productive trip to China.

Since 2015 it has been illegal in China to use organs from executed prisoners for transplants. The passage of that law was the result of a long struggle between an opaque, often black market system of transplantation, and an emerging transparent system based on voluntary donation.  The transparent system has made, and is continuing to make, enormous strides.

In Shenzhen I visited the China Organ and Transplant Response System (COTRS), run by Dr. Haibo Wang, which organizes and records the data of transplant patients and donors. 

It also collects large amounts of data on all hospital stays at China’s largest hospitals. Together with the National Institute of Health Data Science at Peking University, run by Dr. Luxian Zhang, they are assembling a vast data resource that will have many uses.

In Beijing I also visited the China Organ Transplant Development Foundation, run by Dr. Jeifu Huang, which plays a role in guiding the emerging body of legislation through which transplants are being organized in China with increased transparency.

I also spoke at the Beijing Summit on Health Data Science.

It was a busy week that left me optimistic that we'll see continued big progress in healthcare delivery in China, including but not limited to transplantation.

Some photos were taken...

President Trump's Executive Order on kidney care

On July 10, while I was in China, President Trump issued an executive order touching on all aspects of care for kidney patients, including dialysis and transplantation from both deceased and living donors.

Here's the text of that executive order:
Executive Order on Advancing American Kidney Health
 Issued on: July 10, 2019

Because I anticipated being potentially incommunicado when the executive order was announced, I had filed an op-ed article (giving my proxy to my coauthor Greg Segal for any necessary last-minute edits) to be published on CNN's web site, applauding the order:
The Trump administration's organ donation efforts will save lives
By Alvin E. Roth and Greg Segal
Updated 1:20 PM ET, Wed July 10, 2019

As it happens, a reporter for PBS news hour reached me by phone in China, and so I got to chime in in person:
Trump’s plan to combat kidney disease aims to save money and lives. Can it?
Health Jul 10, 2019 4:39 PM EDT


The part of the executive order that touches most closely on my work on kidney exchange is Section 8:

"Sec. 8.  Supporting Living Organ Donors.  Within 90 days of the date of this order, the Secretary shall propose a regulation to remove financial barriers to living organ donation.  The regulation should expand the definition of allowable costs that can be reimbursed under the Reimbursement of Travel and Subsistence Expenses Incurred Toward Living Organ Donation program, raise the limit on the income of donors eligible for reimbursement under the program, allow reimbursement for lost-wage expenses, and provide for reimbursement of child-care and elder-care expenses."

Regarding deceased donor transplants, Section 7 says

"Sec. 7.  Increasing Utilization of Available Organs.  (a)  Within 90 days of the date of this order, the Secretary shall propose a regulation to enhance the procurement and utilization of organs available through deceased donation by revising Organ Procurement Organization (OPO) rules and evaluation metrics to establish more transparent, reliable, and enforceable objective metrics for evaluating an OPO’s performance.

(b)  Within 180 days of the date of this order, the Secretary shall streamline and expedite the process of kidney matching and delivery to reduce the discard rate.  Removing process inefficiencies in matching and delivery that result in delayed acceptance by transplant centers will reduce the detrimental effects on organ quality of prolonged time with reduced or cut-off blood supply."

***************

Here is some of the news coverage:

Trump signs executive order revamping kidney care, organ transplantation By Lenny Bernstein July 10 (Washington Post);
Trump signs executive order to transform kidney care, increase transplants 
By Jen Christensen and Betsy Klein, CNN Updated 4:21 PM ET, Wed July 10, 2019

This executive order is well worth supporting, and it will need support to achieve the goals it outlines.  The Secretary of Health and Human Services has been directed to do things in fairly broad terms, and we'll have to watch carefully to see the results, which will be interpreted, contested, and implemented through multiple political/regulatory processess

*************

Regarding removing financial disincentives for kidney (and liver) donors, I'm on the advisory board of the federally funded National Living Donor Assistance Center (NLDAC), which has been able, under very tight constraints, to reimburse some donors for some travel expenses (see related posts here).  A minimalist interpretation/implementation of the Executive Order would be to relax some of the constraints on whose expenses and which expenses can be reimbursed, and to increase NLDAC's budget accordingly.  A more expansive interpretation would be to remove some of those constraints so that no donor would have to pay to rescue someone with kidney failure by donating a kidney.