Medicaid Expansion Tied to Lower Mortality Among Young Adults With Kidney Failure

Medicaid expansion under the Affordable Care Act (ACA) was linked to lower 1-year mortality among young adults with kidney failure who were starting dialysis, a cohort study suggested.

One-year mortality declined from 3.6% before Medicaid expansion to 2.1% after the expansion among 19- to 23-year-olds, while among 14- to 18-year-olds, who presumably would be minimally affected by the expansion, 1-year mortality went from 0.7% pre-expansion to 1.1% post-expansion, reported Shailender Swaminathan, PhD, of Brown University in Providence, Rhode Island, and colleagues.

The adjusted difference-in-difference estimate, representing the relative differences in outcomes between young adults and adolescents pre- and post-expansion, was -1.8 percentage points (95% CI -2.9 to -0.7), they noted in JAMA Pediatrics.

“Medicaid expansion under the ACA was associated with a decline in 1-year mortality among young adults aged 19 to 23 years initiating dialysis, compared with adolescents aged 14 to 18 years not affected by the eligibility expansion,” Swaminathan and colleagues wrote.

These mortality reductions “underscore the critical importance of continued Medicaid coverage for children with serious health conditions transitioning into young adulthood,” they added. “It remains important to determine whether policies that curtail Medicaid funding or limit eligibility risk reversing these gains.”

Prior to the ACA, young adults had the highest rates of uninsurance in the U.S., Swaminathan and colleagues noted. Meanwhile, half of young adults have at least one chronic condition, and the transition between pediatric and adult care can be tied to poor outcomes and inadequate access.

Previous studies have shown that ACA coverage expansions lowered mortality among middle-aged adults, but to date, there has been limited evidence regarding the impact of these expansions on mortality among young adults.

The findings “support the mechanistic association between the ACA Medicaid expansion and health outcomes for adolescents and young adults,” wrote Alon Peltz, MD, and Jay Berry, MD, MPH, both of Boston Children’s Hospital, in an accompanying editorial.

“Regression of healthcare coverage and benefits previously enabled by the ACA could ensue, potentially affecting access to high-quality dialysis and related care for adolescents and young adults with chronic kidney disease as well as care for adolescents and young adults with other complex, chronic conditions,” they added.

Swaminathan and colleagues noted that mortality reductions from ACA coverage expansions “may be concentrated among young adults with high-risk clinical conditions where a lack of access to medical care could plausibly lead to immediate adverse consequences.” For instance, young adults facing kidney failure “have cardiovascular mortality rates that are up to 500 times greater than the age-matched general population,” they emphasized, and are “10 times more likely to lack insurance coverage at dialysis initiation compared with children initiating dialysis, and more than half receive no predialysis nephrology care.”

For their study, Swaminathan and colleagues examined changes in outcomes between 4,791 young adults age 19 to 23 years with kidney failure who were starting dialysis relative to 2,348 children age 14 to 18 years (a comparison group with unchanged eligibility) in states that expanded Medicaid eligibility under the ACA.

Among 19- to 23-year-olds, the proportion who were uninsured declined from 19.4% to 7.8% after Medicaid expansion, and the proportion with Medicaid coverage increased from 37.1% to 48.5%. Among 14- to 18-year-olds, those proportions were 4% vs 1.9% and 50.5% vs 54.3%, respectively. These resulted in an adjusted difference-in-difference estimate of -9.1 percentage points for uninsurance and 8.4 percentage points for Medicaid.

Rates of predialysis nephrology care among 19- to 23-year-olds increased from 57.4% pre-expansion to 66.1% post-expansion, and corresponding estimates for 14- to 18-year-olds were 73.7% and 77.8% (with a difference-in-difference estimate of 6.8 percentage points).

For both hours of hemodialysis (≥4 vs <4) and peritoneal dialysis (vs hemodialysis), the increase among 19- to 23-year-olds was greater than the increase among 14- to 18-year-olds, with difference-in-difference estimates of 9.9 percentage points and 8.9 percentage points, respectively. Difference-in-difference estimates for catheter (vs graft or fistula) use for hemodialysis and receipt of a kidney transplant within 1 year were not significant.

Limitations included that the study’s findings may not be generalizable to individuals with other chronic health conditions, Swaminathan and colleagues noted, and that data did not include information on all potential pathways by which insurance coverage may lead to lower mortality (i.e., access to medications, reduction of cardiovascular risk factors, and care coordination.)