Medicaid Expansion Association with End-Stage Liver Disease Mortality Depends on Leniency of Medicaid Hepatitis C Virus Coverage.

Abstract

BACKGROUND AND AIMS\nThe Affordable Care Act (ACA) expanded Medicaid around the same time that direct-acting antivirals (DAAs) became widely available for the treatment of hepatitis C virus (HCV). However, there is significant variation in Medicaid HCV treatment eligibility criteria between states. We explored the combined effects of Medicaid expansion and leniency of HCV coverage under Medicaid on liver outcomes.\n\n\nMETHODS\nWe assessed state-level end-stage liver disease (ESLD) mortality, listings for liver transplant (LT), and listing-to-death ratio (LDR) for adults 25-64 years old using data from UNOS and CDC WONDER. States were divided into four nonoverlapping groups based on expansion status on January 1, 2014 (expansion versus non-expansion) and leniency of Medicaid HCV coverage (lenient versus restrictive coverage). Joinpoint regression analysis evaluated for significant changes in slope over time (joinpoints) during the pre-expansion (2009-2013) and post-expansion (2014-2018) time periods.\n\n\nRESULTS\nWe found significant changes in annual percent change (APC) for population-adjusted ESLD deaths between 2014-2015 in all cohorts except for the non-expansion/restrictive cohort, in which deaths increased at the same APC from 2009-2018 (APC +2.5% [95% CI 1.8, 3.3]). In the expansion/lenient coverage cohort, deaths increased at an APC of +2.6% (95% CI 1.8, 3.5) until 2014 and then tended to decrease at an APC of -0.4% (95% CI -1.5, 0.8). LT listings tended to decrease over time for all cohorts. For LDR, only the expansion/lenient and expansion/restrictive cohorts had statistically significant joinpoints.\n\n\nCONCLUSION\nImprovements in ESLD mortality and LDR were associated with both Medicaid expansion and leniency of HCV coverage under Medicaid. These findings argue for the implementation of more lenient and widespread public health insurance to improve liver disease outcomes, including mortality.