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Original Investigation
December 4, 2018

Association of Medicaid Expansion With 1-Year Mortality Among Patients With End-Stage Renal Disease

Author Affiliations
  • 1Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
  • 2Providence VA Medical Center, Providence, Rhode Island
  • 3Public Health Foundation of India, New Delhi, India
  • 4SRM University, Amaravati, India
  • 5Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
  • 6Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
  • 7Department of Medicine, University of Washington School of Medicine, Seattle
JAMA. 2018;320(21):2242-2250. doi:10.1001/jama.2018.16504
Key Points

Question  Was the expansion of Medicaid under the Affordable Care Act (ACA) associated with lower mortality for persons with end-stage renal disease?

Findings  In this observational study of 236 246 nonelderly patients with end-stage renal disease initiating dialysis comparing mortality between the preexpansion period and the postexpansion period, the change in 1-year mortality among patients in Medicaid expansion states compared with those in nonexpansion states was −0.8% vs −0.2%, a difference that was statistically significant.

Meaning  Among patients with end-stage renal disease initiating dialysis, the ACA Medicaid expansion was associated with significant improvements in 1-year survival.


Importance  The Affordable Care Act Medicaid expansion may be associated with reduced mortality, but evidence to date is limited. Patients with end-stage renal disease (ESRD) are a high-risk group that may be particularly affected by Medicaid expansion.

Objective  To examine the association of Medicaid expansion with 1-year mortality among nonelderly patients with ESRD initiating dialysis.

Design, Setting, and Participants  Difference-in-differences analysis of nonelderly patients initiating dialysis in Medicaid expansion and nonexpansion states from January 2011 to March 2017.

Exposure  Living in a Medicaid expansion state.

Main Outcomes and Measures  The primary outcome was 1-year mortality. Secondary outcomes were insurance, predialysis nephrology care, and type of vascular access for hemodialysis.

Results  A total of 142 724 patients in expansion states (mean age, 50.2 years; 40.2% women) and 93 522 patients in nonexpansion states (mean age, 49.7; 42.4% women) were included. In Medicaid expansion states, 1-year mortality following dialysis initiation declined from 6.9% in the preexpansion period to 6.1% after expansion (change, −0.8 percentage points; 95% CI, −1.1 to −0.5). In nonexpansion states, mortality rates were 7.0% before expansion and 6.8% after expansion (change, −0.2 percentage points; 95% CI, −0.5 to 0.2), yielding an adjusted absolute reduction in mortality in expansion states of −0.6 percentage points (95% CI, −1.0 to −0.2). Mortality reductions were largest for black patients (−1.4 percentage points; 95% CI, −2.2, −0.7; P=.04 for interaction) and patients aged 19 to 44 years (−1.1 percentage points; 95% CI, −2.1 to −0.3; P=.01 for interaction). Expansion was associated with a 10.5-percentage-point (95% CI, 7.7-13.2) increase in Medicaid coverage at dialysis initiation, a −4.2-percentage-point (95% CI, −6.0 to −2.3) decrease in being uninsured, and a 2.3-percentage-point (95% CI, 0.6-4.1) increase in the presence of an arteriovenous fistula or graft. Changes in predialysis nephrology care were not significant.

Conclusions and Relevance  Among patients with ESRD initiating dialysis, living in a state that expanded Medicaid under the Affordable Care Act was associated with lower 1-year mortality. If this association is causal, further research is needed to understand what factors may have contributed to this finding.