Trump-aligned lawfare group America First Legal, founded by former White House aide Stephen Miller, has petitioned federal health agencies to repeal a Biden-era regulation that promotes kidney transplant allocation based on race rather than medical need. The regulation, part of the Increasing Organ Transplant Access (IOTA) Model, was initially designed to address racial disparities in organ transplantation but has since become the subject of intense legal and political scrutiny.
The IOTA Model, introduced by the Centers for Medicare and Medicaid Services (CMS), mandates hospitals to participate in a payment system where financial incentives are tied to performance metrics related to organ transplant access. Under the rule, hospitals are encouraged to implement ‘health equity plans’ that identify and monitor ‘disparities’ based on race and identity, using quantitative metrics to assess progress. Critics, including America First Legal, argue that this framework violates Title VI of the Civil Rights Act and the Equal Protection Clause, as it potentially normalizes race-based decision-making in critical medical care.
AFL attorneys, such as Megan Redshaw, have accused the Biden Administration of creating a rule that ‘treats race as a substitute for medical judgment,’ arguing that it risks condemning patients to death on waitlists based on immutable traits rather than clinical necessity. The group also claims that the rule exceeds CMS’ statutory authority and violates the Administrative Procedure Act, which requires federal agencies to follow proper procedural guidelines when implementing regulations.
Proponents of the IOTA Model, such and CMS, have defended the regulation as a necessary step to address long-standing racial disparities in kidney transplant access. Data has shown that Black and Latino patients are more likely to develop kidney failure but less likely to be placed on transplant waitlists or receive transplants. The rule is part of a broader initiative by the Biden Administration to combat systemic inequities in healthcare, including Executive Order 13985, which mandated equity assessments for all federal programs.
Amid this legal battle, AFL has also filed Freedom of Information Act (FOIA) requests to investigate the role of outside groups in shaping the final rule, alleging that the process was influenced by partisan actors pushing for a ‘DEI lens’ in healthcare. While the Biden administration has faced criticism for this approach, the legal challenge represents a broader ideological clash over the role of identity-based policies in public health and healthcare delivery in the U.S.