Kidney Transplants Covered by Medicaid Increased in States After Medicaid Expansion

Medicaid expansion has helped more young, low-income adults with advanced kidney disease to avoid the costs and poor quality-of-life associated with dialysis, reports a study in the Journal of General Internal Medicine from researchers at Drexel University College of Medicine and the Dornsife School of Public Health at Drexel.

The study included 15,775 United States adults age 21-64 who received a pre-emptive kidney transplant (i.e., a transplant before needing dialysis treatment) from 2010-2017.

The team examined the numbers of living and deceased donor kidney transplants, respectively, that occurred during the four years leading up to Medicaid expansion and the four years following the date of expansion in states that opted to expand Medicaid as part of the Affordable Care Act, compared to trends in preemptive transplants in states that chose not to expand Medicaid. 

Researchers found that the overall number of pre-emptive kidney transplants covered by Medicaid have increased by 37 percent in states that did not expand Medicaid and by 66 percent in states that did expand Medicaid. Medicaid-covered preemptive, living-donor kidney transplants increased by 0.7 percentage points in non-expansion states, and by 2.2 percentage points in expansion states.

The Affordable Care Act became law in March 2010, expanding the nation’s Medicaid program, particularly to almost all non-elderly adults whose income is at or below 138 percent of the federal poverty level. This 100 percent federal funding coverage — for states that elected to receive it — began Jan. 1, 2014, (90 percent coverage starting in 2020).

“More Americans die from chronic kidney disease than from breast cancer, prostate cancer, and many other well-known diseases,” said lead author Meera N. Harhay, MD, an associate professor of Medicine at Drexel College of Medicine. “From improving early detection of kidney disease to increasing outreach and educational efforts, there are many steps that we can take to advance care for those with kidney disease. To promote early access to transplants, expanding Medicaid was clearly one of those steps.”

Approximately 37 million Americans suffer from chronic kidney disease, a condition in which the kidneys cannot properly pass waste and filter blood. In the advanced form of chronic kidney disease, a living donor transplant is often the best option to avoid dialysis, but health insurance is needed to cover the costs of the procedure. Although transplant before the need for dialysis treatment is the ideal scenario for individuals with advanced kidney disease, Medicare coverage is only available to non-elderly individuals after they begin dialysis. The shortage of kidneys available for transplant requires that people without a living donor often wait for five to 10 years on dialysis before receiving a transplant, and many die on dialysis before they get that opportunity.

The research findings come amidst President Donald Trump signing an executive order in July aimed at improving kidney care. Its goals include increasing rates of preemptive kidney transplant, identifying and treating at-risk populations in earlier stages of kidney disease, removing financial barriers to living organ donation, among others. The study also comes at a time when the fate of the ACA, and Medicaid expansion, are also in question.

Last year, there were 36,500 transplants of any organ in the United States. A total of 21,167 of these, 59 percent, were kidney transplants, according to the United Network for Organ Sharing. 

A total of 33 states and Washington D.C. have expanded Medicaid under the Affordable Care Act (ACA), covering millions of previously uninsured Americans – including those with kidney disease who are not dialysis-dependent. The latest research follows a study Harhay published in Journal of General Internal Medicine in October 2018 with Ryan M. McKenna, PhD, an assistant professor in Drexel’s Dornsife School of Public Health, which found that 30 percent of the lowest -income individuals in the U.S. with kidney disease were uninsured in 2015 and 2016, despite coverage gains made by Medicaid.

The authors of the study were funded to conduct this research by grants from the National Institutes of Health’s National Institutes of Diabetes and Digestive and Kidney Diseases and National Heart, Lung, and Blood Institute, as well as support from the Health Resources and Services Administration.

In addition to Harhay and McKenna, an additional author on the research includes Michael O. Harhay, PhD, from the University of Pennsylvania.