When Apple visionary Steve Jobs got a liver transplant in 2009 many wondered why the operation took place in Tennessee — more than 2,000 miles away from his home in Northern California.

The answer has to do with money and the complexities of the U.S. transplant system. A typical patient with failing organs gets listed at only one transplant center close to them. But the rules set by the United Network for Organ Sharing, a nonprofit that manages the country's organ transplant system under a federal government contract, allow people to apply for and get on wait lists at multiple centers simultaneously, and Jobs had the resources to do this.

That gave Jobs numerous advantages: (1) more chances of moving up a list, (2) more chances of getting matched with an appropriate organ, and (3) an in with centers with the shortest wait times no matter where they were. With access to a private plane, Jobs also had a way to get to those centers quickly while those organs were still viable and could easily pay for the temporary housing needed for the long recovery period — luxuries that are difficult for all but the most wealthy to afford.

It turns out he was not the only one working the system this way, according to a study presented this week at the American Heart Association's annual meeting in Orlando.

Using data from the United Network for Organ Sharing, researchers looked at wait times for nearly half a million patients from 2000 to 2013. The information included 33,928 candidates on heart transplant wait lists, 24,633 on lung transplant wait lists, 103,332 on liver transplant wait lists and 223,644 on kidney transplant wait lists.

2 percent of heart patients were on more than one list, as were 3.4 percent of lung patients, 6 percent of liver patients and 12 percent of kidney patients. Those patients, who were wealthier and more likely to be insured, had higher transplant rates and lower death rates while waiting. In contrast, patients with state-run Medicaid insurance often don't have the option to get listed more than once or in other states.

Getting approved for a transplant at any one center is an expensive and time-consuming process that often requires evaluations, tests and interviews with a half-dozen or more specialists. Each hospital has its own procedures, and many of them require regular check-in appointments every two weeks or six months to stay on the transplant lists.

Lead author Raymond Givens, a transplant fellow at Columbia University Medical Center, said the multiple listings strategy appears to give an edge to wealthy patients over those with the most medical need.

"It undermines a bedrock principle of organ transplantation — which is that the sickest people should be transplanted first," Givens said. "We firmly believe the multiple listing policy needs to be reconsidered."

Other critics of the organ transplant system have argued that the main issue is not the multiple listings rule, but the wildly different wait times in transplant regions around the country. In one region a patient may have to wait two or more years for a transplant, while in another the wait could be as short as six months.

Part of the problem is one of nature — organs can only be out of the body for a certain amount of time before being transplanted — but it also has to do with the politics of the boundaries of regions. Each center has first priority for organs received from a certain geographic area. If they cannot use the organs then it can be offered to neighboring regions and then to the rest of the country. But some regions have a larger population than others and some regions have larger needs for organs, making the ratio of supply and demand unequal.

Two years ago, for example, Nicholas Hermsen's wife, who was 37-years-old at the time, had to go to San Francisco from their home 500 miles away for a lung transplant. He said she was first listed at the University of Southern California Los Angeles for 2.5 years, but at the University of California-San Francisco for only 10 months before she was called.

"We are middle class and this was a struggle for us to do financially, not to mention the emotional toll since the kids rarely got to see their mom during that year. The bottom line was she would have died if it wasn’t for the double listing," Hermsen said.

Hermsen added that, "I can guarantee you that my wife was much, much sicker than most other lung transplant patients around the country who received transplants while she was waiting — and that must include people who were transplanted who were both poorer and richer than we are."

This post has been updated.

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