title: Insurance Type and Solid Organ Transplantation Outcomes: A Historical Perspective on How Medicaid Expansion Might Impact Transplantation Outcomes.
abstract: The number of Medicaid beneficiaries has increased under the Affordable Care Act, improving access to solid organ transplantation in this disadvantaged patient cohort. It is unclear what impact Medicaid expansion will have on transplantation outcomes. We performed a retrospective cohort analysis to measure the frequency and variation in Medicaid transplantation and post-transplantation survival in Medicaid patients.
  
  
  
  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). Outcomes measures included 5-year post-transplantation 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.
  
  
  
  Medicaid patients comprised 8.6% of all organ transplant recipients. Fewer transplantations were performed than expected among Medicaid beneficiaries for all organs except liver (liver: observed to expected ratio = 1.21; 95% CI, 0.68-1.90; heart: observed to expected ratio = 0.89; 95% CI, 0.44-1.49; lung: observed to expected ratio = 0.57; 95% CI, 0.22-1.06; renal: observed to expected ratio = 0.32; 95% CI, 0.08-0.72). Medicaid transplant recipients were listed with more severe organ failure and experienced shorter transplant wait times. Post-transplantation survival was lower in Medicaid patients compared with private insurance for all organs. Post-transplantation survival in Medicaid patients was similar to Medicare patients for heart, liver, and renal but lower in lung.
  
  
  
  Medicaid organ transplant beneficiaries had significantly lower survival compared with privately insured beneficiaries. The more severe organ failure among Medicaid beneficiaries at the time of listing, suggested a pattern of late referral, which might account for worse outcomes. Implementation of the Affordable Care Act gives the opportunity to develop the necessary infrastructure to ensure timely transplantation referrals and improve long-term outcomes in this vulnerable population.
authors.affiliation: Department of Surgery-Transplantation, University of Alabama at Birmingham, Birmingham, AL. Electronic address: ddubay@uabmc.edu.
authors.forename: Derek A
authors.initials: DA
authors.lastname: DuBay
authors.affiliation: Department of Surgery-Transplantation, University of Alabama at Birmingham, Birmingham, AL.
authors.forename: Paul A
authors.initials: PA
authors.lastname: MacLennan
authors.affiliation: Department of Surgery-Transplantation, University of Alabama at Birmingham, Birmingham, AL.
authors.forename: Rhiannon D
authors.initials: RD
authors.lastname: Reed
authors.affiliation: Department of Surgery-Transplantation, University of Alabama at Birmingham, Birmingham, AL.
authors.forename: Brittany A
authors.initials: BA
authors.lastname: Shelton
authors.affiliation: School of Public Health-Biostatistics, University of Alabama at Birmingham, Birmingham, AL.
authors.forename: David T
authors.initials: DT
authors.lastname: Redden
authors.affiliation: Department of Medicine-Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL.
authors.forename: Mona
authors.initials: M
authors.lastname: Fouad
authors.affiliation: Department of Medicine-Preventive Medicine, University of Tennessee, Memphis, TN.
authors.forename: Michelle Y
authors.initials: MY
authors.lastname: Martin
authors.affiliation: Department of Surgery-Transplantation, University of Alabama at Birmingham, Birmingham, AL.
authors.forename: Stephen H
authors.initials: SH
authors.lastname: Gray
authors.affiliation: Department of Surgery-Transplantation, University of Alabama at Birmingham, Birmingham, AL.
authors.forename: Jared A
authors.initials: JA
authors.lastname: White
authors.affiliation: Department of Surgery-Transplantation, University of Alabama at Birmingham, Birmingham, AL.
authors.forename: Devin E
authors.initials: DE
authors.lastname: Eckhoff
authors.affiliation: Department of Surgery-Transplantation, University of Alabama at Birmingham, Birmingham, AL.
authors.forename: Jayme E
authors.initials: JE
authors.lastname: Locke
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D005500:Follow-Up Studies; D006297:Health Services Accessibility / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008484:Medicaid / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data*; D008875:Middle Aged; D016377:Organ Transplantation / Q000191:economics / Q000401:mortality* / Q000706:statistics & numerical data*; D017063:Outcome Assessment, Health Care; D058991:Patient Protection and Affordable Care Act; D012042:Registries; D012189:Retrospective Studies; D016019:Survival Analysis; D014481:United States / Q000453:epidemiology