In its review, completed 18 months ago, the White House’s U.S. Digital Service recommended that the government “break up the current monopoly” that the United Network for Organ Sharing, the nonprofit agency that operates the transplant system, has held for 36 years. It pushed for separating the contract for technology that powers the network from UNOS’s policy responsibilities, such as deciding how to weigh considerations for transplant eligibility.

About 106,000 people are on the waiting list for organs, the vast majority of them seeking kidneys, according to UNOS. An average of 22 people die each day waiting for organs. In 2021, 41,354 organs were transplanted, a record.

UNOS is overseen by the Health Resources and Services Administration (HRSA), but that agency has little authority to regulate transplant activity. Its attempts to reform the transplant system have been rejected by UNOS, the report found. Yet HRSA continues to pay UNOS about $6.5 million annually toward its annual operating costs of about $64 million, most of which comes from patient fees.