Impact of ACA Medicaid Expansion on Heart Transplant Listings in Minorities

Study Questions:

Is the Affordable Care Act (ACA) Medicaid Expansion associated with increased census-adjusted heart transplant listing rates for racial/ethnic minorities?

Methods:

The study investigators analyzed 5,651 patients from early adopter states (implemented the ACA Medicaid Expansion by January 2014) and 4,769 patients from nonadopter states (no implementation during the study period) from 2012 to 2015. They derived these data from the Scientific Registry of Transplant Recipients. The primary outcome of interest was the monthly census-adjusted rate of heart transplant listing before and after January 2014. The latter data, stratified according to race/ethnicity, was fit to piecewise linear models.

Results:

The majority of patients listed for transplant were Caucasian in both the early adopter and nonadopter states (62.8% and 60.2%, respectively), followed by African-American patients (20.9% and 29.3%) and Hispanic patients (9.7% and 7.8%). A 30% increase in the rate of heart transplant listings for African-American patients in early adopter states occurred immediately after the ACA Medicaid Expansion on January 1, 2014 (before 0.15 to after 0.20/100,000; increase 0.05/100,000; 95% confidence interval [CI], 0.01-0.08), whereas the rates for African-American patients in nonadopter states remained constant (before and after 0.15/100,000; increase 0.006/100,000; 95% CI, –0.03 to 0.04). The trend was opposite in Hispanic patients, with no significant change in early adopter states (before 0.03 to after 0.04/100,000; increase 0.01/100,000; 95% CI, –0.004 to 0.02) and a significant increase in nonadopter states (before 0.03 to after 0.05/100,000; increase 0.02/100,000; 95% CI, 0.002-0.03). There were no significant changes in listing rates among Caucasian patients in either early adopter states or nonadopter states (early adopter—before 0.08 to after 0.09; increase 0.004/100,000; 95% CI, –0.01 to 0.02; nonadopter—before and after 0.08; increase 0.01/100,000; 95% CI, –0.001 to 0.03). Heart transplant listing rates stabilized after initial changes post-ACA Medicaid Expansion. From 2014 to 2015, the rate of change over time was similar within each race/ethnicity.

Conclusions:

The authors concluded that ACA Medicaid Expansion was associated with a significant increase in heart transplant listings in African-American patients, but not among Hispanic or Caucasian patients.

Perspective:

This is an important paper because it demonstrates the beneficial impact of ACA Medicaid Expansion on heart transplant listings in African-American patients who are two- to three-fold more likely to have HF, and at a younger age than the Caucasian population. It would be interesting to know whether this beneficial impact also occurred in financially underprivileged individuals irrespective of ethnic background. Hopefully this paper would reach the desks of lawmakers who are currently in the process of replacing the ACA so that they can retain important desirable elements of this legislation, as shown by this study.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Cardiac Surgery and Heart Failure, Acute Heart Failure, Heart Transplant

Keywords: African Americans, Ethnic Groups, Health Policy, Heart Failure, Heart Transplantation, Hispanic Americans, Medicaid, Patient Protection and Affordable Care Act, Transplantation


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