M. L. Samoylova1, B. I. Shaw1, T. Risoli2, S. Peksoe2, V. Wang3, L. McElroy1 1Duke University Medical Center,Abdominal Transplant Surgery,Durham, NC, USA 2Duke University,Biostatistics & Bioinformatics,Durham, NC, USA 3Duke University Medical Center,Medicine, Population Health Sciences,Durham, NC, USA
Introduction: The Patient Protection and Affordable Care Act (ACA) was enacted in 2010 and aimed to extend health insurance coverage to all Americans. Preliminary data indicate that the ACA has expanded insurance coverage and healthcare access, but has not necessarily improved disparities in access to subspecialty care. In this study, we aim to evaluate the effect of ACA implementation on payor demographics and outcomes for patients listed for kidney transplantation.
Methods: Data for all adult patients registered for the kidney transplant waiting list in the United States between 2007 and 2018 were abstracted from the Scientific Registry of Transplant Recipients. For patients with multiple records, the first listing in the timeframe was used for analysis. Summary statistics for waiting list registrants and recipients were tabulated by era, defined as 2007-2010, 2011-2014, 2015-2018. We then performed multivariable competing risks time-to-event regression to estimate cause-specific hazard ratios of transplant and death or delisting on the waiting list to evaluate the effect of payor on waiting list outcomes over time.
Results: A total of 345,073 patients met the inclusion criteria. Compared to pre-ACA, the proportion of Asian and Hispanic patients on the waiting list increased over time (6.0, 6.9, 7.5% Asian per era, 16.4, 17.6, 19.1% Hispanic per era). Age at listing and BMI increased over time, while the proportion of patients on dialysis at time of registration decreased. The proportion of patients with Medicaid listed as their primary insurance increased from 7.4% to 7.8% and 9.8% over time, while the proportion of patients with private insurance remained relatively unchanged. Payor distribution and outcomes over time are listed in Table 1. Compared with the privately insured, waitlisted patients with Medicaid had an increased risk of death or delisting (Cause Specific HR 1.12 [1.09, 1.15], p<0.0001) and a lower likelihood of transplant. This trend persisted over time.
Conclusion: Despite its stated goals, the passage of the ACA in 2010 led to only a modest increase in the proportion of patients on the kidney transplant waiting list who received their insurance primarily through the Medicaid expansion. This effect is likely attenuated by variable implementation at the state level. Furthermore, disparities persist in the outcomes of Medicaid patients on the kidney transplant waiting list. Our further work will focus on understanding patterns of inactivation/delisting and outcomes of transplantation among Medicaid patients.
