Implementation of the Affordable Care Act and Solid-Organ Transplantation Listings in the United States

The Affordable Care Act (ACA) was designed to facilitate health care access for underinsured and uninsured patients via Medicaid expansion and the insurance exchange market.¹ As of September 2015, an estimated 17.6 million individuals enrolled through the ACA, with a total 35% reduction in the number of uninsured.² Because heart transplantation in the United States has largely excluded uninsured patients,³ we hypothesized that implementation of the ACA would result in increased transplant listings. We therefore investigated patterns of heart, liver, and kidney listings related to the implementation of the ACA.

Using the United Network for Organ Sharing registry, we compared listings for heart, liver, and kidney transplantation during identical periods before (from January 1, 2012, to September 30, 2013)⁴ and after implementation of the ACA (from January 1, 2014, to September 30, 2015) in states that adopted Medicaid expansion (n = 25, including the District of Columbia) or did not adopt Medicaid expansion (n = 21). Five states were excluded because Medicaid expansion was implemented after January 1, 2014.⁴ Percent changes of listed patients were compared using the χ² test, with P < .05 considered statistically significant. Institutional review board approval was waived because the data in the United Network for Organ Sharing are public and deidentified.

Solid-organ transplant listings increased by 1850 (2%) from 88 111 to 89 961 in the pre- and post-ACA periods. The impact on transplant listings was organ-specific: heart transplants increased by 17% (from 5670 to 6607), liver transplants by 2% (from 19 360 to 19 697), and kidney transplants by 1% (from 63 081 to 63 657).

Increases in total organ listings did not significantly differ in ACA vs non-ACA states (738 [1.6%] vs 1003 [3.0%]; P = .10). Heart transplant listings increased significantly more in ACA states than non-ACA states (569 [21%] vs 279 [12%]; P = .02), with a trend for a lesser increase in kidney transplant listings (429 [2%] vs 30 [0%]; P = .05) but not liver transplant listings (139 [1%] vs 232 [3%]; P = .21).

There was a significant increase in organ listings of Medicaid patients in ACA compared with non-ACA states (1169 [23%] vs 94 [5%]; P < .001): heart (86 [22%] vs 4 [2%]; P = .08), liver (373 [21%] vs 8 [1%]; P = .001), and kidney (710 [25%] vs 82 [8%]; P = .003). Fewer Medicare patients were listed overall, but this was less prominent in ACA states (−441 [−3%] vs −967 [−6%]; P = .01) (Figure). Also, the number of privately insured patients listed increased only in non-ACA states (8 [0%] vs 1345 [9.3%]; P < .001).

There is emerging evidence that Medicaid expansion through the implementation of the ACA is associated with an increase in the number of heart transplant listings. We believe that these data support our hypothesis that the ACA allows previously uninsured patients enhanced access to heart transplantation. While there has been a clear increase in the number of heart transplant listings, it is intriguing to speculate that the lack of a similar increase in the number of kidney transplant listings may reflect the effect of previously mandated federal insurance programs limited to patients with end-stage renal disease on dialysis. Similarly, the findings related to liver transplantation may result from lower incidence of liver failure because of the effectiveness of novel treatment of hepatitis C, traditionally the most common cause for liver transplantation in the United States.⁵

It is important to note, however, that the number of heart transplant listings also increased in non-ACA states, suggesting that this may be influenced by factors other than ACA status. For example, the disproportionate increase in the number of heart transplant listings compared with other organs may be partly related to the expansion of durable ventricular assist device programs across the country, enabling more patients to live long enough to be listed.

Nevertheless, ACA-driven expansion of heart transplants may not necessarily result in better outcomes because low socioeconomic status and Medicaid insurance have been associated with lower rates of survival among patients who underwent a solid-organ transplant.⁶ Finally, longer transplant lists will potentially exacerbate the donor shortage crisis, making expansion of donor pools and reexamination of organ allocation strategies even more urgent.

Corresponding Author: Guilherme H. Oliveira, MD, Advanced Heart Failure Center, Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Ave, LKS 3012, Cleveland, OH 44106 (guilherme.oliveira@uhhospitals.org).

Published Online: August 3, 2016. doi:10.1001/jamacardio.2016.2067.

Author Contributions: Dr Oliveira had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Oliveira and Al-Kindi contributed equally.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: Oliveira, Al-Kindi.

Drafting of the manuscript: Oliveira, Al-Kindi.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Al-Kindi.

Study supervision: Oliveira, Simon.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.