The AJT Report

Abstract

The Supreme Courts ruling on the Affordable Care Act allowed states to opt out of the law’s Medicaid expansion. In this issue of “The AJT Report,” we look at how the expansion—and nonparticipation in the expansion—might impact the field of transplantation. The Supreme Courts ruling on the Affordable Care Act allowed states to opt out of the law’s Medicaid expansion. In this issue of “The AJT Report,” we look at how the expansion—and nonparticipation in the expansion—might impact the field of transplantation. News and issues that affect organ and tissue transplantation Transplant leaders weigh in on how Medicaid expansion—or opting out of expansion—might impact transplantation Starting next year, as part of the Affordable Care Act (ACA), Medicaid eligibility will be expanded for millions of people who now lack any form of health insurance. For people in need of organ transplants, this may be a mixed blessing. Medicaid is meant to be a safety net for people with no other options for medical care, but its administration varies widely among states. Currently, some states require recipients to have an income no higher than 50% of the federal poverty level (FPL) for a family of four, while in others, the qualifying income can be as high as 100% of the FPL. Single, childless adults are particularly vulnerable: in some states they don’t qualify for Medicaid at all, while in others, coverage is far more limited than it is for, say, children and pregnant women.1American Public Health Association. Medicaid Expansion. www.apha.org/advocacy/health+reform/ACAbasics/medicaid.htm. Accessed April 30, 2013Google Scholar The ACA sets the minimum qualifying income for Medicaid benefits at 133% of the FPL. However, the first 5% of income will be excluded from the calculation, so the “effective” income floor is actually 138% of the FPL, translating into $15,414 annually for an individual or $31,809 for a family of four. According to some estimates, these changes may swell state Medicaid rosters by 11 million or more by 2022.1American Public Health Association. Medicaid Expansion. www.apha.org/advocacy/health+reform/ACAbasics/medicaid.htm. Accessed April 30, 2013Google Scholar Many state governors have complained that their budgets are too overstretched to accommodate these changes. The federal government has sweetened the deal by providing 100% of the cost of covering these newly eligible people through 2016, and 90% thereafter. But some governors are still threatening to opt out, saying that even that additional 10% is too much. However, many observers agree with Kathleen Sebelius, Secretary of the U.S. Department of Health and Human Services, who has said she believes that most, if not all, of the states will eventually come around. 1,2Kennedy K. Sebelius: GOP governors will eventually expand Medicaid. USA Today. March 21, 2013. www.usatoday.com/story/news/politics/2013/03/21/health-care-law-third-anniversary-medicaid-expansion-sebelius/2006485. Accessed April 30, 2013.Google Scholar Already, Governors Rick Scott of Florida and John Kasich of Ohio have announced their intention to take the funds despite initial expressions of protest.3Medicaid expansion fight harms you: Our view. USA Today. March 26, 2013. www.usatoday.com/story/opinion/2013/03/26/medicaid-expansion-republican-governors-editorials-debates/2023075. Accessed April 30, 2013.Google Scholar How those in need of organ transplants will fare under the expansion is still unclear. More people certainly will have access to care, says David A. Axelrod, MD, section chief of transplantation surgery at Dartmouth-Hitchcock Medical Center in Lebanon, NH. “Many of our patients have been denied transplants for financial reasons, so I think this is an important step forward,” he says. This is especially true given that the ACA prohibits insurers from denying coverage of pre-existing conditions. “Some insurance companies consider organ donation a pre-existing condition, and once we can avoid that, it may help to add some new potential donors to the pool,” he says. Additionally, better access to nephrology care could mean that more people come to transplant earlier in the course of their illness, which could in turn improve outcomes for transplant centers.4Zavala EY. Healthcare reform: Potential implications for transplantation (presentation delivered September 27, 2012 atVanderbilt University). www.vanderbilthealth.com/transplant/42201. Accessed April 30, 2013.Google ScholarKEY POINTS•While the ACA expands eligibility for Medicaid, individual states are allowed to opt out of this expansion.•Expanded coverage will likely mean better care for many transplant donors and recipients.•Questions remain about how expansion might impact the organ supply, reimbursement and immunosuppressant drug coverage. •While the ACA expands eligibility for Medicaid, individual states are allowed to opt out of this expansion.•Expanded coverage will likely mean better care for many transplant donors and recipients.•Questions remain about how expansion might impact the organ supply, reimbursement and immunosuppressant drug coverage. Expanded coverage may be especially good news for younger patients who are making the transition from pediatric to adult care, says Gabriel Danovitch, MD, medical director for the kidney and pancreas transplant program at the University of California, Los Angeles. “This is an extremely high-risk group because many of these patients got kidney transplants when they were kids, and find that when they reach adulthood they no longer have coverage for their medications or associated costs. That unquestionably leads to graft loss and, in the most severe cases, loss of life.” These very real benefits come with some equally significant downsides and unanswered questions. For patients awaiting transplants, perhaps the most important thing to remember is that, while it may improve access to care, the new legislation does little to increase the number of available organs. So “I’m not sure [the expansion] is going to do anything to increase the transplant rate, because that’s limited by the organ supply,” says Michael Abecassis, MD, director of the comprehensive transplant center at the Feinberg School of Medicine at Northwestern University in Chicago. Reimbursement is another question. Organ acquisition costs, which are largely beyond the control of the transplant center, may range from 23% of the total cost for a heart transplant to 60% for a kidney.4Zavala EY. Healthcare reform: Potential implications for transplantation (presentation delivered September 27, 2012 atVanderbilt University). www.vanderbilthealth.com/transplant/42201. Accessed April 30, 2013.Google Scholar And, says Dr. Axelrod, “in many states, the Medicaid payment is inadequate to cover even those costs, let alone the costs of the transplant itself. So, from the point of view of the transplant center, along with the lack of organs, there’s the inadequate payment.” In fact, he predicts that “if it gets to be too much of a problem, without enough income from private payers to offset those losses, smaller centers may find it harder and harder to survive, which could lead to the consolidation of some transplant programs.” If that happens, “the patients who are least able to travel to access care and who have the most difficulty finding the resources they need are going to be the most affected. Already, some of our patients can’t keep their appointments unless you give them a gas card. So it’s a huge problem.” As Bruce Kaplan, MD, chief of the division of nephrology at the University of Arizona College of Medicine in Tucson, puts it, the question may boil down to “what therapeutic interventions, including transplant, are we willing to pay for? Because it’s going to be a zero-sum game in terms of money. Do you pay for prostate screening or transplant? Colonoscopies, or transplant? Which one actually gives you more ’health’ for the dollar? These are things people are going to have to wrestle with.” Then there is the complex calculus of a patient’s life circumstances. “It’s not just your insurance coverage; it’s the neighborhood you live in; your social support network; the physicians you have, and what geographic region you live in; all those factors play a role in determining your access to transplant. So while Medicaid would be extremely beneficial for this patient population, it’s not going to fix the problem entirely,” says Rachel Patzer, PhD, assistant professor in the division of transplant medicine at Atlanta’s Emory University School of Medicine. People who qualify for Medicaid are likely to fare poorly on most of these measures. And, said Dr. Patzer, who has studied the challenges facing low-income people who need kidney transplants, “we hear anecdotally that a physician or social worker may decide against offering someone a transplant because they assume they won’t be able to afford the medication or get a ride to the transplant center. It’s really inappropriate, but it’s supported by data showing that patients at lower socioeconomic levels are less likely to have those kinds of conversations with their physician, and are less likely to be waitlisted for kidney transplantation.” Additionally, the states that are opting out of the Medicaid expansion are states that traditionally have poorer access to transplant, she says. “A lot of my research has been in the Southeast, and our network (Georgia, North Carolina and South Carolina) has the lowest transplant rates in the nation. All of these states opposed Medicaid expansion.” If those governments remain adamant, she says, “we are likely to see an increase in health disparities in those states, not only for transplant access and outcomes, but for other health conditions as well.” Equally contentious is the question of a patient’s immigration status. “Many parts of the country with high immigrant populations must grapple with the extraordinarily difficult task of caring for patients who are undocumented and, as a result, those people often receive totally inadequate care,” says Dr. Dano-vitch. “I believe that any legislation that stabilizes the status of people residing in this country and enhances their access to medical care is to be welcomed.” In fact, immigration reform may actually increase organ availability, “he adds.” Right now, many potential living donors don’t come forward because they’re concerned about their immigration status. With immigration reform, some of those people may agree to donate organs to relatives. Also, the more that minority or immigrant populations feel part of the society they’re living in, the greater the chances are that they or their families will agree for them to be deceased donors, should that possibility arise.“ Meanwhile, how the expansion will affect drug coverage is still anyone’s guess. ”Nothing in the ACA changes the three-year time limit that Medicare imposes on drug reimbursement for kidney recipients, “says Dr. Abecassis.” However, that time limit does not exist for Medicaid, so I think for the drugs, the Medicaid expansion will actually help.“ Undoubtedly, expanding Medicaid will bring medical coverage to a woefully neglected segment of the population, which is to be applauded, says Dr. Axelrod. Patients with end-stage organ failure will get earlier referrals to specialists and a higher rate of transplantation than if they didn’t have insurance, he adds. “If we want more patients to have access to care, what we’re going to have to figure out is how to do more with fewer resources.” BiS