Affordable Care Act’s Medicaid Expansion Improves Liver Transplant Waitlist Placement, Especially for Certain Minorities

Media Contact: Caroline Laurin
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Alexandria, VA – Data from a new study presented this week at The Liver Meeting Digital Experience® – held by the American Association for the Study of Liver Diseases – found that U.S. states that took part in the Affordable Care Act’s Medicaid expansion, which extended health care coverage to more low-income citizens, improved liver transplant waitlist placement, especially for certain racial groups.

One of the original goals of the Affordable Care Act (ACA) was to improve health equity and access to care by expanding Medicaid in states. So far, only some states have participated in this expansion of insurance coverage to more low-income residents. To assess the impact of expansion, a group of researchers compared expansion and non-expansion states by looking at waitlist placement for liver.

"Prior literature has demonstrated improvement in health inequity resulting from ACA Medicaid expansion in a variety of domains throughout health care. However, despite the well-documented inequities and disparities in liver transplantation, there has been no compelling study to date that has been able to demonstrate measurable gains in liver disease care resulting from ACA Medicaid expansion," says the study’s co-author, Nabeel Wahid, MD, an internal medicine resident at New York Presbyterian Hospital/Cornell Weill Medicine in New York, N.Y. "Our goal was to understand the impact that early ACA Medicaid expansion had on end-stage liver disease (ESLD) mortality, listings for liver transplantation and racial disparities in liver diseases."

The study included data from transplant centers in 18 states that expanded Medicaid on Jan. 1, 2014, compared to a control group of centers in 14 states that did not expand coverage during the study period. The researchers also compared data from 2009-2013 to 2014-2018 to assess the impact of Medicaid expansion. The study’s primary outcome was listing-to-death ratio (LDR), or how effectively states waitlisted patients for a liver transplant compared to deaths from ESLD. Liver transplant waitlist data came from the United Network for Organ Sharing (UNOS) database. ESLD mortality figures came from the U.S. Centers for Disease Control and Prevention (CDC) WONDER database. The researchers also analyzed year-to-year trends and annual percentage change (APC) to see if Medicaid expansion had a delayed impact on care. They also evaluated the impact on racial disparities in subgroup analysis.

The researchers found that LDR was significantly greater in participating states compared to non-participating states both before and after expansion. Starting one year after early ACA Medicaid expansion (2015), the annual percent change in LDR increased in expansion states only, primarily due to improvements in ESLD deaths (lower denominator) rather than increased listings (higher numerator). While ESLD deaths continued to increase throughout the study period in non-expansion states, ESLD deaths in expansion states started to slowly decline in expansion states one year after expansion. Whites, African Americans and Asians saw more notable improvements in liver disease care within expansion states than in non-expansion states.

States that expanded Medicaid under the ACA had more effective waitlist placement for liver transplants compared to states that did not expand Medicaid. It took a whole year for this positive impact to be appreciated, a delay that reflects the months that it typically takes for liver transplant patients to be identified, evaluated and listed, the researchers noted.

"In a time of increasing national-level attention on health care policy, our findings demonstrate tangible impacts on liver disease care attributable to Medicaid expansion which could be used to drive future health care policy changes," says Dr. Wahid.

Editor’s Note: This study is ongoing, and updated data will be presented at The Liver Meeting Digital Experience™

Dr. Nabeel Wahid will present these findings at The Liver Meeting Digital Experience™ during Parallel: Health Services Research and Public Health on November 16 at 10:30 AM ET. The corresponding abstract, "Affordable Care Act Medicaid Expansion Improved Liver Transplant Waitlist Placement and Slowed Racial Disparities" can be found in the journal, HEPATOLOGY.

About the AASLD
AASLD is the leading organization of clinicians and researchers committed to preventing and curing liver disease. The work of our members has laid the foundation for the development of drugs used to treat patients with viral hepatitis. Access to care and support of liver disease research are at the center of AASLD’s advocacy efforts.