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Original ArticlesTransplantation
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Association between Medicaid Expansion under the Affordable Care Act and Preemptive Listings for Kidney Transplantation

Meera N. Harhay, Ryan M. McKenna, Suzanne M. Boyle, Karthik Ranganna, Lissa Levin Mizrahi, Stephen Guy, Gregory E. Malat, Gary Xiao, David J. Reich and Michael O. Harhay
CJASN July 2018, 13 (7) 1069-1078; DOI: https://doi.org/10.2215/CJN.00100118
Meera N. Harhay
1Division of Nephrology and Hypertension, Department of Medicine, and
2Epidemiology and Biostatistics and
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Ryan M. McKenna
3Health Management and Policy, Drexel University Dornsife School of Public Health, Philadelphia, Pennsylvania;
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Suzanne M. Boyle
1Division of Nephrology and Hypertension, Department of Medicine, and
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Karthik Ranganna
1Division of Nephrology and Hypertension, Department of Medicine, and
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Lissa Levin Mizrahi
1Division of Nephrology and Hypertension, Department of Medicine, and
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Stephen Guy
4Division of Multi-Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania; Departments of
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Gregory E. Malat
4Division of Multi-Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania; Departments of
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Gary Xiao
4Division of Multi-Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania; Departments of
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David J. Reich
4Division of Multi-Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania; Departments of
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Michael O. Harhay
5Palliative and Advanced Illness Research Center and
6Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, and
7Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; and
8Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Pennsylvania
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Abstract

Background and objectives Before 2014, low-income individuals in the United States with non–dialysis-dependent CKD had fewer options to attain health insurance, limiting their opportunities to be preemptively wait-listed for kidney transplantation. We examined whether expanding Medicaid under the Affordable Care Act was associated with differences in the number of individuals who were pre-emptively wait-listed with Medicaid coverage.

Design, setting, participants, & measurements Using the United Network of Organ Sharing database, we performed a retrospective observational study of adults (age≥18 years) listed for kidney transplantation before dialysis dependence between January 1, 2011–December 31, 2013 (pre-Medicaid expansion) and January 1, 2014–December 31, 2016 (post-Medicaid expansion). In multinomial logistic regression models, we compared trends in insurance types used for pre-emptive wait-listing in states that did and did not expand Medicaid with a difference-in-differences approach.

Results States that fully implemented Medicaid expansion on January 1, 2014 (“expansion states,” n=24 and the District of Columbia) had a 59% relative increase in Medicaid-covered pre-emptive listings from the pre-expansion to postexpansion period (from 1094 to 1737 listings), compared with an 8.8% relative increase (from 330 to 359 listings) among 19 Medicaid nonexpansion states (P<0.001). From the pre- to postexpansion period, the adjusted proportion of listings with Medicaid coverage decreased by 0.3 percentage points among nonexpansion states (from 4.0% to 3.7%, P=0.09), and increased by 3.0 percentage points among expansion states (from 7.0% to 10.0%, P<0.001). Medicaid expansion was associated with absolute increases in Medicaid coverage by 1.4 percentage points among white listings, 4.0 percentage points among black listings, 5.9 percentage points among Hispanic listings, and 5.3 percentage points among other listings (P<0.001 for all comparisons).

Conclusions Medicaid expansion was associated with an increase in the proportion of new pre-emptive listings for kidney transplantation with Medicaid coverage, with larger increases in Medicaid coverage among racial and ethnic minority listings than among white listings.

  • Adult
  • Ethnic Groups
  • European Continental Ancestry Group
  • Hispanic Americans
  • Humans
  • Insurance, Health
  • kidney transplantation
  • Logistic Models
  • Medicaid
  • Patient Protection and Affordable Care Act
  • renal dialysis
  • Renal Insufficiency, Chronic
  • Retrospective Studies
  • United States
  • Received January 3, 2018.
  • Accepted April 13, 2018.
  • Copyright © 2018 by the American Society of Nephrology
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Clinical Journal of the American Society of Nephrology: 13 (7)
Clinical Journal of the American Society of Nephrology
Vol. 13, Issue 7
July 06, 2018
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Association between Medicaid Expansion under the Affordable Care Act and Preemptive Listings for Kidney Transplantation
Meera N. Harhay, Ryan M. McKenna, Suzanne M. Boyle, Karthik Ranganna, Lissa Levin Mizrahi, Stephen Guy, Gregory E. Malat, Gary Xiao, David J. Reich, Michael O. Harhay
CJASN Jul 2018, 13 (7) 1069-1078; DOI: 10.2215/CJN.00100118

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Association between Medicaid Expansion under the Affordable Care Act and Preemptive Listings for Kidney Transplantation
Meera N. Harhay, Ryan M. McKenna, Suzanne M. Boyle, Karthik Ranganna, Lissa Levin Mizrahi, Stephen Guy, Gregory E. Malat, Gary Xiao, David J. Reich, Michael O. Harhay
CJASN Jul 2018, 13 (7) 1069-1078; DOI: 10.2215/CJN.00100118
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  • Medicaid Expansion and Incidence of Kidney Failure among Nonelderly Adults
  • Failure to Advance Access to Kidney Transplantation over Two Decades in the United States
  • Trends in Disparities in Preemptive Kidney Transplantation in the United States
  • The Affordable Care Act, Kidney Transplant Access, and Kidney Disease Care in the United States
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Keywords

  • Adult
  • ethnic groups
  • European Continental Ancestry Group
  • Hispanic Americans
  • humans
  • Insurance, Health
  • kidney transplantation
  • Logistic Models
  • Medicaid
  • Patient Protection and Affordable Care Act
  • renal dialysis
  • Renal Insufficiency, Chronic
  • Retrospective Studies
  • United States

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