One Company Has Billed the Organ Transplant Network Since 1986. It Never Fired a Failing Partner.

Since 1986, one company has run the machine that decides who gets a donated kidney, liver, heart, or lung — and for almost forty years, nothing was ever taken away from it for failing.▸ The United Network for Organ Sharing (UNOS) has held the sole federal contract to operate the Organ Procurement and Transplantation Network (OPTN) since the network's founding, per the Congressional Research Service, funded almost entirely by a fee it helps set on the hospitals it serves. In January 2026, the Government Accountability Office totaled up what that arrangement has produced: a waiting list of more than 100,000 people, 13 deaths a day, and — until five months before the report was published — zero organ-procurement organizations ever removed from the system for failing the patients it exists to serve.

OPTN doesn't run on a congressional budget in any meaningful sense.▸ Per GAO, "the federal government generally contributes about 10 percent of the OPTN's annual operating costs" through Health Resources and Services Administration (HRSA) appropriations. The other roughly 90 percent comes from the OPTN patient registration fee — a mandatory charge transplant hospitals pay for every candidate they add to the national wait list, set at $1,036 per patient for fiscal year 2026, effective October 1, 2025.

Two more numbers round out the picture.▸ First, Congress did put real new money in: the HRSA appropriation for fiscal year 2024 included a $23 million increase, earmarked for the agency's OPTN Modernization Initiative after years of complaints about the network's aging technology. Second, and separately, GAO found that "in fiscal year 2024, the contractor received about $9.6 million from transplant programs" for supplemental services outside its federal OPTN contract — a monthly fee UNOS charges transplant programs directly. GAO's finding wasn't that the fee is illegal; it's that HHS "has not assessed the risks" of the entity running the government's organ network also selling it paid add-ons, a conflict of interest nobody in authority had bothered to examine.

The money buys a system that still can't keep pace with the queue.▸ In 2022, per the CRS report, just over 42,000 transplants were performed against a wait list of 103,327 people. By May 2025, per GAO, the wait list still stood at more than 100,000 — barely moved, after three more years and roughly 41,000 deceased-donor transplants in 2024 alone (deceased donors account for over 85 percent of all organ donations).

Kidneys are the wait list's real crisis: they made up 52 percent of every deceased-donor transplant performed in 2024, more than livers, hearts, and lungs combined.▸ And the matching system itself isn't running clean — GAO found that in 2024, 19 percent of organ allocations were allocated out of sequence, meaning the network's own priority algorithm was bypassed and organs went to patients other than the ones it said should get the first offer.

The network that runs on hospital fees also polices its own members — and for most of its history, that policing produced no consequences at all.▸ As of the CRS report's writing in February 2025, "HHS has never decertified an [organ procurement organization] despite having the authority to do so," even as evaluators flagged years of uneven recovery rates across the network's 55 OPOs, 250 transplant hospitals, and 138 histocompatibility labs. Part of the reason: OPTN's member-review process is built to be private. Per the CRS report, it is "an entirely confidential process in which the OPTN keeps all materials, information, and correspondence to and from members ... private," by design, to "encourage full disclosure by members."

That streak ended in September 2025 — GAO's report notes that "prior to September 2025, no OPO had ever been decertified mid-certification cycle."▸ One finally was. It took the government roughly forty years, a Senate Finance Committee hearing titled A System in Need of Repair, and an act of Congress rewriting how the network can be run to produce a single removal.

Dollar and percentage figures for OPTN funding are for fiscal year 2026 unless otherwise noted; deceased-donor organ-share percentages are for calendar year 2024 as reported by GAO, and the "all other organs" share is derived by subtracting the four reported categories from 100%, since GAO did not report it separately.