Association between private insurance and living donor kidney transplant: Affordable Care Act as a natural experiment.

BACKGROUND

Private insurance coverage is associated with higher rates of living donor kidney transplantation (LDKT) but whether this is attributable to confounding is not known.

AIM

To study the association between increased access to private health insurance and LDKT.

METHODS

Retrospective cohort study using United States transplant registry data. We identified incident candidates aged 22-29 years who were waitlisted for a kidney-only transplant from 2005-2014, excluding prior transplant recipients and those with missing data. We calculated the hazard of LDKT after waitlisting for those with private insurance other insurance pre-Affordable Care Act (ACA) post-ACA, using death and delisting as competing events, for candidates affected by the policy change (age 22-25 years) those who were not (age 26-29 years).

RESULTS

A total of 13817 candidates were included, of whom 46% were age 22-25 years and 54% were age 26-29 years. Among candidates aged 22-25 years at listing, those listed post-ACA were more likely to have private insurance compared to those listed pre-ACA (42% 35%), but there was no difference in private insurance coverage between eras among candidates aged 26-29 years at listing. In adjusted competing risk regression, privately insured patients age 22-25 years were less likely to receive a LDKT post-ACA compared to pre-ACA [hazard ratio (HR) = 0.88, 95%CI: 0.78-1.00], as were those aged 22-25 years old with other insurance types (HR = 0.80, 95%CI: 0.69-0.92). These associations were not seen among candidates age 26-29 years.

CONCLUSION

Candidates age 22-25 years were likelier to have private insurance post-ACA, without an increased rate in LDKT. Demonstrations of associations between insurance and LDKT are likely attributable to residual confounding.