Kern, Q., Shorbaji, K., Gibney, B., Paoletti, L., Whelan, T., Kilic, A., and Hashmi, Z.
The Affordable Care Act's (ACA) Medicaid expansion (ME) has expanded Medicaid coverage to nearly all adults with incomes up to 138% of the Federal Poverty Level ($17,774 for an individual in 2021) and provided states with an enhanced federal matching rate for their expansion populations. To date, 38 states have adopted the Medicaid expansion. We sought to evaluate lung waitlist and transplantation outcomes in states that have adopted ME. The United Network for Organ Sharing (UNOS) registry was used to identify all isolated adult lung waitlist and transplant patients between January 2010 and June 2022. Patients in states that have adopted ME were divided into pre-ME and post-ME groups based on each state's ME adoption date. Patients in states that have not adopted ME were excluded. Primary outcomes were center waitlisting and transplantation volumes, patient waitlist time and 1-year post-transplantation mortality. Kaplan-Meier and multivariable Cox proportional hazards models were used for unadjusted and risk-adjusted analyses, respectively. A total of 18,473 lung transplant patients were waitlisted and 18,704 were transplanted in states that have adopted ME within the study period [Waitlist: (patients pre-ME: 5,470 patients vs. post-ME: 13,003 patients), Transplantation: (pre-ME: 6,010 patients vs. post-ME: 12,694)]. There was an increase in annual center volumes of both waitlisting (pre-ME: 53.65±35.19 patients vs. post-ME: 58.46±33.92, p<0.001) and transplantation (pre-ME: 52.64±33.83 patients vs. post-ME: 59.97±34.93, p<0.001) [Figure 1]. Patient waitlist time was significantly decreased post-ME (pre-ME: 56 days [17, 153] vs. post-ME 48 days [14, 151], p=0.004). In an unadjusted analysis, patients transplanted post-ME had a higher 1-year survival rate (pre-ME: 87.1 % vs. post-ME 88.6 %, log-rank p = 0.002). In a risk-adjusted analysis, the Hazard Ratio (HR) of 1-year post-transplantation mortality in post-ME patients was 0.79 (0.70-0.88, p<0.001). States that have adopted the 2014 Affordable Care Act's Medicaid expansion demonstrated an increase in lung waitlisting and transplantation volumes. Patients waitlist time and mortality outcomes have significantly improved. Results suggest that states that have not adopted Medicaid expansion yet may need to consider it. [ABSTRACT FROM AUTHOR]