Reexamining the Impact of Insurance Type on Kidney Transplant Waitlist Status and Posttransplantation Outcomes in the United States After Implementation of the Affordable Care Act

Abstract

Background. Insurance type, a marker of socioeconomic status, has been associated with poor access to kidney transplant (KT) and worse KT outcomes before the implementation of the Affordable Care Act (ACA) and the revised Kidney Allocation System (KAS). In this study, we assessed if insurance type remained a risk marker for worse waitlist and transplant outcomes after ACA and KAS. Methods. Using Scientific Registry of Transplant Recipients data, we assessed insurance type of waitlisted candidates pre- (2008–2014) versus post- (2014–2021) KAS/ACA using chi-square tests. Next, we performed a competing risk analysis to study the effect of private versus public (Medicare, Medicaid, or government-sponsored) insurance on waitlist outcomes and a Cox survival analysis to study posttransplant outcomes while controlling for candidate, and recipient and donor variables, respectively. Results. The proportion of overall KT candidates insured by Medicaid increased from pre-KAS/ACA to post-KAS/ACA (from 12 667 [7.3%] to 21 768 [8.8%], P < 0.0001). However, KT candidates with public insurance were more likely to have died or become too sick for KT (subdistribution hazard ratio [SHR] = 1.33, confidence interval [CI], 1.30-1.36) or to receive a deceased donor KT (SHR = 1.57, CI, 1.54-1.60) but less likely to receive a living donor KT (SHR = 0.87, CI, 0.85-0.89). Post-KT, KT recipients with public insurance had greater risk of mortality (relative risks = 1.22, CI, 1.15-1.31) and allograft failure (relative risks = 1.10, CI, 1.03-1.29). Conclusions. Although the implementation of ACA marginally increased the proportion of waitlisted candidates with Medicaid, publicly insured KT candidates remained at greater risk of being removed from the waitlist, had lower probability of living donor kidney transplantation, and had greater probability of dying post-KT and allograft failure. Concerted efforts to address factors contributing to these inequities in future studies are needed, with the goal of achieving equity in KT for all.

Comparison Between Black Non‐Hispanic and White Non‐Hispanic Simultaneous Pancreas‐Kidney Transplant Candidates and Recipients

“…Additionally, in a systematic review conducted by Lu et al [14], several studies revealed structural racism and biases, which include racial profiling by clinicians and providers, and social determinants of health, such as poor neighborhoods and built environmental conditions, contributed to lower access to kidney transplantation among Black patients. Across studies, various socioeconomic variables, such as low income, neighborhood poverty, publicly funded insurance, limited levels of knowledge regarding the transplantation process, and logistical issues, such as lack of transportation and far distance to transplant centers, have consistently been associated with disparities in access to transplant in the Black population, despite Black patients demonstrating more serious disease status compared to White patients [15][16][17][18][19][20].…”