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Heart transplant listings increased in black patients with ACA Medicaid expansion
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With the implementation of the Affordable Care Act’s Medicaid expansion, an increase in the rate of listings for heart transplants was seen among black patients, but no change was noted among Hispanic or white patients.
“Underinsurance limits access to transplants, especially among racial/ethnic minorities,” Khadijah Breathett, MD, from the division of cardiology at the University of Colorado, Anschutz Medical Campus, Aurora, and colleagues wrote.
The researchers examined whether changes were seen in heart transplant listing rates among racial and ethnic groups after the implementation of the Affordable Care Act’s (ACA) Medicaid expansion.
The researchers examined data on 5,651 patients in the Scientific Registry of Transplant Recipients in states that were considered early adopter states — defined as implementing the ACA Medicaid expansion by January 2014. Data on another 4,769 patients were examined from non-adopter states — defined as states that did not implement the ACA Medicaid expansion during the study period. The data were analyzed from 2012 to 2015.
Listings by race
In early adopter states, the rate of heart transplant listings increased significantly (30%) for black patients. This occurred directly after the ACA Medicaid expansion on Jan. 1, 2014 (0.15 per 100,000 people before to 0.2 per 100,000 people after; 0.05 per 100,000 increase; 95% CI, 0.01-0.08). Meanwhile, in non-adopter states, the rate of heart transplant listings for black patients stayed relatively the same (0.15 per 100,000 people before and after; 0.006 per 100,000 increase; 95% CI, –0.03 to 0.04).
In early adopter states, no significant change was seen for Hispanic patients (0.03 per 100,000 people before to 0.04 per 100,000 people after; 0.01 per 100,000 increase; 95% CI, –0.004 to 0.02) vs. non-adopter states, where a significant increase was noted (0.03 per 100,000 before to 0.05 per 100,000 after; 0.02 per 100,000 increase; 95% CI, 0.002-0.03). Among white patients, there were no significant changes in listing rates found.
“This outcome suggests that broader expansion of the ACA may help mitigate racial/ethnic disparities in access to care,” Breathett and colleagues wrote.
Core goals
In an accompanying editorial, Marvin A. Konstam, MD, from the CardioVascular Center, Tufts Medical Center, Boston, wrote: “The central question is whether we will we now regress and abandon the three core societal goals of universal coverage, cost containment and pursuit of quality. Also, any efforts to advance these goals are hollow without a focus on eliminating health care disparities. The findings of Breathett et al suggest that we are seeing some success in this direction, with reduction in the disparate allocation of high-reward interventions such as heart transplant. Shall we now forsake those successes?
“If we achieve consensus around our core goals, then there is no escaping a role of government in subsidizing health care for our least fortunate citizens. But beyond this fact, there are other legitimate choices to make: the relative roles of the private vs. public sectors; service-based vs. value- and population-based payment models; and payer-focused vs. provider- and patient focused decision-making and risk-bearing. Let us hope that as this next round of the debate unfolds, it focuses less on the name of the act and more on serving the health care needs of our entire population,” Konstam wrote. – by Suzanne Reist
Disclosure: Breathett reports no relevant financial disclosures. Please see the full study for a list of the other researchers’ relevant financial disclosures. Konstam reports serving on the board of trustees of Minuteman Health, a cooperative health insurance company, and Tufts Medical Center Inc.
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