People from socioeconomically distressed communities who underwent heart transplantation between 2004 and 2018 faced a 10% greater relative risk of experiencing graft failure and dying within five years compared to people from non-distressed communities. In addition, following implementation of the 2018 UNOS Heart Allocation policy, transplant recipients between 2018 and 2022 faced an approximately 20% increase in relative risk of dying or experiencing graft failure within three years compared with the pre-policy period. This is despite the fact that the proportion of distressed patients remained the same over both eras.