Insurance Churn and Survival After Heart Transplantation in the Modern Era: A National Cohort Study

Background. Heart transplantation (HT) in the United States continues to be increasingly performed in the setting of expanding Medicare and Medicaid public insurance coverage. We analyze the impact of recipient insurance trajectories on long-term graft and recipient survival following the 2018 United Network for Organ Sharing (UNOS) heart allocation change. Methods. Adults aged 18-64 undergoing first-time HT between 10/2018 and 3/2024 were identified in the UNOS database. Patients surviving ≥1 year were stratified by insurance trajectory (private vs. public, including Medicare, Medicaid, and VA) at waitlist, transplantation, and 1-year follow-up. Kaplan-Meier and Cox regression models were used to assess survival and graft failure risk. Results. Among 15,864 patients, 42.5% had continuous private insurance, 33.9% had continuous public insurance, 12.6% transitioned from private to public, 4.8% transitioned from public to private, and 6.3% experienced multiple transitions. Five-year survival (p<0.0001) and graft survival (p=0.03) were poorer in patients with continuous public insurance or who transitioned from private to public insurance. Primary graft dysfunction rates were highest among recipients with continuous public insurance (1.4%; p<0.0001). Continuous public insurance (HR 1.27, p<0.0001) and multiple transitions (HR 1.19, p=0.04) increased mortality risk compared to continuous private insurance. Continuous public insurance (HR 1.29, p=0.01), private-to-public transition (HR 1.32, p=0.03), and multiple transitions (HR 1.09, p=0.02) were linked to higher graft failure risk. Public-to-private transition was associated with lower graft failure risk (HR 0.73, p=0.02). Residence in distressed communities increased mortality (HR 1.21, p=0.003) and graft failure risk (HR 1.31, p=0.001). Conclusions. Public insurance and insurance instability are associated with worse HT outcomes, while gaining private insurance was associated with improved outcomes, highlighting disparities in post-transplant care.