Est. 2026 · Pennsylvania
The Algorithm
Thirty-Seven Years · One Contractor · The Most Consequential Private Code in American Medicine
From 1986 to 2023, a single private nonprofit held the federal contract to operate the entire US organ transplant system. It decided who received the kidney, the liver, the heart. Its algorithm determined who lived. In 37 years, the contract was never seriously recompeted. The GAO documented systematic failures. Thirty patients died per day on the waitlist. This is the architecture of who gets to live.
There are systems whose failures cost money. There are systems whose failures cost time. And there are systems whose failures cost lives — specifically, measurably, with names attached and waiting list positions documented. The United States organ transplant system belongs to the last category. When it fails, the failure has a face, a blood type, and a zip code.
From 1986 to 2023, the operational center of that system was a single private nonprofit organization based in Richmond, Virginia: the United Network for Organ Sharing, known as UNOS. Under a federal contract awarded by the Health Resources and Services Administration, UNOS operated the Organ Procurement and Transplantation Network — the OPTN — the national infrastructure through which donated organs are matched to patients. UNOS maintained the waitlist. UNOS built and ran the matching algorithm. UNOS set allocation policy. UNOS governed the data. For 37 to 40 years, depending on how you count the renewals, one private nonprofit was the architecture of American organ allocation.
The contract was never seriously recompeted. The National Organ Transplant Act of 1984, which created the OPTN, specified a private nonprofit contractor. UNOS, evolving from earlier regional coordination networks, won the initial award and retained it through every subsequent renewal cycle — cycles that critics note were structured as single-vendor processes. The organization that operated the system was also the membership organization for the transplant centers and professionals whose daily practice the system governed. It was, simultaneously, the regulator and the regulated, the standard-setter and the standard-subject, the keeper of the algorithm and the association of the people the algorithm served.
The algorithm determined who lived. The people who built the algorithm were employed by an organization whose members' metrics depended on how the algorithm ran. That is not a conflict of interest. It is the structure of the system.
FSA asks: what is the structure that makes this possible, and who benefits at each layer? The organ system answers that question with a precision unusual even for the most legible institutional architectures. The layers are identifiable. The incentives at each layer are documentable. The insulation is named, funded, and maintained.
The Source is a deceased donor and their family — encountered at the most acute moment of human experience, the hours surrounding a death, and asked to consent to organ procurement by representatives of organizations that are financially incentivized to obtain yes. The family's grief is the entry point of the supply chain. No other supply chain in American life begins in an ICU.
The Conduit is the Organ Procurement Organization — one of 57 regional monopolies, each holding exclusive procurement rights in its designated service area, funded primarily through Medicare reimbursement, with no OPO ever having been fully decertified for poor performance until the reforms of the early 2020s. The OPO recovers the organ. The OPO handles consent. The OPO coordinates with hospitals. And the OPO operates without competition in its territory regardless of its performance.
The Conversion is the algorithm — the UNet matching system, proprietary code owned and operated by a private nonprofit, that takes a recovered organ and produces a ranked list of recipients. The algorithm encodes values: how to weight time on the waitlist against likelihood of survival, how to balance geography against equity, how to handle pediatric patients and sensitized patients and patients with rare blood types. These are not technical questions. They are ethical ones. They were answered, for 37 years, by a private organization whose governing board was populated by the transplant professionals whose centers' outcomes depended on the answers.
The Insulation is the most refined layer in this series. "Science-based allocation." "Evidence-driven policy." "Life-saving mission." "Nonprofit governance." These framings are not false — the allocation is scientifically informed, the mission is genuinely life-saving, the governance is technically nonprofit. But each framing performs the same function: it places the allocation architecture beyond the reach of the challenge that the structure actually warrants. You cannot question an algorithm that is presented as medical science. You cannot challenge a policy that is presented as nonprofit mission. The insulation does not defend the system from criticism. It makes criticism feel inappropriate.
To understand how a private nonprofit came to hold life-and-death allocation authority for four decades, you need the National Organ Transplant Act of 1984. NOTA was well-intentioned legislation passed at a moment when organ transplantation was rapidly expanding as a medical possibility and the country had no coordinated national system to manage it. The ad hoc regional networks that had developed — most notably the Southeast Organ Procurement Foundation, or SEOPF — were insufficient for national scale.
NOTA's architects made two consequential decisions. First, they created the OPTN as a private nonprofit contractor rather than a government agency — an explicit choice to avoid federal bureaucracy and leverage the expertise of the transplant medicine community. Second, they prohibited compensation for organ donation, establishing the altruistic donation framework that has governed American organ procurement ever since. Both decisions were reasonable responses to the conditions of 1984. Both decisions have consequences that NOTA's authors did not fully anticipate.
The private nonprofit contractor decision created the conditions for UNOS's monopoly. NOTA specified the contractor structure. UNOS, as the organization that had emerged from the existing regional networks, was the natural first contractor. Once in place, the organization accumulated institutional knowledge, relationships, data infrastructure, and political position that made meaningful competition at each renewal cycle increasingly implausible — not by design, but by the ordinary operation of incumbency advantage in a technically complex, relationship-dependent system.
The oversight structure of the organ transplant system was, for most of its history, a maze of fragmented jurisdictions with no single actor clearly responsible for the system's performance. HRSA oversaw the OPTN contract. CMS oversaw OPO certification and reimbursement. The OPTN board — whose membership UNOS substantially controlled — set allocation policy. No agency had both the authority and the mandate to hold the entire system to account for the thing that mattered most: how many patients died waiting while recoverable organs were discarded.
The Government Accountability Office examined the organ transplant system across multiple reports spanning decades. Senate investigators documented dozens of serious errors — transportation failures, organs arriving with tire tracks on coolers, wrong blood type transmissions, infections passed to recipients, communication breakdowns that resulted in organs expiring before they could be used. One analysis linked approximately 70 deaths to OPTN and OPO operational failures in the decade from 2010 to 2020.
The operational failures were serious. But the structural finding was more damaging: the oversight architecture that should have detected and corrected these failures had not done so, because the architecture was not designed to. HRSA oversaw a contractor that provided HRSA with its own performance data. CMS certified OPOs that were never decertified. The OPTN board governed a system whose members funded the board's operating organization. The checks were present on paper. They were not functional in practice.
A 2026 GAO report — after the formal transition to multi-vendor contracting had begun — urged HHS and HRSA to strengthen modernization plans and risk management frameworks. UNOS agreed with the recommendations. The willingness to agree with recommendations for improvement after a 37-year monopoly has ended is not the same as accountability for what the monopoly produced.
The organ system's insulation layer is structurally different from the plasma industry's. Plasma insulation is linguistic — the word "donation" doing the work. Organ insulation is jurisdictional — the diffusion of accountability across HRSA, CMS, the OPTN board, and Congress such that no single actor was clearly responsible for the system's aggregate performance. When everything is everyone's responsibility, nothing is anyone's accountability. The system produced 30 deaths per day on the waitlist. The question of whose failure that was has never been cleanly answered, because the architecture was designed — not by conspiracy, but by the structural logic of distributed oversight — to make it unanswerable.
The organ transplant system is the most consequential allocation architecture in American medicine. It decides, through a combination of algorithm, policy, and institutional structure, who among the 100,000+ patients on the waitlist receives the next available organ. The decisions it makes are irreversible in both directions — a wrong allocation cannot be recalled, and a patient who dies waiting cannot be restored.
This series applies FSA to that architecture in full — the consent obtained in grief, the 57 regional monopolies that recover the organs, the algorithm that allocates them, the board that governed the algorithm, the contract that was never recompeted, and the country that built a better model and chose not to use it. Eight posts. The system examined layer by layer, the insulation removed, the structure named.
