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Abstract: TH-OR46

The Impact of Affordable Care Act Medicaid Expansions on Dialysis Facility Medicaid Enrollment and Quality Measures

Session Information

Category: Dialysis

  • 801 Dialysis: Hemodialysis and Frequent Dialysis


  • Reaves, Allison Cook, Tufts Medical Center, Boston, Massachusetts, United States
  • Tighiouart, Hocine, Tufts Medical Center, Boston, Massachusetts, United States
  • Thomas, Cindy Parks, Brandeis University Heller School for Social Policy and Management, Waltham, Massachusetts, United States
  • Weiner, Daniel E., Tufts Medical Center, Boston, Massachusetts, United States

The Centers for Medicaid and Medicare Services proposed using Medicare Medicaid dual eligible enrollment (DEE) to adjust for social risk in dialysis facility quality scores. Because Medicaid eligibility varies by state, in part due to variable uptake of Affordable Care Act (ACA) Medicaid expansions, we examined the extent to which dialysis facility location in an expansion state was associated with increased DEE and improved dialysis facility quality scores.


Using data from the ESRD Quality Improvement Program (QIP) and US Renal Data System, we identified a longitudinal cohort of US hemodialysis dialysis facilities with ESRD QIP data from 2012-2018. We tested whether location in an expansion state was associated with increases in the proportion of Medicaid-enrolled incident and dual-eligible enrolled prevalent dialysis patients as well as improved ESRD QIP total performance scores (TPS) and vascular access scores (VAS). We compared pre-expansion data (2012-2013) with early and late post-expansion times points (2015 and 2018, respectively). We used a difference-in-differences approach and adjusted for facility patient characteristics and area-level social vulnerabilities.


Expansions were associated with increases in incident patient Medicaid enrollment in the early and late expansion periods (5.5 percentage points, 95% CI (4.6, 6.5) and 7.4 percentage points, 95% CI (6.4, 8.4), respectively) and increases in dialysis facility DEE in the late expansion period (1.3 percentage points, 95% CI (0.7, 1.9)). Facility location in an expansion state was also associated with an increase of 2.2 points (95% CI (1.3, 3.1)) in TPS in the late expansion period. Catheter measure scores were lower and fistula measure scores higher in facilities located in expansion states. There was not a clear pattern of improvement in VAS associated with expansions.


Dialysis facilities in states that have not implemented Medicaid expansions may experience lower growth of Medicaid enrollment due to limited Medicaid coverage available to their patients and may also have a greater decline in quality scores. Accordingly, adjustments to quality performance metrics based on DEE may favor facilities located in expansion states and further exacerbate health disparities among patients receiving dialysis.


  • Other NIH Support