Changes in Heart Transplant Listings by Insurance and Race During the COVID Public Health Emergency

BACKGROUND: Socioeconomic inequities in access to heart transplantation, including those based on insurance coverage and race or ethnicity, are well documented. During the COVID pandemic, the federal government declared a Public Health Emergency (PHE), which prevented states from disenrolling people from Medicaid. We sought to determine whether this policy was associated with changes in the insurance or racial composition of the heart transplant waiting list. METHODS: Using the United Network for Organ Sharing thoracic data set, we conducted an observational cohort study that analyzed weekly counts of adults (aged >17 years) added to the heart transplant waitlist between January 1, 2018 and December 31, 2022. We obtained ratios of pre-PHE to PHE waitlisting rates by payer and race while accounting for demographics, trends over time, and overdispersion using latent lognormal Poisson dynamic generalized linear models. RESULTS: There were 8224 heart transplant listings before the PHE and 12 261 during. We found no change in listing among privately insured (rate ratio [RR], 1.06 [95% CI, 0.91–1.24]), Medicare (RR, 1.11 [95% CI, 0.94–1.30]), or other government coverage listings (RR, 1.13 [95% CI, 0.91–1.39]), but did find an increase in Medicaid-covered listings (RR, 1.19 [95% CI, 1.01–1.42]). We found no increase in transplant listings during the PHE for patients who were White (RR, 1.03 [95% CI, 0.90–1.21]), but did find increases among patients who were Black (rate ratio, 1.20 [95% CI, 1.04–1.43]), Hispanic (RR, 1.24 [95% CI, 1.06–1.49]), and Asian/American Indian or Alaska Native/Hawaiian or Pacific Islander/multiracial (RR, 1.36 [95% CI, 1.14–1.66]). CONCLUSIONS: The COVID-related PHE was associated with changes in the insurance and racial composition of the heart transplantation waitlist that, if maintained, could reduce socioeconomic inequities in access to heart transplantation.