Not All Coverage Is Equal: State-Level Medicaid Eligibility Drives Waitlist and Survival Outcomes for Pediatric
Yusuf Ciftci1, Vina L Nguyen1, Sarah Shan1
1Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Background:
Medicaid expansion (ME) improves access to and survival after pediatric LT. The association between citizenship status, ME, waitlist, and survival outcomes has not been studied.
Methods:
Pediatric LT candidates and recipients from 2005 to 2023 in the UNOS database were identified and divided based on state ME status, broad Medicaid eligibility for non-citizens, and citizenship status at the time of listing or LT. Study outcomes included 1-year transplant probability and waitlist mortality, and 1-, 5-, and 10-year overall survival (OS) and graft survival (GS).
Results:
There were 10 753 waitlist candidates in the national cohort (10 364 citizens, 389 non-citizens) and 4356 waitlist candidates in broad eligibility states (4152 citizens, 204 non-citizens). After ME, there were no significant differences in transplant probability and significantly lower waitlist mortality for citizens. Similar trends were observed for non-citizens. There were larger relative improvements in transplant probability (0.8% vs. 9.2%) and waitlist mortality (54.3% vs. 77.1%) for non-citizens in broad eligibility states compared to the national cohort after ME. There were 7264 recipients in the national cohort (7096 citizens, 168 non-citizens) and 2806 recipients in broad eligibility states (2710 citizens, 96 non-citizens). Nationally, citizens had improved post-LT survival, while non-citizens trended toward improved post-LT survival after ME. Similar trends were observed in broad eligibility states.
Conclusions:
ME is associated with improved outcomes for citizens, while similar trends were observed for non-citizens. Non-citizens in broad-eligibility states had larger improvements in outcomes. State-level Medicaid eligibility is an important driver of outcomes for non-citizen children.
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