Association of state Medicaid expansion policies with pediatric liver transplant outcomes

Holly Payton Shifman, Chiung Yu Huang, Andrew F. Beck, John Bucuvalas, Emily R. Perito, Evelyn K. Hsu, Noelle H. Ebel, Jennifer C. Lai, Sharad I. Wadhwani

Research output: Contribution to journalArticlepeer-review


Children from minoritized/socioeconomically deprived backgrounds suffer disproportionately high rates of uninsurance and graft failure/death after liver transplant. Medicaid expansion was developed to expand access to public insurance. Our objective was to characterize the impact of Medicaid expansion policies on long-term graft/patient survival after pediatric liver transplantation. All pediatric patients (<19 years) who received a liver transplant between January 1, 2005, and December 31, 2020 in the US were identified in the Scientific Registry of Transplant Recipients (N = 8489). Medicaid expansion was modeled as a time-varying exposure based on transplant and expansion dates. We used Cox proportional hazards models to evaluate the impact of Medicaid expansion on a composite outcome of graft failure/death over 10 years. As a sensitivity analysis, we conducted an intention-to-treat analysis from time of waitlisting to death (N = 1 1901). In multivariable analysis, Medicaid expansion was associated with a 30% decreased hazard of graft failure/death (hazard ratio, 0.70; 95% confidence interval, 0.62, 0.79; P < .001) after adjusting for Black race, public insurance, neighborhood deprivation, and living in a primary care shortage area. In intention-to-treat analyses, Medicaid expansion was associated with a 72% decreased hazard of patient death (hazard ratio, 0.28; 95% confidence interval, 0.23-0.35; P < .001). Policies that enable broader health insurance access may help improve outcomes and reduce disparities for children undergoing liver transplantation.

Original languageEnglish
Pages (from-to)239-249
Number of pages11
JournalAmerican Journal of Transplantation
Issue number2
StatePublished - Feb 2024


  • Medicaid
  • Medicaid expansion
  • disparities
  • equity
  • health policy
  • health services
  • insurance
  • liver transplantation
  • pediatrics


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