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Clin J Am Soc Nephrol. 2018 Jul 6;13(7):1069-1078. doi: 10.2215/CJN.00100118. Epub 2018 Jun 21.

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

Author information

Division of Nephrology and Hypertension, Department of Medicine, and
Epidemiology and Biostatistics and.
Health Management and Policy, Drexel University Dornsife School of Public Health, Philadelphia, Pennsylvania.
Division of Nephrology and Hypertension, Department of Medicine, and.
Division of Multi-Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania; Departments of.
Palliative and Advanced Illness Research Center and.
Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, and.
Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; and.
Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Pennsylvania.



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.


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.


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).


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; Logistic Models; Medicaid; Patient Protection and Affordable Care Act; Renal Insufficiency, Chronic; Retrospective Studies; United States; kidney transplantation; renal dialysis

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