Change in Health Insurance Coverage After Liver Transplantation Can Be Associated with Worse Outcomes

Background: Health insurance coverage changes for many patients after liver transplantation, but the implications of this change on long-term outcomes are unclear. Aims: To assess post-transplant patient and graft survival according to change in insurance coverage within 1 year of transplantation. Methods: We queried the United Network for Organ Sharing for patients between ages 18–64 years undergoing liver transplantation in 2002–2016. Patients surviving > 1 year were categorized by insurance coverage at transplantation and the 1-year transplant anniversary. Multivariable Cox regression characterized the association between coverage pattern and long-term patient or graft survival. Results: Among 34,487 patients in the analysis, insurance coverage patterns included continuous private coverage (58%), continuous public coverage (29%), private to public transition (8%) and public to private transition (4%). In multivariable analysis of patient survival, continuous public insurance (HR 1.29, CI 1.22, 1.37, p < 0.001), private to public transition (HR 1.17, CI 1.07, 1.28, p < 0.001), and public to private transition (HR 1.14, CI 1.00, 1.29, p = 0.044), were associated with greater mortality hazard, compared to continuous private coverage. After disaggregating public coverage by source, mortality hazard was highest for patients transitioning from private insurance to Medicaid (HR vs. continuous private coverage = 1.32; 95% CI 1.14, 1.52; p < 0.001). Similar differences by insurance category were found for death-censored graft failure. Conclusion: Post-transplant transition to public insurance coverage is associated with higher risk of adverse outcomes when compared to retaining private coverage.