Abstract: Medical insurance payment policies are important institutional factors affecting the accessibility of organ transplantation technology and health equity. Through a systematic sorting and comparative analysis of medical insurance payment policies for organ transplantation in 19 provinces across China, this study reveals the structural dilemmas in the current payment system, including ambiguous priority of protection, insufficient depth of protection, regional welfare barriers, and the separation of services and protection. The formation of the above problems is closely related to the institutional tension between the high-cost nature of organ transplantation technology and the long-standing principle of "ensuring basic needs" adhered to by basic medical insurance. Based on this, on the premise of adhering to the framework of "ensuring basic needs" for medical insurance and the sustainability of insurance funds, this paper proposes to optimize the current system from four aspects: first, reconstruct the institutional calibration mechanism for the priority of organ transplantation protection under the framework of "ensuring basic needs"; second, improve the medical security system covering the whole cycle of organ transplantation through the coordination of multi-level systems, and enhance the risk-sharing function within the affordable scope of insurance funds; third, strengthen national leadership and overall coordination, and promote the bottom-line equity of medical security for organ transplantation by unifying the minimum protection standards and payment rules; fourth, take the pilot implementation of regional integration as a breakthrough point to alleviate the predicament of cross-regional medical security for organ transplantation.