Medicaid Expansion Association With End‐Stage Liver Disease Mortality Depends on Leniency of Medicaid Hepatitis C Virus Coverage

Abstract

The Affordable Care Act expanded Medicaid around the same time that direct‐acting antivirals became widely available for the treatment of hepatitis C virus (HCV). However, there is significant variation in Medicaid HCV treatment eligibility criteria between states. We explored the combined effects of Medicaid expansion and leniency of HCV coverage under Medicaid on liver outcomes. We assessed state‐level end‐stage liver disease (ESLD) mortality rates, listings for liver transplantation (LT), and listing‐to‐death ratios (LDRs) for adults aged 25 to 64 years using data from United Network for Organ Sharing and Centers for Disease Control and Prevention Wide‐Ranging Online Data for Epidemiologic Research. States were divided into 4 nonoverlapping groups based on expansion status on January 1, 2014 (expansion versus nonexpansion) and leniency of Medicaid HCV coverage (lenient versus restrictive coverage). Joinpoint regression analysis evaluated the significant changes in slope over time (joinpoints) during the pre‐expansion (2009‐2013) and postexpansion (2014‐2018) time periods. We found significant changes in the annual percent change for population‐adjusted ESLD deaths between 2014 and 2015 in all cohorts except for the nonexpansion/restrictive cohort, in which deaths increased at the same annual percent change from 2009 to 2018 (annual percent change of +2.5%; 95% confidence interval [CI], 1.8‐3.3]). In the expansion/lenient coverage cohort, deaths increased at an annual percent change of +2.6% (95% CI, 1.8‐3.5) until 2014 and then tended to decrease at an annual percent change of −0.4% (95% CI, −1.5 to 0.8). LT listings tended to decrease over time for all cohorts. For LDRs, only the expansion/lenient and expansion/restrictive cohorts had statistically significant joinpoints. Improvements in ESLD mortality and LDRs were associated with both Medicaid expansion and leniency of HCV coverage under Medicaid. These findings suggest the importance of implementing more lenient and widespread public health insurance to improve liver disease outcomes, including mortality.

Patients Hospitalized for Complications of Cirrhosis may Have Benefited From Medicaid Expansion Under the Affordable Care Act

“…We also factored into the analysis the effect of increased availability of directly acting hepatitis C virus (HCV) antiviral treatment because the clearance of the virus may be associated with lower risks of complications of cirrhosis and, therefore, reduced hospitalization risk. 12 …”

Cancer statistics forAmericanIndian andAlaskaNative individuals, 2022: Including increasing disparities in early onset colorectal cancer

“…However, these drugs are expensive and unaffordable for many in the AIAN community because of the high prevalence of poverty and low insurance coverage (Table 1). Furthermore, many state Medicaid programs have restrictive requirements for HCV treatment, exacerbating disparities in liver cancer and other viral hepatitis‐related liver diseases 177 . The USPSTF recently expanded the recommendation of one‐time testing for HCV infection to all adults aged 18–79 years (from only those born during 1945 through 1965) to reduce the burden of disease in the United States 178 .…”

Does Liver Transplant Center Size Matter? Center Size Disparities and the Unintended Consequences of Transplant Regulation—A Commentary

“…12 In addition, availability of Medicaid coverage for direct-acting antivirals improves pretransplant mortality in HCV patients. 13 Finally, a major impetus of the recently implemented Acuity Circles allocation system has been the normalization of the geographic disparities in liver transplantation. The data from this article predates the recently adopted allocation changes, but it suggests geographic disparities may extend beyond regional borders.…”

“…12 In addition, availability of Medicaid coverage for direct- acting antivirals improves pretransplant mortality in HCV patients. 13…”