Wealthy patients list at multiple transplant centers; Medicaid patients cannot

US transplant policy allows patients to register at multiple transplant centers simultaneously, effectively multiplying their chances of receiving an organ offer. But multiple listing requires the financial resources to travel to distant centers for evaluation (typically 1-2 full days of testing), maintain relationships with multiple transplant teams, and relocate on short notice when an organ becomes available. Data show that patients who multi-list are disproportionately younger, white, privately insured, and more educated. Only 5.8% of kidney candidates and 3.3% of liver candidates multi-list, and those who do receive transplants significantly faster. Medicaid patients, who are disproportionately Black and Hispanic, often cannot afford evaluation travel or time off work, and some Medicaid plans restrict coverage to in-state transplant centers. The UNOS Ethics Committee recommended limiting multiple listing to 'exceptionally difficult to match' patients, but this recommendation has not been implemented as binding policy. The result is a system where organ allocation is theoretically based on medical urgency and wait time but is functionally modulated by wealth. This persists because banning multiple listing would be politically difficult—it would appear to restrict patient choice—and because the patients who benefit from the current system have the resources to advocate for its preservation.