Association of Medicaid Expansion with Tunneled Dialysis Catheter Use at the Time of First Arteriovenous Access Creation.

Abstract

OBJECTIVE\nIn the United States, many low-income patients initiating hemodialysis are uninsured before qualifying for Medicare. Inadequate access to pre-dialysis care may delay their arteriovenous (AV) access creation and increase tunneled dialysis catheter (TDC) use. The 2014 Affordable Care Act expanded eligibility for Medicaid among low-income adults, but not every state adopted this measure. We evaluated whether Medicaid expansion was associated with decreased TDC use for hemodialysis initiation.\n\n\nMETHODS\nWe queried the United States Vascular Quality Initiative state-level database for non-Medicare patients undergoing initial AV access creation from 2011-2018. We evaluated associations of receiving initial AV access in states that expanded Medicaid with concurrent TDC use, survival, and insurance coverage.\n\n\nRESULTS\nData were available for patients in 31 states: 19 states expanded Medicaid from January 2014 to February 2015. Among 8,462 patients in the post-expansion period from March 2015 to December 2018, 58% were in Medicaid expansion states. Patients in Medicaid expansion states less often had concurrent TDCs (40% vs 48%, P<.001). In multivariable analysis, Medicaid expansion was independently associated with fewer TDCs (OR 0.7, 95% CI 0.6-0.8, P<.001). Three-year survival was similar between patients in Medicaid expansion and nonexpansion states (84.7% vs 85.2%, P=.053). Multivariable cox-regression confirmed the finding (HR 0.95, 95% CI 0.82-1.1, P=.482). In difference-in-differences analysis, Medicaid expansion was associated with a 9.2-percentage point increase in Medicaid coverage (95% CI 2.7-15.8, P=.009). Hispanic patients exhibited a 30.1-percentage point increase in any insurance coverage (95% CI .3-59.9, P=.048).\n\n\nCONCLUSIONS\nPatients in Medicaid expansion states were less likely to have TDCs during initial AV access creation, suggesting earlier pre-dialysis care. Hispanic patients benefited from increased insurance coverage. Expanding insurance options for the underserved may improve quality metrics and cost-savings for hemodialysis patients.