Public Release: 

Medicaid expansion helps low-income patients get on transplant waitlist before dialysis

American Society of Nephrology

Highlights

  • In states that expanded Medicaid under the Affordable Care Act to cover more low-income individuals, there was an increase in the number of Medicaid beneficiaries who were preemptively waitlisted to receive a kidney transplant.
  • Medicaid expansion was associated with greater gains racial and ethnic minorities in being listed pre-emptively on the transplant waitlist compared with whites.

Washington, DC (June 21, 2018) -- New research indicates that Medicaid expansion under the Affordable Care Act has helped to place many low-income individuals with chronic kidney disease (CKD) on the kidney transplant waiting list before starting dialysis. In addition, after expansion, there were larger gains in pre-emptive listing for minorities with Medicaid coverage than for whites. The findings appear in an upcoming issue of the Clinical Journal of the American Society of Nephrology (CJASN).

Kidney transplantation is considered more cost-effective than dialysis, and preemptive wait-listing--or placing patients on the kidney transplant waiting list before they require dialysis--can help minimize the time that patients will eventually need to spend on dialysis before receiving a kidney transplant. Access to the kidney transplant waiting list is generally contingent on having health insurance coverage, however. Medicare provides a health insurance safety net once individuals develop kidney failure and require dialysis, but prior to Medicaid expansion under the Affordable Care Act, no similar safety net existed for low income individuals with advanced CKD who were not yet on dialysis.

Studies are needed to determine whether Medicaid expansion under the Affordable Care Act has provided opportunities for low-income individuals with CKD to get the care they need. To investigate, Meera Nair Harhay, MD, MSCE, FASN (Drexel University College of Medicine) and her colleagues examined information from the United Network of Organ Sharing database on adults listed for kidney transplantation before dialysis dependence in 2011-2013 (pre-Medicaid expansion) and 2014-2016 (post-Medicaid expansion). "We explored whether Medicaid expansion, in offering an option for health insurance coverage for low-income individuals in the United States, would be associated with an increase in the number of Medicaid beneficiaries on the kidney transplant waiting list," said Dr. Harhay.

The team found that after states expanded Medicaid to cover more low-income individuals, there was an increase in preemptive listings of Medicaid beneficiaries. States that fully implemented Medicaid expansion on January 1, 2014 had a 59% relative increase in Medicaid-covered preemptive listings from the pre-expansion to post-expansion period, compared with an 8.8% relative increase among Medicaid non-expansion states. From the pre- to post-expansion period, the adjusted proportion of listings with Medicaid coverage decreased by 0.3 percentage-points among non-expansion states and increased by 3.0 percentage-points among expansion states.

Also, more of the new racial/ethnic minority listings from expansion states were Medicaid beneficiaries, as compared with the new white listings. In addition, Medicaid beneficiaries on the waiting list from Medicaid expansion states were more likely to be employed and functionally independent than Medicaid beneficiaries on the waiting list from non-expansion states.

The authors noted that additional studies are needed to determine whether long-term transplant outcomes differ among candidates who were listed with expanded Medicaid coverage compared with those with other coverage options.

In an accompanying editorial, Nitender Goyal, MD and Daniel Weiner, MD, MS (Tufts Medical Center) note that policies that improve access to care can have a tremendous impact on the delivery of medical care. "Harhay and colleagues elegantly quantified this by describing the effects of access to Medicaid on preemptive kidney transplant listing. Much harder to quantify but likely far more numerous are the patients who, because of earlier diagnosis and treatment of their kidney disease may never need to be listed for a kidney transplant, but rather will be able to maintain kidney health with better access to medical care," they wrote.

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Study co-authors include Ryan M. McKenna, PhD, Suzanne M. Boyle, MD, Karthik Ranganna, MD, Lissa Levin Mizrahi, MD, Stephen Guy, MD, Gregory E. Malat, PharmD, Gary Xiao, MD, David J. Reich, MD, and Michael O. Harhay, PhD.

Disclosures: The authors reported no financial disclosures.

The article, entitled "Association Between Medicaid Expansion Under the Affordable Care Act and Preemptive Listings for Kidney Transplantation," will appear online at http://cjasn.asnjournals.org/ on June 21, 2018, doi: 10.2215/CJN.00100118.

The editorial, entitled "The Affordable Care Act, Kidney Transplant Access and Kidney Disease Care in the United States," will appear online at http://cjasn.asnjournals.org/ on June 21, 2018.

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