October 31, 2018
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Lower mortality rate seen among patients on dialysis in states with Medicaid expansion

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During the first three years of expansion, fewer patients with ESRD died within a year of starting dialysis in states that expanded Medicaid coverage under the Affordable Care Act compared with patients in states that did not expand care.

“To my knowledge, this is the first study to find an association between Medicaid expansion under the ACA and lower death rates in adults,” Amal Trivedi, MD, senior author and an associate professor at Brown’s School of Public Health, said in a press release about the study from Brown University. “Prior research on the effects of Medicaid expansion have generally found that expansion is associated with substantial gains in coverage, access to care, use of preventive health services and in some studies, better self-rated health.”

Trivedi and colleagues tracked more than 230,000 non-elderly patients with ESRD between 2011 and 2017. In January 2014, 25 states and the District of Columbia extended Medicaid to non-elderly residents with incomes at or below 138% of the poverty level, while 25 states did not, according to the press release. Eight more states have expanded Medicaid since then.

The number of patients who died within the first year of beginning dialysis — defined in the study as from the 91st day to the end of the 15th month of dialysis treatment — decreased from 6.9% prior to Medicaid expansion to 6.1% after expansion, according to the release. In non-expansion states, the mortality rate was 7% from January 2011 to January 2014 (prior to the ACA) and was 6.8% from January 2014 to March 2017.

“Multiple factors not explored in our paper may have contributed to the reduction of mortality among patients with end-stage renal disease,” Shailender Swaminathan, MD, lead author and an adjunct assistant professor at Brown's School of Public Health, said in the release. “Medicaid may have resulted in better adherence to treatment sessions, normally three times a week, because it eliminated copayments of about $150 per week. On the other hand, because out-of-pocket medical payments were reduced, Medicaid may have also improved patients' finances, thereby improving health. More research may be essential to unravel this.”

Medicaid expansion also improved pre-dialysis care for kidney disease, as indicated by the surgical placement of a fistula or graft before beginning dialysis, Trivedi said. Data from expansion states showed an increase of 2.3 percentage points in the number of patients beginning dialysis with a fistula or graft.

The study also found black patients and patients between the ages of 19 and 44 years had larger decreases in mortality rates, by 1.4 percentage points and 1.1 percentage points, respectively. Trivedi said this is likely because these groups traditionally had lower rates of insurance. As black and Hispanic people are more likely to develop ESKD — 3.5 times and 1.5 times respectively — Trivedi said, “Medicaid expansion in the states that have yet to expand may be a significant strategy to address racial and ethnic health disparities among patients with end-stage renal disease.”

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Reference:

https://news.brown.edu/articles/2018/10/dialysis

Disclosure: The NIH (grant R01DK113398-01) supported this research.