Digestive Diseases and Sciences

, Volume 63, Issue 6, pp 1463–1472 | Cite as

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

  • Clifford Akateh
  • Dmitry Tumin
  • Eliza W. Beal
  • Khalid Mumtaz
  • Joseph D. Tobias
  • Don HayesJr.
  • Sylvester M. Black
Original Article



Health insurance coverage changes for many patients after liver transplantation, but the implications of this change on long-term outcomes are unclear.


To assess post-transplant patient and graft survival according to change in insurance coverage within 1 year of transplantation.


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.


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.


Post-transplant transition to public insurance coverage is associated with higher risk of adverse outcomes when compared to retaining private coverage.


Liver transplantation Graft survival Human Medicaid Survival Insurance 



Liver transplantation


End-stage liver disease


Model for end-stage liver disease


Patient Protection and Affordable Care Act


United States of America


United Network for Organ Sharing


Analysis of variance


Transjugular intrahepatic portosystemic shunt


Donor risk index


Length of stay


Hazard ratios


Confidence interval


American College of Surgeons


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Supplementary material

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Supplementary material 1 (DOCX 63 kb)
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Supplementary material 2 (DOCX 25 kb)
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Supplementary material 3 (DOCX 31 kb)
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Supplementary material 4 (DOCX 23 kb)


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Division of General and Gastrointestinal Surgery, Department of SurgeryOhio State University Wexner Medical CenterColumbusUSA
  2. 2.Division of Transplantation, Department of SurgeryOhio State University Wexner Medical CenterColumbusUSA
  3. 3.Division of Gastroenterology, Hepatology and Nutrition, Department of Internal MedicineOhio State University Wexner Medical CenterColumbusUSA
  4. 4.Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Internal MedicineOhio State University Wexner Medical CenterColumbusUSA
  5. 5.Section of Pulmonary Medicine, Department of PediatricsNationwide Children’s HospitalColumbusUSA
  6. 6.Department of Anesthesiology and Pain MedicineNationwide Children’s HospitalColumbusUSA
  7. 7.Department of Anesthesiology and Pain MedicineOhio State University Wexner Medical CenterColumbusUSA
  8. 8.Department of PediatricsOhio State University College of MedicineColumbusUSA
  9. 9.Ohio State University Wexner Medical Center - Faculty TowerColumbusUSA

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