Not All Coverage Is Equal: State‐Level Medicaid Eligibility Drives Waitlist and Survival Outcomes for Pediatric Non‐Citizens

Medicaid expansion (ME) improves access to and survival after pediatric LT. The association between citizenship status, ME, waitlist, and survival outcomes has not been studied. Pediatric LT candidates and recipients from 2005 to 2023 in the UNOS database were identified and divided based on state ME status, broad Medicaid eligibility for non-citizens, and citizenship status at the time of listing or LT. Study outcomes included 1-year transplant probability and waitlist mortality, and 1-, 5-, and 10-year overall survival (OS) and graft survival (GS). There were 10 753 waitlist candidates in the national cohort (10 364 citizens, 389 non-citizens) and 4356 waitlist candidates in broad eligibility states (4152 citizens, 204 non-citizens). After ME, there were no significant differences in transplant probability and significantly lower waitlist mortality for citizens. Similar trends were observed for non-citizens. There were larger relative improvements in transplant probability (0.8% vs. 9.2%) and waitlist mortality (54.3% vs. 77.1%) for non-citizens in broad eligibility states compared to the national cohort after ME. There were 7264 recipients in the national cohort (7096 citizens, 168 non-citizens) and 2806 recipients in broad eligibility states (2710 citizens, 96 non-citizens). Nationally, citizens had improved post-LT survival, while non-citizens trended toward improved post-LT survival after ME. Similar trends were observed in broad eligibility states. ME is associated with improved outcomes for citizens, while similar trends were observed for non-citizens. Non-citizens in broad-eligibility states had larger improvements in outcomes. State-level Medicaid eligibility is an important driver of outcomes for non-citizen children.