Joe Biden's 'Equity Agenda' Has a New Target: Kidney Transplants

HHS proposal would push hospitals to prioritize low-income patients in bid to address 'racial inequities'

HHS Secretary Xavier Becerra (Getty Images)
May 27, 2024

The Biden administration unveiled a plan that would push American hospitals to prioritize low-income patients when performing kidney transplants, a move Health and Human Services secretary Xavier Becerra says is aimed at rooting out "racial inequities" in the "transplant process."

The proposal, which Becerra's agency announced on May 8, would place 90 of the nation's 257 transplant hospitals into a pilot program that uses an annual point system to grade participants. Under the system, a successful kidney transplant counts as one point. A transplant furnished to a low-income patient, however, counts as 1.2 points thanks to a "health equity performance adjustment," thus incentivizing the hospitals to prioritize such patients.

At the end of each year, those points are applied to a transplant quota. Hospitals that meet their quota receive as much as $8,000 per transplant; those that don't may have to pay up to $2,000 per transplant.

While the proposal uses income to categorize patients rather than race, Becerra made clear that the scoring system is meant to address racial concerns. In his statement announcing the proposal, he touted the Biden administration's "concrete steps to remove racial bias … in the transplant process."

"The organ transplant industry, like every other part of society, is not immune to racial inequities," he said. "Black Americans disproportionately struggle with life-threatening kidney disease, yet they receive a smaller percentage of kidney transplants. The Biden-Harris administration is taking concrete steps to remove racial bias when calculating wait times and rooting out profiteering and inequity in the transplant process."

The proposal reflects the Biden administration's fixation on "equity." Shortly after taking office, in January 2021, President Joe Biden issued an executive order outlining an "ambitious whole-of-government equity agenda" in which federal agencies "must recognize and work to redress inequities in their policies and programs."

The Department of Health and Human Services kidney transplant proposal cites that executive order directly. The agency did not respond to a request for comment.

For Dr. Stanley Goldfarb, a kidney specialist who served as University of Pennsylvania School of Medicine associate dean, the Biden administration's proposal attempts to sidestep the legal thorniness that would accompany making race an explicit factor in kidney transplants—while still achieving the same effect.

"They probably don't want to say ‘we're doing this for black patients,’ because they know they're going to get into trouble with it," said Goldfarb, the founder of the anti-woke medical group Do No Harm and father of Washington Free Beacon chairman Michael Goldfarb.

"So these are ways around it to do what they're trying to accomplish."

Under the proposed model, which Becerra's agency released through the Centers for Medicare and Medicaid services, hospitals are given an annual score determined by three factors: number of transplants, organ acceptance rates, and post-transplant outcomes.

The majority of a participating hospital’s score—60 out of 100 possible points—comes down to the number of transplants performed in comparison to a government-determined "transplant target," with low-income patients weighted an extra 20 percent.

"Each kidney transplant that is furnished to a patient who meets the low-income definition would be multiplied by 1.2, thus counting that transplant as 1.2 instead of 1," the proposal says. "The resulting count of the overall number of kidney transplants performed during the PY [performance year], after the health equity performance adjustment is applied, would then be compared to the transplant target."

Hospitals that meet or exceed the transplant target receive 60 points—the same number required to receive an up to $8,000-per-transplant kickback from the federal government. Those that don't can be penalized. Starting in year two of the program, hospitals that score a 40 or below are fined up to $2,000 per transplant. Hospitals that score between 41 and 59 points neither receive nor owe money.

The proposal defines low-income patients as those who are "in one or more of the following groups: The uninsured, Medicaid beneficiaries, Medicare-Medicaid dually eligible beneficiaries, Recipients of the Medicare LIS, [and] Recipients of reimbursements from the Living Organ Donation Reimbursement." The Biden administration considered making "rural" a low-income qualification but opted not to do so, according to the proposal.

The proposal also concedes a potential "concern" regarding the program: that it "may incentivize shifting of kidney transplants from one type of patient to another." The proposal nonetheless dismisses that concern, saying the "health equity performance adjustment" is meant to "promote improvement activities that would increase access to all patients while recognizing that low-income patients may face more barriers to care."

Ninety of the nation’s 257 transplant hospitals will be forced into the program should it be finalized. The program could begin as early as January 2025, according to Becerra's announcement.

For Goldfarb, the incentive structure at the core of the Biden administration's proposed equity initiative is misguided. He cited research showing that relatives of black patients are less likely to donate a kidney—often due to issues that are unrelated to finances, such as preexisting conditions. Medicare, meanwhile, covers the final stage of kidney failure for Americans of any age.

"I'm quite in favor of outreach to patients who have trouble accessing the health care system," Goldfarb told the Free Beacon. "I'm just not sure this is the case with kidney transplants. I think it's much more a case of patient unwillingness to pursue this and families' unwillingness to donate kidneys."

"And so I think what they've just decided is, 'We'll just give an incentive to the hospitals to do this and let them figure out how to do this,'" he continued. "But I don't know that there's a real system in place to allow that. So either you're going to have a system that ends up being purely on the basis of race, or it's going to be a system that fails totally."

Other medical institutions’ "health equity" initiatives have landed them in hot water.

At the University of California, Los Angeles medical school, a mandatory "health equity" class taught future doctors that weight loss is a "hopeless endeavor" and featured a guest speaker who led students in chants of "Free, Free Palestine" and demanded they bow to "mama earth," the Free Beacon reported. UCLA launched a probe into the class last month.