Subsidizing Altruism in Living Organ Donation.

Abstract

Background: In 2008 the Department of Health and Human Services began to reimburse donors' travel-related expenses via the National Living Donor Assistance Center (NLDAC). Eligibility is limited to donors and recipients with incomes below 300% of the poverty level. Donors file applications for reimbursement through hospitals. Taking advantage of variation in the time when hospitals signed-up for the program, we estimate the impact of the NLDAC on the number of non-pediatric living donor transplants. Methods: Using UNOS data for all non-pediatric living organ transplants conducted between 2003 and 2012 we construct a data set consisting of the total number of transplants conducted per a month for all transplant centers conducting non-pediatric living donor transplants within the United States. This data is merged with a data set identifying all transplant centers that elected to participate in NLDAC as well as the number of applications filed with NLDAC each year. Additional control variables were constructed to control for a center's current regulatory status with CMS, the length of their current waiting list and time-varying and transplant center controls. Using a difference-in-difference estimation strategy, controlling for the inherent selection problem that arises in this environment, we estimate the causal relationship between participation in the NLDAC program and the effect it has on non-pediatric living organ transplantation. Results: Using a set of control variables to take advantage of the timing when hospitals enroll in NLDAC as well as selection into the program our difference-in-difference estimator estimates the causal relationship between participation in NLDAC and non-pediatric living organ transplantation. We find that the program increased the number of living donor transplants by 12%. Furthermore, we find that the treatment effect is heterogeneous across transplant centers and that these results are robust to empirical falsification tests. Conclusion: Although the returns from receiving a living donor transplant (versus waiting for a deceased donor organ) are large, apparently many donors and recipients are unable or unwilling to incur the upfront travel-related expenses. The NLDAC was an effective subsidy for donor's altruism.