Insuring Hearts (and Kidneys, Lungs and Livers)

August 17, 2009, 6:00 am
Insuring Hearts (and Kidneys, Lungs and Livers)
By Nancy Folbre

Nancy Folbre is an economics professor at the University of Massachusetts Amherst.
Stuart Bradford

Here’s a gory indicator of inequality in access to health care in the United States: People who lack health insurance are far more likely to donate organs than to receive them.

A recent study by the physicians Andrew A. Herring, Steffie Woolhandler and David U. Himmelstein based on hospital data for 2003 finds that 16.9 percent of organ donors were uninsured, compared to 0.8 percent of transplant recipients.

Perhaps those who lack health insurance are more likely to suffer the types of accidents that facilitate post-mortem transplants (the study does not explore this issue). But economics seems to play a big role on the receiving end: Few of the uninsured are good candidates for transplants because they can’t afford the costly immunosuppressive therapy required for their success.

The costs of organ transplants are high, but so too are the benefits — ranging from many years of additional life to reduced need for expensive procedures like dialysis.

The need for organs far exceeds the supply currently available, raising tough questions for health care policy.

Trafficking in human body parts, a powerful theme in a highbrow film (”Dirty Pretty Things“) and a science-fiction thriller (”The Island“), now intrudes widely into reality. Most individuals can get by with one kidney, and black markets for this organ are widespread in many poor countries like India.

In a Freakonomics post last year, Steven Dubner described Iran’s system for regulating legal organ sales and suggested that the United States should experiment with organ vending.

Illegal organ sales have apparently made it to the United States, with recent allegations that a Brooklyn rabbi (describing himself as a matchmaker) has been buying kidneys in India and Israel for $10,000 and selling them here for $160,000.

In the wake of this scandal, a recent commentary by Sally Satel in The Wall Street Journal argued that United States policy should allow the government to offer donors and/or their families some benefits — such as health insurance benefits or funeral expenses — while guaranteeing that organs are not literally bought and sold.

In our current health insurance regime, living donors (those who donate a dispensable organ such as a kidney or part of a liver), often fear that they will be unable to obtain or retain health insurance because absence of an organ will be construed as a “pre-existing condition” that poses too much risk for the insurer. Current reforms under discussion in Congress would solve this problem by disallowing refusals based on pre-existing conditions.

Another policy option would entail making organ donation after death an “opt-out” rather than an “opt-in” choice: Individuals could be required to explicitly deny permission rather than explicitly provide it. This policy, now in effect in Spain and several other European policies, has been widely discussed, but recently rejected, in Britain.

However, none of these policy options address the problems faced by the currently uninsured. Further, under our current system, offering health insurance as an incentive to donate organs could put considerable economic pressure on desperate low-income families to give up body parts.

As the sociologist Kieran Healy observes in his book “Last Best Gifts,” cultural norms and moral values play an important role in organ donation. Successful systems rely on principles of fairness, as well as economic incentives.

By that standard, our current system requires reform. As Professors Herring, Woolhandler and Himmelstein put it, “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.”

http://economix.blogs.nytimes.com/2009/08/17/insuring-hearts-and-kidneys-lungs-and-livers/