Affordable Care Act Medicaid expansion associated with increased liver transplant waitlist access without worsening mortality

Abstract

Background and Aims: It is unclear what impact Affordable Care Act (ACA) Medicaid expansion has had on the liver transplantation (LT) waitlist. We aimed to assess associations between ACA Medicaid expansion and LT waitlist outcomes. Methods: The United Network for Organ Sharing Standard Transplant Analysis and Research (UNOS STAR) database was queried for patients listed for LT between January 1, 2009 and December 31, 2018. Our primary outcome was waitlist mortality and our secondary outcomes included Medicaid use on the LT waitlist and transplant rate. States were divided into groups based on their expansion status and the study period was divided into two time intervals—pre-expansion and post-expansion. Difference-in-difference (DiD) models were created to assess the impacts of expansion on each of the outcomes and for racial/ethnic and gender groups. Results: 56,414 patients from expansion states and 32,447 were from non-expansion states were included. 3-year waitlist mortality decreased at a similar rate in both cohorts (DiD estimate: 0.1, [95% CI −1.1, −1.4], p = 0.838), but Medicaid use increased (DiD estimate: + 7.7, [95% CI 6.7, 8.7], p < 0.001) to a greater degree in expansion states after expansion than non-expansion states. Between the two time intervals, Medicaid use on the LT waitlist increased from 19.4% to 26.1% in expansion states but decreased from 13.4% to 12.1% in non-expansion states. In patients on Medicaid, there was a slight increase in 3-year transplant rate associated with Medicaid expansion (DiD estimate + 5.0, [95% CI 1.8, 8.3], p = 0.002), which may in part be explained by differences in patient characteristics. Conclusion: Medicaid expansion was associated with increased Medicaid use on the LT waitlist without worsening overall waitlist mortality or transplant rate, suggesting that lenient and widespread public health insurance may increase access to the LT waitlist without adversely affecting outcomes.

Access and outcomes in liver transplant candidates: How and when we measure is as important as what we measure

“…In this issue of Liver Transplantation, Wahid and colleagues investigated the impact of Medicaid expansion following the introduction of the Affordable Care Act in 2014 on LT waitlist mortality and transplant rates using a difference-in-difference (DiD) model, the current gold standard for assessing the impacts of Medicaid expansion under the Affordable Care Act. [1] UNOS STAR data from 2009 to 2018 was used, during which there was a 34.5% increase in the proportion of waitlisted Medicaid patients, an increase driven by greater inclusion of Black, Hispanic, and Asian patients compared with White patients. Three-year waitlist mortality showed similar reductions in expansion and nonexpansion states.…”