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Est. 2026 · Pennsylvania
The Board
Who Governed UNOS · Who Funded the Regulator · Who Set the Rules They Lived By
The UNOS board was populated primarily by transplant surgeons, transplant physicians, and OPO representatives — the same professionals whose centers and organizations operated under the policies the board set. The organization they governed was funded largely by the mandatory member fees those same centers paid. The regulator was funded by the regulated. The governor was the governed. Senate investigators documented the consequences.
Regulatory capture, as examined in Post V of The Blood Economy, operates through proximity, expertise asymmetry, and the slow institutional drift that occurs when regulated parties participate substantially in setting the standards they are regulated by. The organ transplant system offers a case study in a more concentrated form: not merely capture through influence, but governance through direct participation. The transplant professionals who sat on the UNOS board were not lobbying the regulator. They were the regulator.
The OPTN board — technically the governing body of the Organ Procurement and Transplantation Network — and the UNOS board, which governed the nonprofit contractor operating the OPTN, were historically populated through a nomination and election process in which UNOS member organizations — transplant centers, OPOs, and transplant professionals — held the primary voice. The board that set allocation policy was chosen substantially by the people whose centers' outcomes would be governed by that policy. The board that set OPO performance standards was chosen substantially by OPO representatives. The board that oversaw the UNet algorithm was chosen substantially by the physicians whose patients the algorithm ranked.
The structural argument is precise: when the people who benefit from a policy are the people who set the policy, the policy will systematically reflect their interests. Not through corruption. Through the ordinary operation of institutional perspective — the genuine conviction, held by most board members, that their clinical expertise made them the right people to govern clinical allocation, combined with the structural incapacity to fully account for interests they did not share.
The board was not captured by the transplant professional community. It was constituted by it. The distinction matters. Capture implies an outside force bending an independent institution. This was an institution that was never independent — it was designed, from the beginning, as a community self-governance mechanism. The capture was structural.
The governance conflict was compounded by the revenue architecture. UNOS's federal contract — the HRSA award that formally made it the OPTN contractor — was relatively small, running at approximately $6.5 to $7 million annually at various points in the system's history. But UNOS generated the majority of its revenue through a different channel: mandatory member fees paid by the transplant centers and OPOs that listed patients on the waitlist.
To list a patient on the OPTN waitlist, a transplant center must be a UNOS member. Membership carries mandatory fees. The scale of those fees varies by center volume, but the aggregate — UNOS reported total revenues of more than $80 million in recent years — means that the organization designated as the national regulator of organ allocation derived most of its operating budget from the organizations it was responsible for overseeing.
This is not a subtle conflict. It is a fundamental structural inversion: the regulator depends financially on the regulated. An organization that generates most of its revenue from membership fees paid by transplant centers has a structural incentive to maintain those centers' membership and goodwill. Policies that substantially disadvantage transplant centers — stricter discard rules, more aggressive outcome reporting, penalties for center selectivity — threaten the revenue base that sustains the regulating organization.
The governance structure of the UNOS-OPTN relationship involved layers of boards, committees, and administrative bodies that, in theory, provided checks and balances across the system. In practice, the layers shared personnel, shared institutional interests, and were all ultimately administered by an organization whose board was constituted as described above.
The Senate Finance Committee investigation — led by Senators Wyden and Grassley across 2019 to 2022 — produced the most detailed public accounting of UNOS governance failures in the system's history. The investigation reviewed internal documents, interviewed current and former staff, examined complaint records, and analyzed financial disclosures. Its findings were specific, documented, and damaging.
Patient representation on the UNOS board was not absent. It was structurally disadvantaged. Patient representatives attended the same board meetings, voted on the same policies, and formally had equal standing. But they came to those meetings without the institutional staff support, technical expertise, and data resources that transplant professional members brought. A transplant surgeon voting on allocation policy has spent a career in the system being governed. They understand it at a granular level. They have access to outcomes data from their own center's experience. They have colleagues throughout the national transplant community.
A patient representative — often a former transplant recipient or family member of a recipient, serving in a voluntary capacity — comes to the same meeting with personal experience, genuine commitment, and a perspective the professional members do not have. But they do not have equivalent institutional resources. The disparity in information and expertise between the two categories of board member is structural, and it systematically disadvantages the patients the system exists to serve.
The Securing the US OPTN Act of 2023 addressed the governance conflict directly. The legislation required separation of the OPTN board's governance function from the OPTN contractor's operational function — the two had been conflated in UNOS for 37 years. Under the new framework, the OPTN board would set policy; the contractor would implement it; and the two would no longer be the same organization. The contractor could be competitive; the board's composition could be reformed; the structural merger of regulator and regulated could be undone.
This was the right reform. Whether it works depends on implementation — on whether the new board composition achieves meaningful independence from professional interests, whether the contractor split produces genuine accountability, and whether HRSA exercises the oversight authority it has always technically held but rarely used. Post VIII will examine what the modernization has produced and what it has not.
The UNOS board is the most complete example in this series of insulation operating as governance rather than rhetoric. The plasma industry used a word — "donation" — to insulate its extraction from critique. The organ system used a board — composed of the people being governed, funded by those people's fees — to insulate its allocation architecture from reform. The insulation was not maintained by language or lobbying alone. It was maintained by the governance structure itself. Every board meeting that produced a policy decision was simultaneously a demonstration that the system was being governed — by the right people, with the right expertise, in the right process. The form of governance provided the insulation. The substance of governance was what the Senate investigation documented.
Next · Post VI · The Contract — NOTA 1984. How a reasonable legislative decision became a 37-year monopoly. The rebid that never happened, and why.
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