are discarded. Moreover, not all potential donors consent, with current studies suggesting that roughly 50 percent of potential donors (or their families) consent to donation. CEA • Increasing the Number of Kidney Transplants to Treat End Stage Renal Disease 15 A more realistic assessment of the number of deceased donor kidney transplants that the United States could perform in the long-term may come from looking at Spain. Spain is widely acknowledged to have one of the best deceased-donor organ procurement systems in the world—see figure 4. In an effort to improve its performance and reach 40 deceased donors per million population (pmp) Spain studied, formulated, and implemented best practices for systematically identifying and referring potential donors, optimizing their care to preserve organ function and facilitating the use of organs from expanded criteria and nonstandard risk donors (Matesanz et al. 2017). As a result, in 2019 Spain had a world-leading 72.8 kidney transplants pmp from deceased donors while the United States was the third best country in the world at 50.59 pmp, 70 percent of Spain’s performance (IRODaT Database 2020). Matching Spain’s performance would generate an additional 7,300 kidney transplants from deceased donors.14 While HHS estimated that their regulations could increase the number of deceased donor kidney transplants by roughly 4,500 a year by 2026, it is possible that other regulatory initiatives could further increase the number of transplants. For example, in the United States, the decision to donate organs is “opt-in,” so that a person can only become a donor by affirmatively stating this desire. By increasing the effort required to become a donor, the “opt-in” system provides disincentives for donation. Studies suggest that changing the system to an “opt-out” system, so that a person is assumed to be a donor unless they expressly state otherwise, could increase the number of donation by as much as one-third (Rithalia et al. 2009). 14 Spain’s rate of deceased donor kidney transplants was 72.8 per million population in 2019. Per million population, the United States had a rate of 50.59 deceased donor kidney transplants in 2019. If the United States’ rate of deceased donor kidney transplants pmp matched Spain’s rate, then the United States would perform roughly 7,300 additional deceased donor kidney transplants, which is equal to 328 million (United States population in 2019) times 22.2 (difference between US and Spain’s deceased donor kidney transplant rates in 2019) rounded to the nearest hundred. CEA • Increasing the Number of Kidney Transplants to Treat End Stage Renal Disease 16 0 10 20 30 40 50 Bulgaria Hong Kong Moldova Romania Mexico Greece Kuwait Cyprus Colombia South Korea Latvia Chile Israel Germany Poland Iran Netherlands Denmark Ireland Brazil Switzerland Hungary Lithuania Estonia Sweden Iceland Argentina Slovenia Norway Australia Uruguay Austria Italy United Kingdom Belarus Finland Czech Republic Belgium France Portugal Croatia USA Spain Figure 4. Actual Deceased Organ Donors by Selected Country, 2019 Deceased donors per million population Source: International Registry In Organ Donation And Transplantation. CEA • Increasing the Number of Kidney Transplants to Treat End Stage Renal Disease 17 How Many Additional Living Donor Kidneys Could be Obtained? The literature is not clear on what types of strategies would increase living kidney donation (Barnieh et al. 2017), and it is not clear how effective the NLDAC type incentives are. A difference in difference model that exploited transplant centers’ variation in applications for NLDAC donor assistance found that among participating transplant centers, NLDAC increased the number of living donor kidney transplants by about 14 percent (Schnier et al. 2018). While one paper reported that state laws that provide leave and/or tax benefits for living organ donors have not increased the number of living donors (Lacetera et al. 2014), another found that passage of tax incentive legislation increased living unrelated kidney donation rates by 52 percent in New York (Bilgel and Galle 2015). The Administration’s rules remove financial disincentives to living organ donation by adding reimbursements to living donors for lost wages and child or elder care expenses to current NLDAC incentives and increase the financial threshold for travel as well as subsistence reimbursement. If these new measures can increase the number of living kidney donors by the same 14 percent that was reported for earlier NLDAC incentives (Schnier et al. 2018), the number of living kidney transplants would increase by about 900, rising from 6,442 to 7,348. However, it is worth noting that several studies suggest that increases in the supply of deceased donor kidneys are associated with reductions in the supply of living kidney donations (Dickert-Conlin et al. 2019; Fernandez et al. 2013; Howard 2011). The Economic Benefit of Increasing Kidney Transplantation If United States OPOs matched Spain’s deceased donor kidney transplants pmp rate and HHS’s recent regulations generated another 900 transplants from living donors, the United States would perform an additional 8,200 additional kidney transplants each year. Each transplant would generate cost savings on an ongoing basis, as Medicare spending per