Was the expansion of Medicaid under the Affordable Care Act (ACA) associated with lower mortality for persons with end-stage renal disease?
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.
Among patients with end-stage renal disease initiating dialysis, the ACA Medicaid expansion was associated with significant improvements in 1-year survival.
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.
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.
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.
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.
Swaminathan S, Sommers BD, Thorsness R, Mehrotra R, Lee Y, Trivedi AN. Association of Medicaid Expansion With 1-Year Mortality Among Patients With End-Stage Renal Disease. JAMA. 2018;320(21):2242–2250. doi:10.1001/jama.2018.16504
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