· Identify a policy that is not usually intended to be a health policy but that you think may have important health implications.
The National Organ Transplant Act (NOTA) was originally passed in 1984 for the purpose of establishing the Organ Procurement and Transplant Network, the Scientific Registry of Transplant Recipients, and establishing oversight by the Department of Health and Human Services. Obviously, this is a health policy as it relates to organ transplantation and allocation, but I think it has had important health implications that extend beyond the direct transplant recipient.
When I consider transplantation, there are three enormous areas of inequity that give me pause. First, patients may be denied a life-saving transplant if they do not have appropriate insurance and/or if they do not have appropriate social support. Second, there is geographic disparity in access to transplantation, which is specifically prohibited by NOTA and as a result, all patients are able to be listed for transplant at more than one center; the problem is that generally only wealthy and highly educated patients can take advantage of this opportunity, and so one’s ability to undergo transplant is often limited by their location in this country. Third, it has been consistently demonstrated that the majority of living donors are women. So, while NOTA was intended to establish transplant infrastructure, it has very clearly impacted those with low SES, differentially impacted people based on their geographic location, and disproportionately burdened women with the assuming the role of live donors.
· Describe why an evaluation of that policy is informative (e.g., determining effects of the policy, or primarily a test of hypothesized mediators).
The three issues mentioned above have only been elucidated after evaluating the impact of this policy. In particular, the right to be listed at more than one transplant center arose because of the realization that there was geographic disparity in access to transplant. I will focus on this issue for the remainder of the questions.
· Specify the outcomes and populations you think most affected or least affected by the policy.
The populations most affected by this policy are : 1) patients who are well enough to travel for transplant but unable to do so due to financial or insurance constraints and 2) patients who have moderate disease severity- making it difficult for them to travel for transplant, but also not being ill enough to access transplant in an expeditious fashion.
· Propose a study design to evaluate the policy.
To evaluate this policy, we plan to analyze all patients who are multiply listed and to look at the transplant rates in the regions and donor service areas where the multiply listed patients originally list and in the regions and donor service areas where these patients ultimately undergo transplant.
· Describe biggest challenge to implementing and drawing inferences about the impact of the policy on health.
In order to change this policy, organ allocation in the United States would have to be fundamentally altered, such that any patient listed for transplant would be able to travel if they were well enough to do so, and so that patients with moderate disease severity would be able to access organs from outside their region/donor service area. Ideally this would involve national organ allocation, which is limited by the fact that organs must be preserved.
More broadly, the impact of this policy on health is only limited to those patients who are deemed suitable transplant candidates and are on the waitlist already. This policy does not address the disparities facing those patients who are not listed, but could benefit from, transplantation.