Change in Health Insurance Coverage After Liver Transplantation Can Be Associated with Worse Outcomes
Health insurance coverage changes for many patients after liver transplantation, but the implications of this change on long-term outcomes are unclear.
To assess post-transplant patient and graft survival according to change in insurance coverage within 1 year of transplantation.
We queried the United Network for Organ Sharing for patients between ages 18–64 years undergoing liver transplantation in 2002–2016. Patients surviving > 1 year were categorized by insurance coverage at transplantation and the 1-year transplant anniversary. Multivariable Cox regression characterized the association between coverage pattern and long-term patient or graft survival.
Among 34,487 patients in the analysis, insurance coverage patterns included continuous private coverage (58%), continuous public coverage (29%), private to public transition (8%) and public to private transition (4%). In multivariable analysis of patient survival, continuous public insurance (HR 1.29, CI 1.22, 1.37, p < 0.001), private to public transition (HR 1.17, CI 1.07, 1.28, p < 0.001), and public to private transition (HR 1.14, CI 1.00, 1.29, p = 0.044), were associated with greater mortality hazard, compared to continuous private coverage. After disaggregating public coverage by source, mortality hazard was highest for patients transitioning from private insurance to Medicaid (HR vs. continuous private coverage = 1.32; 95% CI 1.14, 1.52; p < 0.001). Similar differences by insurance category were found for death-censored graft failure.
Post-transplant transition to public insurance coverage is associated with higher risk of adverse outcomes when compared to retaining private coverage.
KeywordsLiver transplantation Graft survival Human Medicaid Survival Insurance
End-stage liver disease
Model for end-stage liver disease
Patient Protection and Affordable Care Act
United States of America
United Network for Organ Sharing
Analysis of variance
Transjugular intrahepatic portosystemic shunt
Donor risk index
Length of stay
American College of Surgeons
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
- 1.Martin P, DiMartini A, Feng S, Brown R, Fallon M. Evaluation for liver transplantation in adults: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation. Hepatology. 2014;59:1144–1165. https://doi.org/10.1002/hep.26972.CrossRefPubMedGoogle Scholar
- 2.UNOS. Transplant trends | UNOS. https://www.unos.org/data/transplant-trends/, 2017. Accessed 21 Feb 2018.
- 7.National Coverage Determination (NCD) for Adult Liver Transplantation (260.1). https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCAId=259&NcaName=Liver+Transplantation+for+Malignancies&ExpandComments=n&CommentPeriod=0&NCDId=70&ncdver=3&id=186&bc=gABAAAAAEEAAAA%3d%3d&, 2017. Accessed 24 July 2017.
- 9.DuBay DA, MacLennan PA, Reed RD, et al. Insurance type and solid organ transplantation outcomes: a historical perspective on how medicaid expansion might impact transplantation outcomes. J Am Coll Surg. 2016;223:611–620.e614. https://doi.org/10.1016/j.jamcollsurg.2016.07.004.CrossRefPubMedPubMedCentralGoogle Scholar
- 20.@KaiserFamFound. Status of state action on the medicaid expansion decision. http://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/, 2017. Accessed 24 July 2017.
- 26.MACPAC. Examining access to care in medicaid and CHIP. https://www.macpac.gov/wp-content/uploads/2015/01/Examining_Access_to_Care_in_Medicaid_and_CHIP.pdf, 2011. Accessed 11 Aug 2017.
- 31.Breathett K, Allen LA, Helmkamp L, et al. The Affordable Care Act medicaid expansion correlated with increased heart transplant listings in African-Americans but not Hispanics or Caucasians. JACC Heart Fail. 2017;5:136–147. https://doi.org/10.1016/j.jchf.2016.10.013.CrossRefPubMedPubMedCentralGoogle Scholar
- 33.Puls MW. 2015 ACS governors survey: surgeons describe the ACA’s effects on access to care. The Bulletin. http://bulletin.facs.org/2016/05/2015-acs-governors-survey-surgeons-describe-the-acas-effects-on-access-to-care/, 2016. Accessed 14 Aug 2017.
- 42.@KaiserFamFound. Health insurance coverage of the total population. http://www.kff.org/other/state-indicator/total-population/, 2016. Accessed 15 Aug 2017.