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Medicaid Expansion Under the ACA Increased Low-Income Patient Access to Kidney Transplants

kidney transplant

June 21, 2018

After states expanded Medicaid to cover more low-income individuals under the Affordable Care Act (ACA), there was a significant boost in the number of chronic kidney disease patients with Medicaid coverage who were placed on the kidney transplant waiting list, according to a new study led by Drexel University researchers.

Medicaid expansion was associated with larger increases in Medicaid coverage among new listings of racial and ethnic minority patients compared to listings of white patients. This suggests that Medicaid expansion may have helped to curb racial and socioeconomic disparities in pre-dialysis chronic kidney disease care in the United States. The findings appear in an upcoming issue of the Clinical Journal of the American Society of Nephrology (CJASN).

More than 93,000 people are currently listed for a new kidney, according to the U.S. Department of Health and Human Services. While black and Hispanic Americans have higher rates of diabetes and high blood pressure than white Americans, putting them at risk for organ failure, historically patients who were white or had private health insurance were more likely to receive an organ transplant.

Kidney transplant waiting list comparison pre- and post-ACA
Medicaid expansion under the Affordable Care Act was associated with a significant increase in the number of individuals who were preemptively wait-listed for kidney transplants with Medicaid coverage.

Kidney transplantation is more cost-effective and associated with better health outcomes than dialysis. Getting on the waiting list early can shorten the amount of time that kidney transplant candidates need to endure dialysis before getting a transplant, with average waiting times of five to seven years. However, access to the list is largely dependent on having health insurance coverage, and Medicare only provides a health insurance “safety net” for individuals without other insurance coverage after they start dialysis.

“The sooner you can get on the list, the sooner you may receive a transplant. However, before the ACA, the majority of patients who got on the waiting list before starting dialysis had private health insurance and were white, even though minorities are substantially more likely than white individuals to end up with late-stage kidney disease,” said the study’s lead author Meera Nair Harhay, MD, an assistant professor of medicine at Drexel University College of Medicine. “Given evidence that millions of low income and minority individuals gained insurance coverage by Medicaid expansion, I wondered whether Medicaid expansion was also changing the socioeconomic and racial makeup of the kidney transplant waitlist.”

Medicaid expansion and the kidney transplant waiting list graph
Thirty-one states and the District of Columbia fully implemented Medicaid expansion under the Affordable Care Act (ACA) after January, 1, 2014. Medicaid expansion after this period was associated with larger percentage-point increases in Medicaid coverage for preemptive listing among racial and ethnic minority listing compared to white listings.

January 1, 2014 marked the beginning of the full implementation of Medicaid expansion in the United States, when the federal government enhanced funding to states that elected to expand Medicaid to cover low-income adults at or below 138 percent of the federal poverty level. Using national data from the United Network of Organ Sharing database over a six-year period, Harhay and her colleagues compared trends in insurance types used for preemptive listings among U.S. states that did and did not expand Medicaid under the ACA. They also examined whether there was evidence of differences in insurance types used for preemptive listings of minorities compared to listings of white transplant candidates after Medicaid expansion

The researchers found that states that expanded their Medicaid programs experienced an increase in preemptive listings of Medicaid beneficiaries. States that fully implemented Medicaid expansion on January 1, 2014 had a 59 percent relative increase in Medicaid-covered preemptive listings (1,094 to 1,737 patients) from the pre-expansion (years 2011-2013) to post-expansion period (years 2014-2016), compared with an 8.8 percent relative increase among Medicaid non-expansion states. From the pre- to post-expansion period, the adjusted proportion of listings with Medicaid coverage increased by 3 percentage-points among expansion states and decreased by 0.3 percentage-points among non-expansion states.

“In states that did not expand Medicaid, millions of individuals with incomes too high to qualify for Medicaid and too low to receive subsidized private insurance remain uninsured,” the study authors write in their conclusion. “Given this coverage gap, it is uncertain if low-income individuals with chronic kidney disease in non-expansion states have had equivalent opportunities to accrue preemptive waiting time for kidney transplantation.”

The authors also found that in expansion states, the proportion of new black listings with Medicaid coverage increased by 4 percentage points, and the proportion of new Hispanic listings with Medicaid coverage increased by 5.9 percentage points, whereas the proportion of new white listings with Medicaid coverage increased by only 1.4 percentage points.

With respect to cost, the study authors note that U.S. spending for chronic dialysis currently exceeds 30 billion dollars per year.

“Policies, such as insurance expansion, that expand access to health care and kidney transplantation services for low-income patients could lessen the number of patients on dialysis and significantly reduce these costs,” said study co-author Ryan McKenna, PhD, an assistant professor at Drexel’s Dornsife School of Public Health. “Our study has shown that expanding Medicaid may provide a pathway to kidney transplantation for low income individuals with kidney disease,” Harhay said.

The study authors concluded that more research is needed to find out whether long-term transplant outcomes differ among candidates who were listed with expanded Medicaid coverage compared with those with other coverage options.