07:46am Saturday 11 July 2020

Broad Medicaid coverage leads to lower rates of kidney failure, researchers find

Manjula Tamura

“Her kidney failure was preventable,” said Tamura, MD, associate professor of nephrology at the Stanford University School of Medicine. “But by the time she came to the hospital, it was no longer reversible.”

With proper medical care, the patient’s kidney failure, known as end-stage renal disease or ESRD, could have been averted, Tamura said. The patient, who was diagnosed with lupus as a teenager, stopped getting medical care at 21, when she no longer qualified for coverage under her parents’ medical insurance and couldn’t afford her own. Now she was facing lifelong dialysis or a kidney transplant.

When the federal government expanded its Medicaid program with the passage of the Affordable Care Act, as a medical researcher Tamura was motivated to ask the question: Does expanded Medicaid coverage translate into better care for low-income patients with chronic diseases, such as kidney disease?

According to the results of a study published March 20 in the Journal of the American Society of Nephrology, the answer, at least for chronic kidney disease is, yes. Tamura is lead author of the study.

For low-income patients with chronic kidney disease, broader Medicaid coverage translated into better medical care and ultimately lower rates of kidney failure or ESRD, according to the study. States with broader Medicaid coverage had lower incidences of kidney failure from 2001 through 2008.

The results point to the potential benefits of states expanding their Medicaid coverage through the new policies offered by the Affordable Care Act. Those changes, which were enacted this year, have been adopted by half of all states so far.

“Our study suggests that Medicaid expansion could support efforts to prevent kidney failure and improve access to kidney disease care,” said Tamura, who is also a nephrologist at the Palo Alto Veterans Affairs Health Care System.

Wolfgang Winkelmayer, MD, associate professor of nephrology and of health research and policy at Stanford, is senior author of the study.
Slow progression

In many cases, kidney disease progresses slowly over a 10- to 20-year period before the end-stage of the disease is reached. This is when the kidneys are no longer able to work, and kidney transplant or dialysis treatments are needed. Early care is essential to preventing the costly and debilitating condition of end-stage renal disease, Tamura said; and when prevention is no longer possible, timely medical care can prepare patients for ESRD treatments such as dialysis and transplantation.

ESRD affects more than 350,000 nonelderly Americans at a cost of $10 billion a year, according to the study. In middle age, diabetes is the No. 1 cause of ESRD.

All Americans can qualify for Medicare coverage after the onset of ESRD, but those under the age of 65 must rely on other sources of insurance or pay out of pocket to cover kidney disease prior to the failure of the kidneys.

Before the Affordable Care Act, only low-income Americans who were pregnant, had a disability or were parents of minors could receive Medicaid coverage if they met their state’s income eligibility levels.

States now have the option to increase Medicaid coverage to all adults under the age of 65 with incomes below 133 percent of the poverty level regardless of whether they are pregnant, disabled or parents of minors.

“The care of patients approaching kidney failure or end-stage renal disease is a useful model to study the potential effects of Medicaid expansion on chronic disease care because ESRD care is costly and the quality of pre-ESRD care is tracked nationally,” Tamura said.
Good model

Kidney disease also makes a particularly good model for this because the risk factors associated with progression to kidney failure tend to cluster among poor and uninsured Americans, according to the study.

Using data from a national ESRD registry, researchers identified 408,535 adults ages 20-64 who developed ESRD from 2001 through 2008. Medicaid coverage during those years among low-income, nonelderly adults ranged from 12.2 to 66 percent, depending on the state, with California averaging between 30 and 35 percent.

For each additional 10 percent of the low-income, nonelderly population covered by Medicaid, the study found there was a 1.8 percent decrease in ESRD incidence.

Low-income, nonelderly adults with ESRD who were on Medicaid also had better access to care in states with broader Medicaid coverage. The study said, for example, that for a 50-year-old white woman, the “access gap” for being put on the kidney transplant wait list if she is on Medicaid versus private insurance is significantly smaller if she lives in a state with broader Medicaid coverage. That gap is 7.7 percentage points smaller in states with high versus low Medicaid coverage. The access gap to transplantation decreases by 4 percentage points, and the access gap to dialysis decreases by 3.8 percentage points, the study found.

In an accompanying editorial, researchers commented on the timeliness of the study and the growing possibility for improvements in access to care and health gains that may accrue to the most vulnerable segments of the population with the availability of health insurance.

“(This) study … will allow us to further examine the association between Medicaid coverage and health-care outcomes,” wrote Rajnish Mehrotra, MD, and Larry Kessler, MD, physician-researchers at the University of Washington, in the editorial.

Other Stanford authors of the study were Benjamin Goldstein, PhD, instructor of biostatistics, and biostatistician Aya Mitani, MPH.

Information about Stanford’s Department of Medicine, which supported this study, is available at http://med.stanford.edu/nephrology/.

Stanford Medicine integrates research, medical education and patient care at its three institutions – Stanford University School of Medicine, Stanford Hospital & Clinics and Lucile Packard Children’s Hospital Stanford. For more information, please visit the Office of Communication & Public Affairs site at http://mednews.stanford.edu/.

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