A Trump-aligned lawfare group, America First Legal (AFL), has petitioned two major U.S. health agencies to repeal a Biden-era regulation they claim promotes organ transplantation allocation based on race, rather than medical need. The regulation, part of the Increasing Organ Transplant Access (IOTA) Model, is designed to address racial disparities in kidney transplant waitlists by encouraging hospitals to integrate race and identity into their allocation processes. While the rule initially included an equity performance adjustment, this component was scrapped before finalization. Instead, the model embeds an equity agenda more subtly through voluntary health equity plans that hospitals are encouraged—though not required—to complete. AFL argues this approach normalizes ‘identity-based preferences’ and violates civil rights laws, including Title VI of the Civil Rights Act and Section 1557 of the Affordable Care Act. The group claims the rule goes beyond CMS’ statutory authority and is ‘arbitrary and capricious’ under the Administrative Procedure Act, effectively treating race as a substitute for medical judgment.
The IOTA Model, which was finalized in 2023, is part of a broader initiative to improve access to kidney transplants for marginalized communities. The rule requires hospitals to participate in a payment program that incentivizes equitable care through financial rewards or penalties. CMS emphasized that the goal was to reduce disparities, noting that Black and Latino patients are disproportionately affected by kidney failure and have lower rates of transplant access. The program was initially proposed in 2021 under a federal executive order mandating ‘Equity Assessments’ and the development of action plans to address systemic barriers. Critics, however, argue that the rule introduces a bias against race, which they say is prohibited under federal law. AFL claims the rule was influenced by the Biden administration’s promotion of ‘diversity, equity, and inclusion (DEI)’ initiatives and that the final rule effectively codified these priorities into the healthcare system.
The AFL petition argues that the regulation violates Title VI of the Civil Rights Act, which prohibits discrimination based on race in federal programs, and Section 1557 of the Affordable Care Act, which extends these protections to healthcare. The group also asserts that the rule contravenes the equal protection clause of the U.S. Constitution, as well as legal precedents established by the Supreme Court. Additionally, AFL claims the rule exceeds CMS’ statutory authority under the Social Security Act and is ‘arbitrary and capricious’ under the Administrative Procedure Act. The lawfare group is part of a broader movement within the Trump administration and its allies to challenge policies they believe promote ‘identity-based preferences,’ citing concerns over government overreach and the erosion of evidence-based medicine.
The AFL case is part of a larger ideological battle over the role of DEI in public policy, with critics arguing that such initiatives prioritize political narratives over medical science. Supporters of the IOTA Model, including CMS, maintain that the regulation is a necessary step to address systemic inequities in healthcare access. The debate reflects broader divisions over the use of race in decision-making processes, particularly in areas where clinical judgment is critical. As the legal battle continues, the outcome could have significant implications for how race is considered in healthcare and public policy more broadly.