Garet Hil founded the National Kidney Registry (N.K.R.) in 2007 after facing the inability to donate a kidney to his ailing daughter. The organization introduced a system where incompatible donors contribute their kidneys to a national pool, allowing patients to find matches more efficiently. Since its inception, N.K.R. has facilitated nearly 12,000 paired donations, significantly outpacing other programs in the field.

Despite its contributions to improving organ donation efficiency, N.K.R. has evolved into a multimillion-dollar enterprise with substantial influence over organ distribution. Interviews with over 100 professionals in transplant medicine and a review of business records indicate that many in the medical community are concerned about the implications of a private entity managing such critical exchanges with minimal government oversight.

As N.K.R. expanded, it began charging hospitals significant fees for access to its donor registry, with some costs ultimately borne by taxpayers through Medicare. Initially a nonprofit, N.K.R. paid over $39 million to a company owned by Hil for technology and services during its first decade. In 2023, the organization transitioned to a for-profit model, further obscuring its financial operations and raising questions about the impact on healthcare equity and access to organ transplants.