Insurance Type and Solid Organ Transplantation Outcomes: A Historical Perspective on How Medicaid Expansion Might Impact Transplantation Outcomes

Abstract

Background The number of Medicaid beneficiaries has increased under the Affordable Care Act (ACA), improving access to solid organ transplantation in this disadvantaged patient cohort. It is unclear what impact Medicaid expansion will have on transplant outcomes. We performed a retrospective cohort analysis to measure the frequency and variation in Medicaid transplantation, and post-transplant survival in Medicaid patients. Study Design Adult heart, lung, liver, and renal transplant recipients between 2002 and 2011 (n=169,194) reported to the Scientific Registry of Transplant Recipients were identified. Transplant recipients were classified based on insurance status (Private, Medicare or Medicaid). Outcome measures included five-year post-transplant survival, summarized using Kaplan-Meier curves and compared with log-rank tests. Organ-specific Cox proportional hazards models were used to adjust for donor and recipient factors. Results Medicaid patients comprised 8.6% of all organ transplant recipients. Fewer transplants were performed than expected among Medicaid beneficiaries for all organs but liver [Observed/Expected ratios (95% CI): liver=1.21 (0.68, 1.90); heart=0.89 (0.44, 1.49); lung=0.57 (0.22, 1.06); renal=0.32 (0.08, 0.72)]. Medicaid transplant recipients were listed with more severe organ failure and experienced shorter transplant wait times. Post-transplant survival was lower in Medicaid patients compared to Private insurance for all organs. Post-transplant survival in Medicaid patients was similar to Medicare patients for heart, liver and renal but lower in lung. Conclusions Medicaid organ transplant beneficiaries had significantly lower survival compared to Privately insured beneficiaries. The more severe organ failure among Medicaid beneficiaries at the time of listing suggested a pattern of late referral, which may account for worse outcomes. Implementation of the ACA affords the opportunity to develop the necessary infrastructure to ensure timely transplant referrals and improve long-term outcomes in this vulnerable population.

Impact of insurance type on eligibility for advanced heart failure therapies and survival

“…In a retrospective review of United Network for Organ Sharing (UNOS) data, DuBay et al found that patients with Medicaid received fewer HT than expected and were listed with more severe organ failure, suggesting listing at a later stage of illness. 13 Studies of other solid organ transplants have shown clear differences in access by insurance type. Patients with public insurance are less likely to be evaluated or listed for kidney and liver transplant 17,18,19 Although a similar proportion of patients with Medicaid and Medicare insurance were listed for HT in our cohort, the proportion was less than that of patients with private insurance, and the reasons patients were ineligible differed according to insurance type.…”

“…10–13 Prior data has confirmed that very few uninsured or underinsured patients receive HT in the United States (US), as most HT programs require adequate insurance coverage and financial resources to list patients for transplantation. 14,15 Currently, little data exists on the impact that insurance has on outcomes after LVAD.…”

Lung transplantation and Affordable Care Act Medicaid expansion in the era of lung allocation score – a retrospective study

“…Dubay et al . reported no differences in waiting time for Medicaid recipients when compared with Medicare and private insurees, once listed. It is, thus, a worthwhile consideration to go further and evaluate barriers to listing as well as those most likely to be encountered immediately following listing as these might serve to stall the pathway to transplantation.…”

Insurance Coverage and Heart Transplant Outcomes

“…[5][6][7][8] Previous studies in heart transplantation have demonstrated higher mortality, decreased graft survival, and higher rates of rejection for recipients receiving heart transplants with Medicare or Medicaid health insurance coverage compared with those with private health insurance. [5][6][7][8] This finding is not unique to heart transplantation, and previous studies have demonstrated that outcomes for other solid organ transplants, including lung, 9 liver, 10 and kidney, 11 are inferior when transplant recipients with public health insurance are compared with transplant recipients with private health insurance coverage.…”