Crossingbordersinsearchofhealth,welfare,andsafety

MarketDesignPerspectivesonInequalityHCEO,Chicago,August2016

AlRothStanfordUniversity

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(Kidneyfailure, Surrogacy,andRefugeequalification)

Healthinequality

• Kidneyfailure

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U.S.Incidentcounts(newpatients)&

adjustedratesofESRD,by

raceFigure1.5(Volume2)

Incident ESRDpatients.Adj:age/gender;ref:2005ESRDpatients.USRDS2012ADR 3

KidneysTransplantedpermillionpopulationU.S.A.

Nigeria,Phillippines (GlobalObservatoryonDonation&Transplantation)

Nigeria

Philippines

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Patientsreceivingrenalreplacementtherapy(dialysis)in2010(estimate)

LiyanageT,NinomiyaT,JhaV,etal.Worldwideaccesstotreatmentforend-stagekidneydisease:asystematicreview.Lancet2015;385:1975-82.

Elsewhere,2-7millionpeopledieeveryyearworldwideduetoinabilitytopay

foreitherdialysisorkidneytransplantation

IntheU.S.,100,000peopleareonthedeceaseddonorwaitinglist,butweonlyhave12,000deceaseddonortransplants

peryear

Papers• GlobalKidneyExchange,MichaelA.Rees,TyB.Dunn,ChristianS.Kuhr,ChristopherL.Marsh,JeffreyRogers,SusanE.Rees,AlejandraCicero,LaurieJ.Reece,AlvinE.Roth,ObiEkwenna,DavidE.Fumo,KimberlyD.Krawiec,JonathanE.Kopke,Samay Jain,MiguelTanandSiegfredo R.Paloyo,submitted.

• “FinancingTransplantCostsofthePoor:GlobalKidneyExchange,” AfshinNikzad,MohammadAkbarpour,MichaelRees,andAlvinE.Roth,workingpaper,2016

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Kidneyexchange—U.S.background• Manymorepeopleneedkidneytransplantsthanthereareavailableorgans.

• ThewaitinglistintheUShasabout100,000people– Thewaitcanbeyears,andmanydiewhilewaiting(4,448in2015,withanother4,377removedfromwaitinglistas“toosicktotransplant”).

– In2015wehad12,250 transplantsfromdeceaseddonors

• Transplantableorganscanalsocomefromlivingdonors.– In2015wehad5,628transplantsfromlivingdonors

• Sometimesdonorsareincompatiblewiththeirintendedrecipient.

• Thisopensthepossibilityofexchange .

Simple two-pair kidney exchange

Donor1Bloodtype

A

Recipient1

BloodtypeB

Recipient2

BloodtypeA

Donor2Bloodtype

B9

Noticethatnomoneychangeshands…

• Kidneyexchangeisan“inkind”exchange

• Section301,NationalOrganTransplantAct

(NOTA),42U.S.C.274e1984: “itshallbe

unlawfulforanypersontoknowingly

acquire,receiveorotherwisetransferany

humanorganforvaluableconsiderationfor

useinhumantransplantation”.10

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2-wayexchangeinvolves4simultaneoussurgeries

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Chains initiated by non-directed (altruistic) donors

Non-directeddonationbeforekidneyexchangewasintroduced

Waitlist

Non-directeddonor

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Chains initiated by non-directed (altruistic) donors

Non-directeddonationbeforekidneyexchangewasintroduced

Non-directeddonationafterkidneyexchangewasintroduced

Waitlist

Non-directeddonor

R1 D1

D2R2

Waitlist

Non-directeddonor

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O O A A B A A A A A

1Jul 2007

AZ

2Jul 2007

OH

3Sep 2007

OH

4Sep 2007

OH

5Feb 2008

MD

6Feb 2008

MD

7Feb 2008

MD

8Feb 2008

NC

9Mar 2008

MD

10Mar 2008

OH

62%CaucWife

Husband

0%Cauc

DaughterMother

23%Cauc

MotherDaughter

0%Cauc

BrotherSister

82%Cauc

HusbandWife

78%HispanicDaughter

Father

64%CaucWife

Husband

100%Cauc

BrotherBrother

46%AA

MotherDaughter

3%CaucFriendFriend

Transplant Date:Recipient's State:

Recipient's PRA:Recipient's Ethnicity:

Recipient-to-DonorRelationship:

1 The initiating donor was an unpaired altruistic donor from Michigan.2 The recipient of Transplant 6 required desensitization to HLA DSA by T and B cell flow cytometry.3 The recipient of Transplant 9 required desensitization to blood group (AHG titer of 1:8).

Recipient's Sexand ABO type:

Donor's Sexand ABO type: AO AO B A A A AB A AB1

2 3

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KPD and NDD Transplants in U.S.

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KPD and NDD as % of LD in the United States

Kidney exchange outside the U.S.

• Wednesday,August3,2016FirstkidneyexchangeinNepal• March7,2016FirstpairedkidneyexchangetransplantdoneinSingapore• Friday,July24,2015KidneyexchangeinTurkey (1st exchangesthere)• April10,2015Afirstnon-directeddonorkidneyexchangechaininItaly• March30,2015AfirstkidneyexchangeinArgentina• March5,2015FirstkidneyexchangeinPoland• Friday,November7,2014KidneyexchangeinSpain:nowmorethan100transplants• June7,2014KidneyexchangeinFrance• December19,2013KidneyexchangeinVienna• August19,2013TenkidneyexchangetransplantsonWorldKidneyDayinAhmedabad,India• July28,2013FirstKidneyExchangeinPortugal:• July23,2013KidneyexchangechaininIndia• June6,2013KidneyexchangebetweenJewishandArabfamiliesinIsrael• December26,2012KidneyexchangeinCanada• December1,2012KidneyexchangeinIndia• June1,2012MikeReesandGreece:anintercontinentalkidneyexchange• March27,2012KidneyexchangeinBritain• February5,2012KidneyexchangeinAustralia,2011• April29,2011FirstkidneyexchangeinSpain• December8,2010NationalkidneyexchangeinCanada• August3,2010KidneyExchangeinSouthKorea• Tuesday,August3,2010KidneyExchangeinSouthKorea• Friday,July30,2010KidneytransplantationadvicefromtheNetherlands• March9,2010KidneyexchangenewsfromBritain (1st 3-waythere)• January27,2010TheAustralianpairedKidneyeXchange (AKX)goeslive• June25,2009KidneyexchangeinCanada (1st exchangethere)• February27,2009KidneyExchangeinAustralia (inWesternAustralia) 18

Globalkidneyexchange:apossibilityofmutualaid

DevelopingWorld

UnitedStates

Transplantsunavailable 19

Two-wayexchange

Firstglobalkidneyexchange,withapairfromthePhilippines—January2015,

AllianceforPairedDonation(Reesetal.)

JoseMamaril receivedakidney fromanon-directedAmericandonor inGeorgia.Hiswife,Kristine,donatedoneofherkidneystoanAmericanrecipientinMinnesota,whosedonorcontinued thechainbydonating toapatientinSeattle.THEBLADE/JETTAFRASER 20

•

Jose Kristine

D2R2

…

Non-directeddonor

Thechaintodate

Safelyhome…

• $50,000escrowfundforpost-surgicalcare

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GlobalKidneyExchange

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TheGKEproposalis“self-financing”.• Backoftheenvelopecalculation:– costofhemodialysis≈$90,000peryear– averagetimeunderdialysis≈5years– costoftransplant≈$120,000persurgery(plus$20,000inmaintenancetherapycostsperpatientperyear)

• Butinsteadystate,waitingtimedecreases.Sodialysiscostswillgodown…howlongwillGKEremainselffinancing?

GKEremainsselffinancingevenwhenitbecomeswidespread.

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Intuition:• Somedomesticpairsimmediatelyfindamatch• Someotherdonotfindamatchuponarrival.– Theyincreasetheaveragewaitingcost

• Internationalpairsgetmatchedtothosethelattertypeofdomesticpairs

• Soeveniftheaveragedialysiscostislessthanthesurgerycosts,GKEcanstillbeself-financingbecauseitmatchesdomesticpatientswithhigher-than-averagedialysiscosts.

Themedicallogisticsmaynotbethehardpart

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Financialflows• Savings:–Medicare—complexlegislative/bureaucratic– Privateinsurers(33months)

• Costs:– Surgeries—transplantcenters– Postsurgicaltreatmentinhomecountries– Infrastructuredevelopmentinhomecountries

• USAID?--SameFederalbudget,butnochangeneededinMedicare

• Allowinsurancecompaniestonominatepatients?26

Repugnanceconstraints

• Livingdonors–Frompoorcountries

• Asafirstreaction,manypeoplearegoingtoconflateglobalkidneyexchangewithbuyingkidneys(whichisillegaleverywhereexceptIran—a‘repugnanttransaction’)

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Repugnance• 1.“theplanisreallynotabouttheinternationalrecipient(nor…abouttheinternationaldonor),butonlyaboutgettingorgansforUScitizens.Soitisexploitative."

• 2.“Letssolveproblemsathomefirst…We shouldencourageprogramsthatallowAmericanstohelpAmericans."

• 3.“Thereisanexploitationofasocialcondition(beingdestituteinaforeigncountry)thatkidneytransplantationshouldnotbetheremedyofresolvingsocialinequities."

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• RepugnanceConcerns:– Inadequatepost-surgicalcare• Escrowfundsforimmunosuppressivedrugsandpostsurgicalcare(inPhilippines)• Basicinfrastructure(inNigeria)—USAID?

– Inappropriate/illegal/unethicaldonorsolicitation(howcanweensurethatforeigndonorsaren’tsellingtheirkidney?)• Familyrequirement?• Fornon-directeddonorstoo?

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Fertilitytourism

• Theurgetohavekidsisstrong.

• Somefertilityservicesarerepugnantinsomeplacesbutnotinothers.

• non-bordercrossing:wombtransplants(WombtransplantsinSweden(wheresurrogacyisillegal)

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GermanSurrogacyLawSurrogacycontractsinwhichawomandeclaresherreadinesstoundergoartificialornaturalinseminationortohaveanembryo,whichisnothers,transferredtoherortocarryababyotherwisetothefulltermareviewedasunethicalandthereforetreatedasvoidinGermany.PursuanttotheEmbryoProtectionActandtheAdoptionPlacementAct,theactivitiesperformedbythosearrangingsurrogatemothersandbyphysiciansinconnectionwithsurrogacyarepunishableoffences.UnderGermanlaw,thewomanwhocommissionsachildinsuchaway(commissioningmother)isnotthemotherofthechild.Themotherofthechildisthewomanwhogavebirthtohim/her,thatis,thesurrogatemotherandnotthecommissioningmother.…Forthisreason,Germanauthoritiescannotrecognizethematernityofacommissioningmotherevenifaforeignbirthcertificateconfirmsherastheostensiblemother.FederalForeignOffice:http://www.auswaertiges-amt.de/EN/Infoservice/FAQ/GermanFamilyLaw/Leihmutterschaft.html?nn=479790

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SurrogatechilddeniedGermanpassport09May2011

By Nisha Satkunarajah AppearedinBioNews 606Achildborntoa surrogatemotherinIndiahasbeenrefusedaGermanpassportdespitethecommissioningGermanparentsbeingnamedonthebirthcertificate.TheGermancouplemadetheapplicationtotheGermanEmbassyinIndiabutapassportwasrefusedaftertheembassysaidithaddoubtsoverthechild'sGermancitizenship.Theplaceofbirthonthechild'sbirthcertificatewasstatedasanagencywhichspecialises insurrogacy.AcourtinBerlinruledtheembassywasentitledtorefusetheapplication.…'ThephenomenoniswidespreadinIndiawheremanychildlessGermansgotofulfil theirwishtohavebabies',aspokesmanforthecourtsaid.'TheythinkitispossiblewithoutanyproblemstotakethechildtoGermany.Butthat'snotthecase'.

Canada:AssistedHumanReproductionAct (2004)

• Paymentforsurrogacy:6. (1) Nopersonshallpayconsiderationtoafemalepersontobeasurrogatemother,offertopaysuchconsiderationoradvertisethatitwillbepaid.

• Actingasintermediary:(2) Nopersonshallacceptconsiderationforarrangingfortheservicesofasurrogatemother,offertomakesuchanarrangementforconsiderationoradvertisethearrangingofsuchservices.

• Surrogatemother—minimumage:(4) Nopersonshallcounselorinduceafemalepersontobecomeasurrogatemother,orperformanymedicalproceduretoassistafemalepersontobecomeasurrogatemother,knowingorhavingreasontobelievethatthefemalepersonisunder21yearsofage.

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Surrogacy• marketdesign/ruleoflaw"Blackmarket"surrogacyinEngland,andsubsequentlegalcomplications

• Ruleoflawisaworkinprogresshttp://www.nytimes.com/2014/07/28/us/surrogacy-agency-planet-hospital-delivered-heartache.html

• Californialaw:escrowaccounts:http://www.leginfo.ca.gov/cgi-bin/displaycode?section=fam&group=07001-08000&file=7960-7962

• Indiaisattractivetosomeforothercontractingcapabilities—e.g.supervisionofthesurrogate’sbehaviorregardingnutrition,sleep,exercise(nottomentiondrinkinganddrugs) 34

Migrationbyrefugeesandothers:• Steps:Qualification(forrefugeestatus,etc.),Determination

ofcountryofasylum,settlementinthatcountry.• Settlement:AlexandWill--settlingrefugeeswhohave

alreadybeengrantedasylumsomewherehassomestrongsimilaritieswith—anddifferencesfrom--schoolchoice.TommyAnderssonandLarsEhlers:matchingrefugeestohousing/landlords.

• Determinationofcountry:thathassomeelementsthatresembleschoolchoice(refugeepreferenceswillbeinformative)butalsohasamuchbiggerpoliticalelementinvolvingcountryquotas—HillelandJesúsFernández-HuertasMoraga haveinterestingideasonchoosingcountrycapacities.

• Butqualifyingforrefugeestatusisadifferentkindofproblem,moreakintopoliceinvestigation,sincetherearesomekindsofinformation(e.g.foreignfighter)thatitmayneverbesafeforapplicantstoadmit…andthisispotentiallyafirstorderproblem,nowthatsecurityissuchahighprofilepoliticalissuewithfar-reachingconsequences

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Brexit:AntiEU/anti-immigrantposters

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Designingproceduresforelicitingandverifyinginformation

• Dominantstrategymechanisms—powerfulbutrare.– “DoyouspeakEnglish?”– DoyouspeakBulgarian?– Didyoucarryagun?

• Policestyleinvestigationsaregoingtobeeasierformigrantswhoarepartofanaccessiblenetwork

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