Medicaid Expansion and its Association With Liver Transplant Outcomes in Adults

Background. We previously found that Medicaid expansion improved outcomes in pediatric liver transplantation. In this study, we examined whether Medicaid expansion was associated with improved adult liver transplant outcomes over a 10-y period. Methods. Using the Scientific Registry of Transplant Recipients database, we analyzed adults who received liver transplants between January 1, 2010, and December 31, 2020. The primary outcomes were posttransplant graft survival and patient survival. Medicaid expansion status was treated as a time-varying covariate. Cox regression was used to evaluate the relationship between Medicaid expansion, insurance type, and other socioeconomic factors with all-cause graft failure. Results. 65,856 adult transplant recipients were included. Seventy-one percent of recipients were in states that implemented Medicaid expansion during the study period. The median age at transplant was 58 y, 85% were White, and 34% were female. Fifty-three percent of patients had private insurance, 29% Medicare and 15% Medicaid. Medicaid expansion was associated with an 8% decreased risk of graft failure/death (HR 0.92; CI, 0.89-0.96; P < 0.001) after adjustment. This effect was greater in patients who had not yet qualified for Medicare, with a 10% decreased risk of graft failure/death (HR 0.90; CI, 0.86-0.93; P < 0.001). In a sensitivity analysis, comparing pre- and postexpansion outcomes over a 3-y period in states that expanded Medicaid, there was a 15% decrease in the risk of graft failure/death (HR, 0.85; CI, 0.80-0.91; P < 0.001). Conclusions. Medicaid expansion was associated with improved outcomes. This suggests that broader access to comprehensive and continuous health insurance may improve long-term outcomes following liver transplantation.