America First Legal (AFL), the conservative law organization founded by Trump White House adviser Stephen Miller, is petitioning two major federal health agencies to immediately repeal a Biden-era kidney transplant payment model that the group argues embeds race-based decision-making into the national organ transplant system.
The petition targets the Increasing Organ Transplant Access (IOTA) Model, a mandatory six-year program created by the Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS). The model scores participating hospitals on achievement, efficiency, and quality in kidney transplantation. Depending on the scores, hospitals may receive financial bonuses, owe money back to the federal government, or break even.
An early draft of the regulation included an equity performance adjustment, but CMS removed it before the rule was finalized. Instead, AFL argues, the rule incorporates its equity agenda through a “voluntary” health equity plan, which hospitals in the mandatory program are urged to adopt. These plans require hospitals to identify “health disparities,” establish “equity goals,” and track progress through quantitative metrics to reduce disparities.
AFL: Rule “Normalizes Discrimination”
In an accompanying statement, America First Legal said, “A federal rule cannot invite or normalize discrimination — not even under the guise of improving ‘equity.’ … Although CMS ultimately made Health Equity Plans ‘voluntary,’ the agency embedded them inside a mandatory federal model that encourages hospitals to integrate race and identity into transplant decision-making.”
AFL attorney Megan Redshaw added that the group views the rule as an extension of broader Biden-era equity directives.
“The IOTA Model is a leftover remnant of an unlawful equity agenda that encouraged hospitals to view lifesaving care through a DEI lens. Federal law requires that organ allocation be based on established medical criteria, not race or identity….”
AFL also claims that 67 of the 103 hospitals required to participate in the IOTA Model are “still engaging” in diversity, equity, and inclusion (DEI) efforts, which the group argues promotes “identity-based preferences” in organ transplantation.
Origins in Biden’s 2021 Equity Executive Order
The IOTA Model emerged after President Biden signed Executive Order 13985 in early 2021, directing federal agencies to evaluate whether “underserved communities” face systemic barriers in accessing federal programs. CMS later sought public input on how to “advance equity and reduce disparities in organ transplantation.”
At the time, CMS emphasized that black Americans are nearly four times more likely, and Latinos 1.3 times more likely, to develop kidney failure than white Americans, while data showed these patients are less likely to be placed on transplant waitlists or receive transplants.
AFL and other Trump-aligned officials have questioned the influence of outside groups during the drafting of the rule and have filed FOIA requests to uncover documents related to the process. They point to several other Biden-era initiatives — including proposals to strengthen “equity” in the national transplant system and updated labeling of donor race and ethnicity data — as evidence of a broader DEI push.
Broader Turmoil in the Transplant System
The U.S. organ transplant system has faced significant scrutiny over the past year. HHS recently announced reforms to the Organ Procurement and Transplantation Network (OPTN) following a federal investigation documenting “disturbing practices by a major organ procurement organization,” including instances where organ retrieval was initiated prematurely.
Legal Claims Against the Rule
AFL argues the IOTA Model violates multiple federal laws and constitutional standards, including:
- Title VI of the Civil Rights Act
- Section 1557 of the Affordable Care Act
- The Equal Protection Clause
- U.S. Supreme Court precedent
- Executive orders issued by President Trump
- Limits on CMS’s authority under the Social Security Act
The group also contends the rule is “arbitrary and capricious” under the Administrative Procedure Act.
Redshaw said, “This rule treats race as a substitute for medical judgment, and it risks condemning patients to die on waitlists based on immutable traits instead of clinical need.”
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