Swaminathan S, et al. - Among 236,246 nonelderly patients with end-stage renal disease (ESRD) initiating dialysis, researchers investigated the relationship of Medicaid expansion with 1-year mortality. Findings revealed that living in a state that expanded Medicaid under the Affordable Care Act was related to lower 1-year mortality among patients with ESRD initiating dialysis.

Methods

• From January 2011 to March 2017, difference-in-differences analysis of nonelderly patients initiating dialysis in Medicaid expansion and nonexpansion states.
• Exposure included living in a Medicaid expansion state.
• One-year mortality was the primary outcome.
• Insurance, predialysis nephrology care, and type of vascular access for hemodialysis were included secondary outcomes.

Results

• In total, there were 142,724 patients in expansion states (mean age, 50.2 years; 40.2% female) and 93,522 patients in non-expansion states (mean age, 49.7; 42.4% female).
• One-year mortality following dialysis initiation declined from 6.9% in the preexpansion period to 6.1% after expansion (change, −0.8 percentage points; 95% CI, −1.1 to −0.5) in Medicaid expansion states.
• Mortality rates in non-expansion states were 7.0% before expansion and 6.8% after expansion (change, −0.2 percentage points; 95% CI, −0.5 to 0.2), resulting in an adjusted absolute mortality reduction in expansion states of −0.6 percentage points (95% CI, −1.0 to −0.2).
• It was observed that mortality reductions were largest for black patients (−1.4 percentage points; 95% CI, −2.2, −0.7; P=.04 for interaction) and patients aged 19 to 44 years (−1.1 percentage points; 95% CI, −2.1 to −0.3; P=.01 for interaction).
• Findings suggested an association of expansion with a 10.5-percentage-point (95% CI, 7.7-13.2) increase in Medicaid coverage at dialysis initiation, a −4.2-percentage-point (95% CI, −6.0 to −2.3) decrease in being uninsured, and a 2.3-percentage-point (95% CI, 0.6-4.1) increase in the presence of an arteriovenous fistula or graft.
• Changes in care for predialysis nephrology have not been significant.