The system that recovers organs from the dead in America is a monopoly — in fact a nested set of them. Roughly 57+ Organ Procurement Organizations each hold the exclusive right to recover organs in an assigned territory, and for nearly four decades a single contractor ran the national network that matches and allocates them. What makes this worth documenting is not allegation but record: the failures of this system are written down by the government itself. This is a sourced walk through that record, and the public data behind it. It is the narrative companion to OrganWatch, where every entity and finding below is linked to its primary source.
The structure: territory and a single contractor
An OPO is a federally designated nonprofit with a government-granted monopoly over organ recovery in its “donation service area.” Hospitals in that area must work with that OPO and no other. Above them sits the Organ Procurement and Transplantation Network (OPTN) — the national matching system, which from 1986 was operated by a single contractor (the United Network for Organ Sharing) for nearly forty years. A monopoly recovering the organs, feeding a monopoly that allocates them: that is the shape of the thing, and it is the backdrop for everything that follows.
The accountability record (it is the government's)
- 2019 — Executive Order 13879 directed HHS to rewrite OPO rules and set organ-supply goals.
- 2020 — CMS final rule (CMS-3380-F) replaced OPOs' self-reported outcomes with two objective measures — a donation rate and a transplant rate — and a tier system in which the bottom performers become eligible for decertification.
- 2022 — Senate Finance Committee, after a nearly two-year bipartisan investigation, held a hearing titled “A System in Need of Repair” documenting OPO underperformance and OPTN governance failures.
- 2023 — HRSA Modernization + the Securing the OPTN Act (H.R. 2544) ended the single-contractor model, authorizing multiple competitive awards to run the network.
- 2024 — HHS-OIG (A-18-22-03400) found the OPTN IT system's cybersecurity controls only partially effective, identifying 22 vulnerabilities.
- 2025 — a bipartisan Grassley-Wyden report found OPOs using practices that can flatter their recertification metrics, and a separate HRSA review of cases where donation was authorized but not completed prompted HHS to announce procurement-protocol reforms.
- 2025 — the first decertification. CMS moved to decertify the Life Alliance Organ Recovery Agency (University of Miami Health System) for chronic underperformance — the first time the federal government has moved to strip an OPO of its territory.
- 2026 — the regime in motion: a competitive replacement awarded for the vacated service area, a new proposed CMS rule (CMS-3409-P), fresh CMS oversight guidance, and a GAO report (GAO-26-107434) warning HHS still lacks detailed plans for the next modernization phase.
# The US organ system is public data. None of it requires a name.
import requests
# 1. SRTR / OPTN — OPO- and center-level performance (deceased & living donors,
# waitlist, transplants). OPO-specific reports are keyed by OPO code (e.g. MAOB).
# https://www.srtr.org/reports/opo-specific-reports/
# 2. CMS — the OPO Conditions for Coverage outcome measures (donation rate +
# transplant rate) and the annual public performance report (tier distribution).
# 3. OrganWatch (this site) — the assembled, source-linked map, keyless JSON:
ow = requests.get("https://ai-analytics.org/organwatch/index.json", timeout=30).json()
print(ow["meta"]["opoCount"], "OPOs;", ow["meta"]["oversightCount"], "oversight actions")
# Every record is institution-level and carries a primary-source link. Zero PII.Why it matters, and what the data can't say
The through-line is structural: a monopoly with weak measurement, graded on data that lags roughly two years, finally facing consequences a quarter-century after the model was set. The honest limits matter too. CMS does not publish a single authoritative roster of each OPO's current tier, so OrganWatch marks per-OPO status “not public” unless a tier is separately sourced; counts of certified OPOs vary by document and year; and this is an institution-level record — it carries no patient or donor data of any kind, because accountability for a public system should never require exposing the people inside it.
Companion: Used Without Consent — the non-transplant side: how unclaimed and indigent bodies are used without consent, and the regulatory gap behind it.
The dataset: OrganWatch — the source-linked map of OPOs, the CMS regime, the oversight timeline, and the for-profit tissue industry, as keyless open data.
Related writing: Healthcare Consolidation in Federal Data — the broader pattern of who owns and runs US healthcare infrastructure.