Medicaid Expansion Reduced Medicare Hospitalizations During Dialysis

Medicaid expansion may help minimize Medicare spending, as it was associated with reduced hospitalizations and hospital days for Medicare beneficiaries with kidney failure who initiated dialysis, a JAMA Health Forum study found.

Medicare provides health insurance coverage for patients with kidney failure starting 91 days after they initiate in-center hemodialysis or home-based dialysis. Medicare spending for beneficiaries with kidney failure accounted for 6 percent of total Medicare spending in 2017.

Still, Medicare beneficiaries without supplemental coverage tend to face high out-of-pocket costs, Part D premiums, and cost-sharing for dialysis.

Expanding Medicaid under the Affordable Care Act (ACA) has helped increase access to affordable health insurance coverage for Medicare beneficiaries.

Researchers used data from the Renal Management Information System’s End Stage Renal Disease Medical Evidence Report to determine how Medicaid expansion impacted Medicare-financed hospitalizations, health insurance coverage, and predialysis nephrology care for adults aged 19 to 64 years with kidney failure.

The study focused on adults with Medicare Part A coverage who initiated dialysis between January 1, 2010, and December 31, 2018. The study period encapsulates outcomes before and after Medicaid expansion, as most states that have expanded Medicaid did so on January 1, 2014.

The sample included 188,671 adults, 97,071 of whom lived in Medicaid expansion states and 91,600 who lived in non-expansion states.

Medicaid expansion was associated with a decrease in hospitalizations of 4.24 admissions per 100 patient-years during the first three months after dialysis initiation. Expansion was also associated with fewer hospitalizations in the first six months after initiation of dialysis (-5.79 admissions per 100 patient-years).

Medicaid expansion was tied to decreases in hospitalizations related to infections at three, six, and 12 months after patients began dialysis. It was also associated with fewer hospital days for infection-related hospitalizations.

Additionally, hospital days for cardiac conditions decreased by 0.13 days per patient-year in the three months after dialysis initiation.

Reducing hospitalizations among patients with kidney failure is a key priority due to the clinical and financial implications. Medicare is the primary payer of care for people with kidney failure and hospitalizations account for 40 percent of Medicare spending on patients receiving dialysis, the study noted.

“The study’s findings suggest spillovers from the ACA’s Medicaid expansion to Medicare in the form of health benefits for Medicare enrollees and reduced spending on hospitalizations, the largest source of expenditures in the Medicare program,” researchers wrote.

Medicaid expansion also led to a significant decrease in mortality rates 12 months after beginning dialysis.

Expanding Medicaid positively impacted health insurance coverage, the study found. Medicaid Expansion correlated with a 2.58 percentage point increase in dual Medicare and Medicaid coverage at 91 days after dialysis initiation.

This increase in dual coverage was larger among Hispanic or Latino patients compared to White patients, researchers noted.

Medicaid expansion was also tied to a 1.65 percentage point increase in the presence of an arteriovenous fistula (AVF) or graft at dialysis initiation for hemodialysis patients. Past research has shown that initiating hemodialysis with an AVF has been associated with lower mortality compared to starting dialysis with a catheter, the study mentioned.

After South Dakota recently approved a measure to expand Medicaid under the ACA, eleven states have yet to implement expansion.

Medicaid Expansion has largely been associated with improved access to care for beneficiaries. For example, one study found that Medicaid expansion helped increased health insurance coverage for low-income individuals with recent criminal legal involvement.

In addition, if all remaining states adopted Medicaid expansion in 2023, Medicaid enrollment would grow by nearly 36 percent, significantly reducing uninsurance rates.