Retrospective Cohort Study
Copyright ©The Author(s) 2025. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Nephrol. Jun 25, 2025; 14(2): 101419
Published online Jun 25, 2025. doi: 10.5527/wjn.v14.i2.101419
Association between private insurance and living donor kidney transplant: Affordable Care Act as a natural experiment
Kathleen Perry, Miko Yu, Joel T Adler, Lindsey M Maclay, David C Cron, Sumit Mohan, Syed A Husain
Kathleen Perry, Miko Yu, Lindsey M Maclay, Department of Nephrology, Columbia University, New York, NY 10032, United States
Joel T Adler, Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX 78701, United States
David C Cron, Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, United States
Sumit Mohan, Syed A Husain, Department of Nephrology, Columbia University Medical Center, New York, NY 10032, United States
Author contributions: Perry K was responsible for data curation; Perry K and Husain SA were responsible for methodology, formal analysis and writing original draft; Adler JT, Mohan S, and Husain SA were responsible for supervision; Mohan S and Husain SA were responsible for resources; Husain SA was responsible for funding acquisition; Perry K, Yu M, Adler JT, Maclay LM, Cron DC, Mohan S, and Husain SA were responsible for conceptualization, investigation, writing review and editing, and visualization; all of the authors read and approved the final version of the manuscript to be published.
Supported by National Institute of Diabetes and Digestive and Kidney Diseases, United States, No. K23DK133729.
Institutional review board statement: This study was approved by the Institutional Review Board of Columbia University Irving Medical Center (No. AAAQ5853).
Informed consent statement: Informed consent was not required for this registry analysis.
Conflict-of-interest statement: SM receives grant funding from Kidney Transplant Collaborative and the NIH, and personal fees from Sanofi, Kidney International Reports and Health Services Advisory Group outside of the submitted work. The other authors declare that they have no financial conflicts of interest to disclose.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Data sharing statement: Data used in this study is available upon request to the Organ Procurement and Transplantation Network.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Syed A Husain, MD, Assistant Professor, Department of Nephrology, Columbia University Medical Center, 622 W 168th Street PH4-465, New York, NY 10032, United States. sah2134@cumc.columbia.edu
Received: September 13, 2024
Revised: December 27, 2024
Accepted: January 14, 2025
Published online: June 25, 2025
Processing time: 208 Days and 0.1 Hours
Abstract
BACKGROUND

Private insurance coverage is associated with higher rates of living donor kidney transplantation (LDKT) but whether this is attributable to confounding is not known.

AIM

To study the association between increased access to private health insurance and LDKT.

METHODS

Retrospective cohort study using United States transplant registry data. We identified incident candidates aged 22-29 years who were waitlisted for a kidney-only transplant from 2005-2014, excluding prior transplant recipients and those with missing data. We calculated the hazard of LDKT after waitlisting for those with private insurance vs other insurance pre-Affordable Care Act (ACA) vs post-ACA, using death and delisting as competing events, for candidates affected by the policy change (age 22-25 years) vs those who were not (age 26-29 years).

RESULTS

A total of 13817 candidates were included, of whom 46% were age 22-25 years and 54% were age 26-29 years. Among candidates aged 22-25 years at listing, those listed post-ACA were more likely to have private insurance compared to those listed pre-ACA (42% vs 35%), but there was no difference in private insurance coverage between eras among candidates aged 26-29 years at listing. In adjusted competing risk regression, privately insured patients age 22-25 years were less likely to receive a LDKT post-ACA compared to pre-ACA [hazard ratio (HR) = 0.88, 95%CI: 0.78-1.00], as were those aged 22-25 years old with other insurance types (HR = 0.80, 95%CI: 0.69-0.92). These associations were not seen among candidates age 26-29 years.

CONCLUSION

Candidates age 22-25 years were likelier to have private insurance post-ACA, without an increased rate in LDKT. Demonstrations of associations between insurance and LDKT are likely attributable to residual confounding.

Keywords: Kidney transplant; End-stage kidney disease; Health policy; Health insurance; Transplantation

Core Tip: In this retrospective cohort study using United States transplant registry data from 2005-2014, we found that although kidney transplant candidates age 22-25 years were more likely to have private insurance following the Affordable Care Act policy change expanding eligibility to remain on parental insurance, this shift in payer mix was not associated with higher rates of living donor kidney transplantation. These data suggest that insurance type itself is not a direct determinant of access to living donor kidney transplant; rather the association of private insurance with higher transplantation rates in prior observational studies is likely a result of unmeasured demographic confounding.