Solid-Organ Transplantation and the Affordable Care Act: Accessibility and Outcomes

MULTIPLE STUDIES AND reports published since the enactment of the Affordable Care Act (ACA) suggest that more people have health insurance coverage, mainly because of Medicaid expansion.1-4 Recent reports have demonstrated an increase in Medicaid insurance coverage by 7.4 per cent compared with the preACA era.3 The few studies evaluating the impact of the ACA on solid-organ transplantation suggest a net increase in the Medicaid patients listed after the enactment of the ACA.5-7 The aim of this study is to evaluate the distribution of insurance coverage among the patients listed for transplantation and assess the waiting list and posttransplant survival by insurance type.

Methods

The United Network of Organ Sharing (UNOS) database was requested from the Organ Procurement and Transplant Network.8 The UNOS data are separately available for thoracic organs, kidney and pancreas, liver, and intestine. For this study, we included individual heart, lung, liver, and kidney transplant (KTx) and waiting list data. Patients listed for combined heart-lung and combined kidney-pancreas were excluded from the analysis. Patients aged <18 years, and listed before the year 2010 and after 2016, were excluded from the analysis. The available insurance data (from the UNOS database) was then reclassified in five main categories: Self (or no-insurance), Medicaid, Medicare, other government (Veterans Affairs, military etc.), and private. The data were also classified by the adoption of Medicaid expansion i.e. states that adopted Medicaid expansion and states that did not.

The distribution of insurance was evaluated for each of the organ by listing year using descriptive statistics and linear/bar graphs. The waiting list survival and posttransplant survival was evaluated for each organ by each insurance type using Kaplan-Meier Curves and compared using log-rank tests.

Results

Kidney

A total of 34,897 patients were listed for KTx in 2010 which increased by 3 per cent to 35,940 in 2016 (Fig. 1). During this period, the proportion of patients listed with Medicare changed from 47 to 44 per cent and Medicaid changed from 7 to 9 per cent. Private insurance remained unchanged at 44 per cent. When evaluating insurance distribution by states that adopted Medicaid expansion versus states that did not, the increase in Medicaid proportion was more prominent in the adopter states (8-11%, P < 0.0001), whereas nonadopter states had marginal increase (3.4-3.9%, P 4 0.02). The proportion of Medicare insurance declined in both adopters and nonadopters, whereas private insurance remained stable (Figs. 2 and 3). The rate of transplant at one year from listing in the Medicaid population was 13 per cent in 2010 and 17 per cent in 2015. This rate in general KTx population was 17 per cent in 2010 and 21 per cent in 2015.

For Medicaid patients listed between 2014 and 2016, waiting list survival at one year was 97 per cent, which was significantly better than patients listed in 2010 to 2013 (94%, P < 0.0001) (Fig. 4). The posttransplant patient survival in the aforementioned groups was 98 per cent and 98 per cent at 30 days, and 88 per cent and 89 per cent at one year (Fig. 5).

Liver

A total of 11,222 patients were listed for liver transplant (LiTx) in 2010 which increased by 6 per cent to 11,956 in 2016 (Fig. 1). During this period the proportion of patients listed with Medicare increased from 22 per cent to 26 per cent, Medicaid increased from 16 per cent to 17 per cent, and private insurance declined from 59 per cent to 52 per cent. When evaluating insurance distribution by states that adopted Medicaid expansion versus states that did not, the Medicaid proportion increased from 17 per cent to 21 per cent (P < 0.0001) in adopters and decreased from 12 per cent to 10 per cent (P 4 0.04) in nonadopter states (between 2010 and 2016). The proportion of Medicare insurance increased in both adopters and nonadopters, whereas private insurance declined (Figs. 2 and 3). The rate of transplant at one year from listing in the Medicaid population remained at 40 per cent in 2010 and 2015. This rate in the general LiTx population was 42 per cent in 2010 and 46 per cent in 2015.

For Medicaid patients listed during 2014 to 2016, waiting list survival at one year was 85 per cent, which was significantly better than patients listed in 2010 to 2013 (78%, P < 0.0001) (Fig. 4). The posttransplant patient survival in the aforementioned groups was 96 per cent and 96 per cent at 30 days and 88 per cent and 89 per cent at one year (Fig. 5).

Heart

A total of 2887 patients were listed for heart transplant (HTx) in 2010, which increased by 26 per cent to 3641 in 2016 (Fig. 1). During this period, the proportion of patients listed with Medicare increased from 30 per cent to 34 per cent, Medicaid increased from 12 per cent to 13 per cent, and private insurance declined from 54 per cent to 49 per cent. When evaluating insurance distribution by states that adopted Medicaid expansion versus states that did not between years 2010 and 2016, the Medicaid proportion increased from 13 per cent to 16 per cent (P 4 0.04) in adopters and remained unchanged in nonadopter states at 9 per cent (P 4 0.9). The proportion of Medicare insurance increased in both adopters and nonadopters, whereas private insurance declined (Figs. 2 and 3). The rate of transplant at one year from listing in the Medicaid population was 54 per cent in 2010 and 49 per cent in 2015. This rate in the general HTx population was 55 per cent in 2010 and 51 per cent in 2015.

For Medicaid patients listed during 2014-2016, waiting list survival at one year was 93 per cent, which was significantly better than patients listed in 2010 to 2013 (87%, P < 0.0001) (Fig. 4). The posttransplant patient survival in the aforementioned groups was 96 per cent and 97 per cent at 30 days and 89 per cent and 90 per cent at one year (Fig. 5).

Lung

A total of 2267 patients were listed for HTx (lung transplant (LuTx)) in 2010 which increased by 16 per cent to 2634 in 2016 (Fig. 1). During this period, the proportion of patients listed with Medicare increased from 33 per cent to 41 per cent, Medicaid increased from 8 per cent to 9 per cent, and private insurance declined from 56 per cent to 47 per cent. When evaluating insurance distribution by states that adopted Medicaid expansion versus states that did not, the Medicaid proportion increased from 8 per cent to 10 per cent (P 4 0.01) in adopters and decreased from 8 per cent to 7 per cent (P 4 0.4) in nonadopter states (between 2010 and 2016). The proportion of Medicare insurance increased in both adopters and nonadopters, whereas private insurance declined (Figs. 2 and 3). The rate of transplant at one year from listing in the Medicaid population was 64 per cent in 2010 and 65 per cent in 2015. This rate in the general LuTx population was 63 per cent in 2010 and 71 per cent in 2015.

For Medicaid patients listed during 2014 to 2016, waiting list survival at one year was 88 per cent, which was significantly better than patients listed in 2010 to 2013 (79%, P 4 0.04) (Fig. 4). The posttransplant patient survival in the aforementioned groups was 96 per cent and 96 per cent at 30 days and 89 per cent and 86 per cent at one year (Fig. 5).

Discussion

Most of the increase in insurance observed after the enactment of the ACA was seen through the expansion of Medicaid, which was adopted by 32 of the 50 states.9 The four most commonly transplanted organs (kidney, liver, heart, and lung) showed an increase in the number of patients listed across all insurance types during the study period (2010-2016); however, the change in proportion of each insurance type (by year) was variable especially based on the adoption of Medicaid expansion.6

The states that adopted Medicaid expansion under the ACA had an increase of 2 to 4 per cent points in the proportion of Medicaid patients listed for transplant between 2010 and 2016, whereas in states that did not adopt the expansion, the proportion of Medicaid patients listed was unchanged during the same period. Apart from Medicaid, the adopter states had significant increases in the proportion of Medicare patients listed across all organ types except the kidney. Between 2010 and 2016, the adopter states had a decline in proportion of private insurance across all organ types except the kidney (unchanged). Distribution of insurance in nonadopter states relatively stayed same during the study period, or had a marginal decline in private insurance, and an increase in Medicare. The proportion of patients listed aged >65 years also increased during the study period (2010-2016) across all organ types, (kidney, 17-19%, liver, 12-20%, heart, 15-19%, and lung, 23-29%) which may explain the increase in proportion of Medicare patients.

Patients had better unadjusted waiting list survival at 30 days and one year in the years after the ACA (2014-2016) compared with the years preceding ACA (2010-2013) within the respective organ types and all insurance types; however, this improvement was more noticeable in Medicaid population compared with other insurance types (Fig. 4). The posttransplant survival at one year was not significantly different within the respective organ types before and after the enactment of ACA. Although the expansion of Medicaid may have had an impact, the improved waiting list survival in recent years is likely multifactorial because of improvements in the pretransplant care of patients (Fig. 5).

The overall distribution of insurance showed that the proportion of government-sponsored insurance (i.e. Medicaid, Medicare, and VA benefits) now accounts for 50 per cent or more of all patients listed for transplant across all organ types except the liver. Listing of patients for LiTx has seen a remarkable drop in use of private insurance from 59 per cent in 2010 to 52 per cent in 2016. Medicaid expansion and increases in Medicare patients are central elements responsible for the gradual increase in government sponsored insurance proportion.

Conclusion

The payer mix in the transplant insurance market is gradually shifting toward government-sponsored insurances. States that adopted Medicaid expansion after the enactment of ACA have significantly higher proportion of transplant patients listed with Medicaid and Medicare, and significantly lower proportion of patients listed with private insurance. Short-term patient survival on the waiting list has improved in the years after enactment of the Affordable Care Act, which is likely based on a variety of factors including Medicaid expansion. Posttransplant survival in pre- and post-ACA era is still comparable.

Acknowledgments

This work was supported in part by the Health Resources and Services Administration contract 234-2005-37011C. The content is the responsibility of the authors alone and does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. Authors have no other relevant financial disclosures.