Complex role of insurance in living donor kidney transplantation: Perspectives from the affordable care act era

The landscape of organ transplantation in the United States reflects a complex and multifaceted reality. According to the latest OPTN/UNOS statistics on kidney transplants, 20446 deceased organ donors contributed to these life-saving procedures, alongside 5798 living donor kidney transplants (LDKT). Despite these advancements, the transplant waiting list remains alarmingly long, with approximately 140165 individuals still awaiting a kidney. In addition, there are still inequalities in access to LDKT. As of December 31, 2022, Black adults accounted for 31.7% of the transplant waiting list, yet only 12.8% of LDKT recipients, compared to 34.1% of deceased donor kidney transplant (DDKT) recipients that year. Conversely, White patients represented 35.5% of those on the list, but comprised 61.4% of LDKT recipients and 35.3% of DDKT recipients. A majority of adult LDKT recipients (54.5%) had private insurance at the time of transplantation, compared to 26.9% of DDKT recipients. In addition, 62.5% of patients with a kidney transplant from a deceased donor were covered by Medicare, in contrast to 37.6% of living donor kidney transplant recipients. In 2022, 33.3% of adult living donor kidney transplant recipients were transplanted without prior dialysis, compared to 12.1% of deceased donor kidney transplant recipients. These data highlight the critical need to dismantle barriers to transplantation, particularly those rooted in insurance coverage and socioeconomic disparities.