Impact of Early Adoption of Affordable Care Act Medicaid Expansion on Heart Transplant Listings in the United States

As part of the affordable care act, medicaid expansion (ME) is expected to increase the number of insured patients, and improve access to care. While the Act took effect in 2014, by June 2012 seven states and the District of Columbia had already implemented ME. We sought to identify the impact of ME on listing for heart transplantation. Using UNOS database, we included all adults listed for heart transplantation (2009-2014) and identified their state of permanent residence. States were divided into ME: California, Colorado, Connecticut, Minnesota, Missouri, New Jersey, Washington and District of Columbia and non-ME which includes all others. We identified trends of listing and method of primary payment, with 2009 as a baseline and we describe changes in pre- (2009-2010) and post-implementation (2011-2014). A total of 17276 patients were listed during the study period, and 3897 (22.6%) were listed in ME states. Compared with 2009, the 2014 annual number of listings increased by 41% in ME vs. 22% in non-ME (p<0.001). There was no change in age, gender, ethnic composition, or education pre and post-2011 in ME states. The percentage of employed patients decreased from 10.4% (pre) to 7.3% (post) in ME (p=0.012), but remained the same in non-ME states (9.7% vs 9.8%, p=0.87) while the number of Medicaid-insured patients increased by 51% in ME vs. 23% non-ME. Heart transplant listings increased two-fold in states where the Affordable Care Act’s medicaid expansion was adopted early, as a result of higher percentages of unemployed and Medicaid patients.