Bipartisan Bill Aims to Prevent Kidney Deaths by Compensating Donors

About 10,000 people die each year in the United States because they did not receive a kidney transplant in time. The pain of such loss spreads to many tens of thousands of relatives and loved ones who suffered the agony of knowing these deaths could have been prevented.

The issue isn’t a shortage of kidneys—there are more than enough healthy people who could donate their spare. (Most of us have two working kidneys, but we only need one.) The crisis exists because not enough people are willing to help a stranger. Generally, that’s because we’re not well informed about the problem or the solutions.

So the question is, how do we increase the number of donors?

One potential solution is H.R. 2687, also known as the “End Kidney Deaths Act.” This proposed legislation would establish a 10-year pilot program offering nondirected donors a $10,000 refundable tax credit for five years, for a total of $50,000. If donors do not owe enough in taxes to utilize the full credit, the government will provide the remaining balance as a check, ensuring they receive the entire $10,000 benefit in each eligible year.

“We estimate that it will save up to 100,000 American lives, as well as $40 billion in taxes every year,” says Elaine Perlman, who donated a kidney to a stranger six months after her son did the same in 2019. She now serves as the executive director of Waitlist Zero, a coalition that is advocating for the bill.

By surveying transplant centers, Waitlist Zero determined they could collectively perform an additional 10,000 surgeries annually, totaling 100,000 lives saved over the course of the decade-long pilot.

Of all the people on the national organ waitlist, 86% are waiting for a kidney, according to Donate Life America.

Tragically, 5,758 patients were removed from the waiting list in 2021 because they died and another 5,371 because they became ‘too sick to transplant,’” according to a 2022 study published by the National Academy of Sciences, Engineering, and Medicine.

“This means that 11,129 patients—about 30 a day—who had been listed for an organ transplant died without receiving one that year,” the report concludes.

In Hawai‘i, some 6,075 residents are living with kidney failure, including 83% that are receiving dialysis treatment, according to the American Kidney Fund. Meanwhile, 813 residents were on the kidney transplant waiting list as of February 2025, but only 1 in 3 on the list received a kidney in 2024, including just 7 from living donors.

A BILL THAT SAVES LIVES AND MONEY

Medicare covers most dialysis costs for 80% of patients at a staggering cost to taxpayers of roughly $90,000 per patient, per year. With the National Kidney Foundation reporting average transplant wait times of three to five years—and many waiting much longer for a compatible match—transplants are a much better solution for the health of the recipient and cost-effectiveness.

Even after factoring the cost of transplant surgery (~$130,000), immunosuppressant medication to prevent kidney rejection (~$25,000 per year), and the $50,000 tax credit given to nondirected donors, the projected savings for taxpayers is $9 billion to $37 billion over 10 years. “So this is a solution to a very solvable problem, and very few pieces of legislation save both lives and money,” says Perlman.

The End Kidney Deaths Act was introduced by both Republican and Democratic representatives. The bill currently has 42 co-sponsors in the House, including Hawai‘i Rep. Jill Tokuda.

“I actually used to work at the National Kidney Foundation. I was their development director in Hawai‘i for a number of years,” says Rep. Tokuda. “I have seen the life-changing effects of altruistic kidney donors. They are literally angels amongst us, and we have to do everything we can to support them. And so, this bill, to me, is a no-brainer. It’s bipartisan, which is great, and quite frankly, I’d love to see it pass so that we can get more people donating.”

Photo courtesy Ryann Noelani Coules | Coules got to meet her recipient, John, and his family on Maui six months after the transplant.

I DONATED ONE OF MY TWO KIDNEYS

This issue is deeply personal to me. On April 23, 2024, I donated a kidney to a stranger. To me, the decision to donate seemed remarkably straightforward: If I have two working kidneys but only need one, why wouldn’t I give my spare to someone whose life depends on it?

One might ask: “Isn’t that taking on a lot of personal risk to help someone you don’t even know?”

While the thought of major abdominal surgery is naturally daunting, the procedure, known as a nephrectomy, is safer than most realize. A NYU Langone Health study spanning three decades found that by 2022, fewer than 1 in 10,000 kidney donors died within the first three months post-surgery.

In fact, many studies have found that kidney donors live longer on average than the general population. This counterintuitive phenomenon is attributed to three primary factors:

1. Potential donors must undergo extensive testing to ensure they are in excellent health to qualify for donation.
2. Donors tend to be highly motivated to maintain a healthy lifestyle after donating.
3. Emotional well-being is a critical part of overall health. Donors frequently report helping someone in a time of need to be a profoundly fulfilling experience.

My transplant team at the Queen’s Medical Center prioritized my well-being at every turn. They thoroughly educated me on the risks and provided constant reassurance that I retained total autonomy over my body, including the right to stop the process at any time. The system even includes a built-in “exit strategy” to protect a donor’s privacy: If someone chooses to withdraw late in the process, the medical team can provide a “medical disqualification” as the official reason, shielding the individual from external pressure or explanation.

Photo courtesy Ryann Noelani Coules | Coules with her anesthesiologist before heading into the operating room.

RISKS AND SAFETY NETS

The kidney that donors keep gradually grows in size and strength, but Penn Medicine reports about 25-30% of kidney function is permanently lost. That may sound like a lot, but the National Kidney Foundation found that less than 1% of kidney donors need a transplant later in life, and the system is designed with a safeguard: All living donors are automatically moved to the top of a waitlist for a kidney transplant from a deceased donor, should they ever need one. And donors who go through the National Kidney Registry’s Donor Shield program receive priority for a living donor transplant.

One of the most common hesitations about donating to a stranger I hear is, “What if a loved one needs a kidney in the future, but I’ve already given my spare away?” The National Kidney Registry addresses this concern through its Voucher Program. Nondirected donors can name up to five loved ones to receive kidney vouchers. If any of those individuals ever needs a transplant, they can redeem their voucher, which moves them to the top of the wait list for a living donor kidney. Once one of these five vouchers is used, the other four are voided. However, a loved one redeeming their voucher does not void the donor’s priority for a future transplant, nor does the donor’s own transplant void their loved one’s voucher.

Photo courtesy Ryann Noelani Coules | Coules says the Queen’s staff “were kind enough to bring me a card and gift basket to my recovery room to express their gratitude.”

DONATIONS FROM DECEASED DONORS CAN’T CLOSE THE GAP

In 2024, deceased donors accounted for 77% of the 27,759 kidney transplants performed in the U.S. Although kidneys from deceased donors usually work well, living donor kidneys are preferred because they allow for more pre-transplant testing and have better blood flow ahead of the transplant.

These factors lead to a longer expected lifespan: According to the American Medical Association, a kidney from a deceased donor lasts 8 to 12 years on average, while a kidney from a living donor typically lasts 15 to 20 years.

The reality is that the deceased donor pool is mathematically incapable of meeting the need. Although more than 170 million Americans were registered organ donors in 2024, Penn Medicine reports only 0.3% of people die in ways that allow for organ donation. For both qualitative and quantitative reasons, a significant increase in living donors is needed to bridge the gap.

Photo courtesy Jill Jweinat | Coules’ recipient, John, and his daughter Jill right before their surgeries, which took place the day after Coules’.

HOW ONE DONATION CAN SET OFF A CHAIN REACTION

Most living donors have an intended recipient—usually a family member, significant other or friend—but they’re not guaranteed to be a medical match. If blood types, tissue types or antibodies are incompatible, the recipient’s immune system will reject the transplant. The National Kidney Registry, the Alliance for Paired Donation and networks at major transplant centers facilitate “paired exchanges” to bypass these biological hurdles. By maintaining a vast database of donors and patients, the registry can coordinate swaps.

How they work: A donor who is incompatible with their loved one gives their kidney to a compatible stranger. In return, the donor’s loved one receives a compatible kidney from a different stranger in the network. These interconnected exchanges create “donor chains,” which can involve multiple pairs across the country, significantly increasing the number of successful transplants performed each year.

Donor chains typically need a nondirected donor to initiate them. Often referred to as altruistic or ‘good Samaritan’ donors, these individuals donate to any compatible patient without a specific recipient in mind.

Their lifesaving gift creates a domino effect, unlocking a sequence of matches that would otherwise remain dormant. My kidney chain, for example, involved eight people in total: 4 people donated, and 4 people received kidneys.

But nondirected donors are remarkably rare; a 2022 study published by the National Library of Medicine found that only 5.6% of living kidney donors are nondirected. The End Kidney Deaths Act seeks to catalyze more donor chains by providing targeted incentives specifically for nondirected donors.

RESPONSE TO OPPOSITION

Adapted kidney transplant chain chart from National Kidney Registry.

A common critique leveled against compensating nondirected donors is that it will exploit the economically disadvantaged, but Perlman says this argument is a fallacy: “It’s not a situation where we’re going to have many low-income people qualifying, because health is correlated with income,” she explains. “And I’ve asked people, ‘Would you be happy if we excluded low-income people from the tax credit?’ And they’re like, ‘oh, no, you can’t do that.’”

Beyond the stringent health requirements, the current system makes it prohibitively expensive for low-income people who want to become kidney donors, even with the current travel and wage reimbursement policies. For someone living paycheck to paycheck, making the donation merely “cost-neutral” is simply not enough, given how disruptive the recovery process is to work and household stability.

Perlman says the most exploitative system is the one we have now, where low-income people are more likely to die waiting and less likely to be able to afford to give. This disparity is illustrated by a 2018 study that found low-income people account for 34% of patients newly diagnosed with end-stage kidney disease, but they only receive 6% of the nation’s kidney transplants. The End Kidney Deaths Act aims to level this field, utilizing a tax credit to transform kidney donation from a financial burden into an accessible, dignified choice. Bottom line: Many low-income patients desperately need a transplant and would greatly benefit from an increased supply of kidneys, which incentivizing nondirected donations could do.

Spreading the tax credit over five years also decreases the chances that someone will donate out of desperation. The End Kidney Deaths Act stipulates that the incentive will kick in beginning the year after the kidney donation and will be delivered gradually over five years.

“If you’re doing this for a loved one, there’s a built-in incentive. But if you’re doing it for a stranger, providing a tax credit makes a lot of sense, because we use the tax credit system to encourage people to engage in pro-social behavior, and it’s quite pro-social to donate a kidney to a stranger,” says Perlman. “I compare people who donate a kidney to strangers more with soldiers and firefighters, EMTs and police officers, who are saving the lives of strangers at some risk to themselves.”

To learn more about the End Kidney Deaths Act, visit endkidneydeathsact.org. Visit tinyurl.com/mtvszbck to see the petition advocating for the bill’s passage. You can read an earlier article I wrote about my personal donation experience at tinyurl.com/48jrja69.