Association of Citizenship Status With Kidney Transplantation in Medicaid Patients

Abstract

<div class="section"> <a class="named-anchor" id="S1"> <!-- named anchor --> </a> <h5 class="section-title" id="d1103473e225">Background</h5> <p id="P1">Although individuals classified as non-resident aliens, including undocumented immigrants, are entitled to receive emergency dialysis in the United States regardless of their ability to pay, most states do not provide them with subsidized care for maintenance dialysis or kidney transplantation. We explored whether non-resident aliens have similar outcomes to US citizens after receiving kidney transplants covered by Medicaid, a joint federal and state health insurance program. </p> </div><div class="section"> <a class="named-anchor" id="S2"> <!-- named anchor --> </a> <h5 class="section-title" id="d1103473e230">Study Design</h5> <p id="P2">Retrospective observational cohort study.</p> </div><div class="section"> <a class="named-anchor" id="S3"> <!-- named anchor --> </a> <h5 class="section-title" id="d1103473e235">Setting &amp; Participants</h5> <p id="P3">All adult Medicaid patients in the US Renal Data System who received their first kidney transplant during 1990–2011. </p> </div><div class="section"> <a class="named-anchor" id="S4"> <!-- named anchor --> </a> <h5 class="section-title" id="d1103473e240">Predictor</h5> <p id="P4">Citizenship status, categorized as US citizen, non-resident alien, or permanent resident.</p> </div><div class="section"> <a class="named-anchor" id="S5"> <!-- named anchor --> </a> <h5 class="section-title" id="d1103473e245">Outcomes</h5> <p id="P5">All-cause graft loss.</p> </div><div class="section"> <a class="named-anchor" id="S6"> <!-- named anchor --> </a> <h5 class="section-title" id="d1103473e250">Measurements</h5> <p id="P6">HRs and 95% CIs estimated by applying Cox proportional hazards frailty models with transplant center as a random effect. </p> </div><div class="section"> <a class="named-anchor" id="S7"> <!-- named anchor --> </a> <h5 class="section-title" id="d1103473e255">Results</h5> <p id="P7">Of 10,495 patients, 8660 (82%) were US citizens, 1489 (14%) were permanent residents, and 346 (3%) were non-resident aliens, whom we assumed were undocumented immigrants. Non-resident aliens were younger, healthier, on dialysis longer, and more likely to have had a living donor. 71% had transplantation in California, and 61% had transplantation after 2005. Non-resident aliens had a lower unadjusted risk of graft loss compared to US citizens (HR, 0.48; 95% CI, 0.35–0.65). Results were attenuated but still significant when adjusted for demographics, comorbidities, dialysis, and transplant-related factors (HR, 0.67; 95% CI, 0.46–0.94). </p> </div><div class="section"> <a class="named-anchor" id="S8"> <!-- named anchor --> </a> <h5 class="section-title" id="d1103473e260">Limitations</h5> <p id="P8">Citizenship status was self-reported, possible residual confounding.</p> </div><div class="section"> <a class="named-anchor" id="S9"> <!-- named anchor --> </a> <h5 class="section-title" id="d1103473e265">Conclusions</h5> <p id="P9">Our study suggests that the select group of insured non-resident aliens who undergo transplantation with Medicaid do just as well as US citizens with Medicaid. Policymakers should consider expanding coverage for kidney transplantation in nonresident aliens, including undocumented immigrants, given the associated high quality outcomes in these patients. </p> </div>