Organ of the State: Chapter 1
Undercover or under the cover?
Present day.
They say your life flashes before your eyes when you’re about to die, but Mason wasn’t thinking of that at all. He wondered if he’d miss his daughter Sadie’s fifth birthday. The table felt cold. Why do they make these rooms like refrigerators? Ow! The tech winked at him as she hooked up his IV. She’s pretty, Mason thought.
Anything to keep his mind off his impending death.
“Here we go.” Robin was smiling. “Just like we planned.”
How could she smile, Mason thought. “Yeah, you’re not the one who’s about to die.”
Robin’s smile faded into the kind folds of her face. She pointed at her embroidered name on her blue scrubs: Dr. Robin Severs. “Trust me. I’m your doctor.”
“Here’s your Sting.” She handed Mason a small plastic cup, the kind patients use to take pills, and another with some water.
“Wait, it’s a pill?”
“Yes, of course. The coating takes about 20 minutes to dissolve in your stomach. That’s the failsafe. Even if you’re dead, your stomach has enough digestive acids to dissolve the coating, and as long as your blood is perfusing, Norevium-17 will enter your bloodstream.”
“So, I take this now?”
“Just before we proceed. Too soon and it might work too early.” Mason still looked worried. “Don’t worry. It will be fine.” That’s why he signed all those releases filled with scary language about his death, and release of liability, because it will all be fine. This isn’t what Mason wanted to be thinking right now.
“It’s worth it,” Mason said, to nobody in particular.
Robin opened a small black case, that contained a small medicine vial and syringe. The vial was labeled “γ-Aminosiloxone” (GAS-4). She precisely loaded the syringe and placed it on the tray by Mason’s IV catheter. She checked her watch, and looked toward the OR door, with its glass window. The face in the window looked back, indicating a barely perceptible “no” shake of the head. It’s not time yet.
So they wait.
“Robin, one question.” Mason was hoarse. He wanted to swallow the water meant for the pill, but he knew he couldn’t have a lot of water in his stomach. The stomach of a dead man is supposed to be empty.
“Yes. Go ahead.”
“Will I dream?”
16 months ago.
“This is odd,” Jim Tulley said, looking over a printed table. “Take a look at this,” he passed the page over to his coworker, Wendy.
“What am I looking at?” Wendy asked, staring at the page filled with numbers.
“See that, it’s the CARE number for, uuh, Virginia, the OPO there. Does it look off to you?”
Wendy scrunched her nose. She didn’t have the gift for spotting inconsistencies that the famous Tulley is known for. Tulley was a data analyst working for CMS, more commonly known as the Centers for Medicare & Medicaid Services.
“Tulley, I am not following you. An OPO in Virginia is using the CARE visualizer about ten times more often than the other OPOs. Maybe they’re paying incentive bonuses based on some trend, or some dude is just hung up on his numbers being perfect.”
“Doesn’t it seem odd to you?”
“Why? Do you think it’s related to my case?”
“It might be.”
Wendy came to Tulley for help with a TIPS line case. It had all the markings of a crank call, but the operator had coded it as possible. It got assigned to Wendy.
After some initial investigation, Wendy was tempted to close the case as undetermined and leave it cold. But at lunch, her supervisor advised her to try another tack. If what the TIPS caller had said was true, it would show up as a refusal, that is, if it was done through UNOS. UNOS has the federal tracking contract for all organ transplants. And if the organs came from any U.S. facility, it would have to be done through UNOS.
Tulley was the office expert on UNOS, so Wendy saw him first.
After her talk with Tulley, Wendy called UNOS, explained who she was—she works for their regulator, and no federal contractor wants to talk to a Fraud, Waste and Abuse task force lawyer with their regulator—and ended up talking to some high level official—a doctor. She told the doctor that a TIPS line caller claimed she paid for a kidney and never received it.
The doctor laughed. “That’s impossible.”
2 days prior to that call.
The people who answer the TIPS line at CMS get all kinds of weird calls, but this one was over the top. An anonymous caller said they paid for a kidney and didn’t get it. The operator had asked who did she pay? The government. Where are you? No answer. How can you buy a kidney? The caller said she paid, but no kidney came. The operator asked her if she’s aware that buying a kidney is illegal. The caller hung up.
The operator would have coded the conversation as a crank call, but the caller seemed so genuine, even believable. Somebody had convinced this lady that she could pay the U.S. government to get a kidney, and they’d deliver a kidney. It’s a terrible scam, but hardly one to occupy the FWA investigators. The operator decided to write it up as a possible case.
When these weird cases come in, Wendy had a process, like a checklist. She checked the call log, and fired off an inquiry to IT to get the call record, including any caller ID. If she got a number, she would call it. Most of the time, it would end in a dead lead or a prank, and she’d close the case. This time, she got a Virginia number, and called it. A man answered. He spoke with a thick accent. Cuban?
Wendy said she was looking for the person who called the CMS TIPS line. The man cursed and asked if she was going to get the kidney they paid for. How much did you pay, Wendy asked. Ten thousand, the man told her. Who did you pay? We paid the government. Did someone from the government come to you and take your money? Yes. They had a badge, all official. Where are you, can we come and see you? The caller hung up.
She called the number again, but there was no answer. Wendy filled out paperwork for a warrant to search phone records, to find out who owned that number. This is the furthest she’d ever gotten on a crank call case. If it was someone pranking, she wanted to punish them for wasting her time, maybe refer a case of making false statements for the FBI. Two hours later, her affidavit was electronically returned approved by the D.C. magistrate judge, with instructions for her to call the DOJ for service.
The next day, the records came back from the carrier; these requests are so common, many carriers have the process automated. It was an international eSim, purchased from a company that sells numbers for foreigners to use in the U.S.A. She looked for the call data to see where the TIPS line calls came from, but Wendy had mistakenly not asked for that data in her application. She only asked for the number’s owner—a rookie mistake, but Wendy didn’t have a lot of experience dealing with international carriers. It took another two days and another round of affidavit, application, approval, and a call to the DOJ for service, to get the actual call record.
The call was placed from Richmond, Virginia, like the number said, but there was no name attached. She called her contact with the FBI, and asked how she could find the caller. “It’s a burner phone,” he said. “You won’t find it. And the call probably didn’t come from Richmond, either.” He explained that some eSim providers hack their own records to cover up the real source of calls when responding to government warrants.
In the byzantine halls of the federal government, lots of things get tucked away in places nobody would ever think to look, and Tulley worked for one of those bastions. CMS, by some magic of government accounting and Congressional jockeying, was in charge of the Organ Procurement Organization data analysis function.
OPOs were created by Congress in 1984, while Ronald Reagan was president. An entire infrastructure dealing with organ transplants was mandated by the National Organ Transplant Act—NOTA. That “Organ Donor” note on people’s driver’s licenses, that’s part of NOTA. All those forms for consent and medical power of attorney, and DNR orders? Much of that came out of NOTA its predecessor, the Uniform Anatomical Gift Act—UAGA, which was first passed in 1968 and has been amended in 1987, and strengthened in 2006. Then there’s UDDA, the Uniform Determination of Death Act, which isn’t really a federal law, but a template for states to make their own law.
There’s a lot of legal work surrounding something that only happens once to every person: death. It was Wendy’s job to know all the jots and tittles of death law. She actually worked for the Health Resources and Services Administration, HRSA, UNOS’s regulator and the watchdog for HHS’s OPTN contract.
Medicaid fraud is more common than many might think—or maybe less common if they believe everything is a racket. Everything from miscoding a medical procedure, to accepting bogus referrals, to handing out pills that nobody asked for, then billing for it. The FWS task force finds these instances, roots out the perpetrators, and takes action. If it’s severe enough, prosecutors can ask for the maximum, $250,000 in fines, or five years in a federal prison (with time off for good behavior). The government can sue for triple damages if they can show financial loss.
But violations of NOTA are far less common; they are unicorns in the healthcare regulatory world. Wendy had never heard of a single federal government prosecution stemming from a NOTA ethical violation. There have been some civil cases, like Colavito v. NYODN. That one attempted to answer the question: who owns a dead person’s kidney that had been willed to another? New York Court of Appeals Justice Albert Rosenblatt offered this legal gem: “writings on the subject go back to Lord Coke, whose 17th century pronouncement that a corpse has no value is a good starting point.”
The law supports an essential belief that organs are only directed to anyone with a medical need. So while a person can will their organs to a recipient of their choice (while alive), that recipient cannot possess any right in the dead body, other than by medical necessity, which means they need the organ to live, and it is medically compatible to the recipient. This, of course, depends on the medical judgement of the donor surgeon doing the organ harvest, the quality of the transplant coordinator data, and the skill and professional determination of the recipient’s transplant surgeon receiving the organ.
If an donor organ is rejected by a recipient, including one who was named in a will to be a recipient (as in a brother who wills his liver to his twin brother suffering from cirrhosis in the event of his demise), then it is in the power of the state to direct that organ to whomever, by law and judgement of medical professionals, needs it most.
The call.
HHS contracts with a company based in Richmond, Virginia, a non-profit named the United Network for Organ Sharing, UNOS, to ensure rigid compliance with NOTA ethical requirements, and the positive tracking of all donated organs, their status, recipients, waiting lists, all in real-time.
UNOS operates three major IT systems to handle this critical task. UNet℠, DonorNet®, and TransNet℠. These systems all work together to ensure complete control of all aspects of organ donation and transplants in the U.S. Hospitals and doctors use UNet to add patients to the national transplant waiting list, and to update the status of those patients, including all medical data related to their condition, need and compatibility requirements. But even doctors have to go through a maze of officialdom to actually sit at a UNet terminal.
Hospitals must apply to join the Organ Procurement and Transplantation Network (OPTN). The application is arduous. If approved, a hospital appoints a site administrator to manage access. Part of the requirement is security. The data in UNet goes far beyond typical doctor’s office medical records, which remain protected by HIPAA and other privacy laws. It can mean life or death for patients on the waiting list.
Donors (many of whom are dead or dying) must first be evaluated and approved by the OPO, which is a separate organization from the hospital or surgeon in whose care the sick patient remains. The OPO then ensures legal compliance by getting consent from the next of kin, and establishing the identity of the donor. All medical data, lab results, and other pertinent information is entered into DonorNet, which then runs an “organ offer” match against the transplant list, and generates—in real time—offers to transplant teams based on many different factors.
One of the factors that is never considered is financial ability or cost. If a patient is on the national transplant waiting list, the primary drivers of receiving an offer are medical need, compatibility of the donor organ, viability (including distance to the patient’s location), and the judgement of the recipient medical team—the surgeon.
Finally, TransNet is used to establish positive identification of the donor, the recipient patient, and the organ. Every specimen is labeled, barcoded, and scanned into UNet. The OPO communicates with the transplant team in real-time, and arranges for transport, tracking and identification of all aspects of the organ donation process at every step.
Wendy knew some of this, but the doctor on the phone patiently led her through their protocols and systems. As she listened, she suspected he was right. It’s impossible to pay for an organ using UNet, and have it delivered, or not delivered. It simply can’t happen.
Except. Unless. The Tenth Man Rule kicks in.
Israel. 1973.
The Egyptian military nearly reached the no-man’s land between the Negev and Jerusalem, which would have enabled it to capture the capital city of Israel, and win against its primary rival. Israel was caught unprepared because of groupthink.
It was Ramadan. The Egyptians had all kinds of logistical challenges. The Egyptian army lacked professional training. The Israelis were confident in their own superiority. And they nearly lost because they didn’t consider the alternative argument.
The Tenth Man Rule means that one person is assigned the task of taking the alternative argument. Groupthink is corrosive. Israel’s use of the Tenth Man Rule kept it on its game for many years—until October 7th, 2023 proved that unicorns do exist.
Wendy knew about the Tenth Man Rule. She learned it from her law school professor who, in another life, was an intelligence officer. She paid attention when it came up in the movie World War Z.
Everything UNOS claimed about being impervious to any kind of ethical or procedural lapse is patently true. Except someone called the TIPS line and said they paid ten thousand dollars for a kidney, that never arrived.
Navy Hill, Richmond, Virginia. 2020.
Xavier Rollins kept a photo of Bill Robinson on the wall behind his desk. Bill “Bojangles” Robinson was a son of Richmond, a Black minstrel and tap dancer in the white world of pre-WWII Vaudeville. He was the first to break the “two-color rule,” performing solo before audiences, and to headline on Broadway.
Navy Hill is a section of Richmond adjacent to what was known as Jackson Ward, a Black neighborhood. But Robinson called Navy Hill his home, and home to the only Black public school in Richmond with Black faculty members. In the 1950s, when interstates were being laid out between major cities, I-65 and I-95, running through Richmond, went right through Navy Hill, and destroyed the community.
But on Seventh and Jackson, and for blocks around it, now stands a forest of biomedical facilities, from the Virginia Department of Forensic Science, to VCU, to in the nook between North Third and Fourth Streets and Jackson, UNOS headquarters.
Xavier was a proponent, and a real estate speculator with an interest in Black history. He invested quite a bit in 2018 when it looked like Richmond’s Mayor Levar Stoney would get his $1.5 billion Navy Hill redevelopment project approved. It was going to include a brand new 17,500-seat arena to replace the closed Coliseum along with jobs, housing, and a transit center. And it was going to make Xavier a billionaire one day.
He scraped and scratched and borrowed and begged together $2 million dollars, including some rather sketchy loans from some rather frightening figures. And in 2020, it all came crashing down. The headline on February 11 read “Richmond’s $1.5B Navy Hill project is dead.” His world reeled.
His phone rang. It was Carlos. “Where’s my money?”
“You’ll get it.”
“Naw, man. You got it now?”
“I can get you a hundred grand in a week.”
“You owe me a million.”
“What? You loaned me five hundred! That’s robbery!” Xavier got loud, then quieted himself, realizing he was at work and his office door was wide open. He got up, crossed the room to close it, looking both ways down the hallway before latching the door.
“Them’s the terms, bro. Or my man’s comin’ to see you.”
“Give me two weeks. I’ll get your money.”
“All of it.”
“All of it.” Xavier hit the end call button, but not before Carlos clicked off the line.
A week after the call with Carlos.
Xavier’s phone rang. Carlos.
“You got my money?”
“I said two weeks.”
“You said two weeks. I said all of it.”
“I need more time.”
“You ain’t got more time.” There was a knock at Xavier’s door. He was at home. It was 7:15 a.m.
“Damn, man, hang on let me answer the door.”
It was Johnson, Carlos’ “man,” who stood every bit of six-foot-eight. “Give Johnson the phone,” Carlos said. Xavier handed it over. Johnson listened and said nothing, then handed the phone back. The call had ended.
“You got two days. I’ll be back.” Johnson turned to go. As he turned, Xavier noticed the bump under Johnson’s jacket, figuring there was a large pistol under there. Johnson stopped for a second, looked up above the kitchen cabinet, which was about level with his eyes. “Nice shotgun, Z. You might want to lose that before I come back. Might fetch some cash, and you gonna need all of it.” Then Johnson went out, closing the door behind him.
Xavier was a dead man, and he knew it. He thought about fleeing, but where would he go? Carlos had “associates” in all the places Xavier would even think of going. And Xavier was sure Carlos had his place watched. Hell, he probably had people watching him at work. Probably had cops on the payroll.
The land he had bought, through several shell companies, was to be where the new arena would sit. And when he bought the land, he faked the property valuation. Then the stupid city council went and hired a consultant, who found there was no good appraisal for the land, and recommended against proceeding. Xavier tried to talk to the consultant, but he didn’t want to expose his own personal involvement. He thought about trying to bribe the consultant, or the city council members who planned to vote against the project. But he had no cash to do it, and Carlos wasn’t in the mood to play games with local politicians. Xavier feared Carlos, but in 2018 there was no other way to get the cash to buy the land.
And now, the land he paid $2 million for was worth—the last investment firm offered $125,000—Carlos wanted his million.
Xavier dialed his real estate agent. Voice mail. “Tell the investor, if he can do $100,000 cash, and I mean cash as in bills, I’ll get him the deed. He can give you the other $25,000 any way you want it. That’s your cut.” And he hung up the line.
The next day.
The agent never called back. Xavier took the day off work, as a sick day. He really felt sick.
His phone rang. He answered without looking. “Ajay! Hey man!”
“Who’s Ajay? Your crack dealer?” It was Carlos.
“Carlos! Sorry. It hasn’t been two days yet.”
“You got my money?”
“I can have a hundred grand tomorrow. Just don’t have Jackson hurt me. I promise I’ll get you the rest.”
“Listen, I don’t know how much time I got. I need all of it. Gotta get out of the country, something called medical tourism. My doc said my kidney’s dead, and my other one is dying. If I don’t get a kidney, I’ll be on a machine. Not gonna do that.”
“Wait…Carlos….” Carlos cut Xavier off.
“There’s a waiting list. And it’s long. I don’t have a lot of time to wait, and people like me don’t get a lot of consideration at hospitals and clinics. My doctor said it could be a year. I ain’t waitin’ a year.”
“Carlos…” Xavier couldn’t get a word in.
“I need that money before I go. And I’m goin. Jackson’s gonna come see you, and give him the money, or we gonna end our business, and with me gone, you gonna be gone too. I don’t need no promises or real estate deeds.”
“Carlos, you need a kidney!”
“Don’t patronize me!”
“I think I can help.”
“You can help by getting me my money!”
“No, I can help get you a kidney.”
Carlos was listening.
Present day.
Robin checked her watch, and looked toward the door. The face in the window nodded slightly and a hand gave a thumbs up.
“It’s time,” Robin said.
Mason closed his eyes. Robin thought he was praying. Then with one motion, Mason took the Sting pill. The coating over the Norevium-17 had a bitter taste and Mason made a face. He drank the water.
Robin looked at the dosimeter display as the tech pointed the receptor wand at Mason’s chest. The Sting pill had a faint radioactive signature, and she was checking to ensure it had moved into Mason’s stomach. The dosimeter registered the correct value.
She took the syringe in her hand and plunged it into the catheter, injecting 15 cc’s of Shelob-9, the code name given to the “death drug,” into Mason’s veins. She started the timer on her phone.
Mason opened his eyes and wordlessly looked into Robin’s.
“Prep the ventilator,” Robin said as the room began pulsing with activity.
Then Mason died.
Look for Chapter 2 soon. Comments are welcome for paid subscribers!
Thank you for reading Risky Tales! This is paid subscriber content. Please share this site if you’re enjoying the story!