America First Legal, the group founded by former Trump advisor Stephen Miller, is investigating a Biden administration transplant program it says is dangerous, discriminatory, and driven by outside special interests.
The Increasing Organ Transplant Access Model, or IOTA Model, took effect July 1 as a mandatory six-year program at 103 hospitals across the United States. It ties Medicare payments to the number of kidneys harvested and transplanted and pressures hospitals to factor race and “equity” into deciding who receives life-saving organs.
America First Legal has filed Freedom of Information Act requests with the Department of Health and Human Services, the Centers for Medicare and Medicaid Services, and the Health Resources and Services Administration. The requests demand “correspondence, meeting agendas, briefing materials, memoranda, draft rules, [and] external third-party submissions” that shaped the policy. AFL counsel Laura Stell told Fox News Digital, “Self-interested third parties should play no role in shaping America’s organ transplant policy.”
The group argues that the IOTA Model fundamentally rewrites transplant medicine. Hospitals that meet federal targets for the number of kidneys transplanted are financially rewarded, while hospitals that fall short are penalized. AFL says this creates perverse incentives to remove organs amid ethical concerns, citing a recent federal investigation that uncovered cases where organs were taken before patients were fully dead.
The program also embeds race into organ allocation. CMS encourages hospitals to draft “Health Equity Plans” that identify racial and ethnic disparities, conduct resource gap analyses, and set benchmarks to achieve racial outcomes. Although CMS labeled these plans voluntary, AFL says the financial structure makes them compulsory because hospitals that refuse to implement them risk financial punishment. In practice, AFL warns, hospitals steeped in diversity, equity, and inclusion programs will be rewarded while those that resist will be disadvantaged.
AFL’s investigation also centers on the influence of outside organizations. For years, groups such as the United Network for Organ Sharing and the Association of Organ Procurement Organizations have lobbied to inject equity into transplant policy. Academic institutions have received millions in federal grants to study race-based allocation schemes for kidneys, livers, and hearts. The FOIA requests seek to expose how these groups and universities may have helped draft the IOTA rule, advised CMS on equity benchmarks, or positioned themselves to benefit financially from the changes. In announcing the investigation, AFL said “outside actors with ideological and financial interests in remaking the transplant system played a direct role in developing this model.”
Biden Administration’s Attempt to Advance “Racial Equity” Throughout Government
The model’s origin can be traced to President Biden’s first executive order on “Advancing Racial Equity and Racial Justice Through the Federal Government.” Within months, CMS began soliciting ideas for how to build equity into the organ transplant process. By early 2022, HRSA was publishing transplant data by race, and by the following year, equity was at the center of a modernization initiative. The IOTA proposal followed in 2024 and was finalized in December before taking effect this summer.
Roughly 5,000 people die every year waiting for a kidney transplant. AFL argues that under the IOTA Model, patients can now be passed over solely because of race, and “underserved populations” such as American Indian or Alaska Native, Black or African American, Hispanic or Latino, and Native Hawaiian or Other Pacific Islander are prioritized. This means a white male with a more urgent medical need could lose priority if a hospital’s equity plan gives preference to another patient based on identity.
AFL has already sued HHS, CMS, and HRSA to uncover records on how race was embedded in organ allocation and has launched multiple investigations into hospitals with DEI-based transplant policies. The group says it intends to pursue litigation, press Congress for oversight, and work to rescind the IOTA rule entirely.
“This is not medicine,” AFL said in a press release. “It is state-sponsored race-based allocation of organs in the most literal life-and-death arena imaginable.”
