Medicare Advantage Enrollment and Access to Kidney Transplant After the 21st Century Cures Act

Importance: Among patients with kidney failure, kidney transplant is associated with better survival and quality of life compared with maintenance dialysis. The 21st Century Cures Act expanded Medicare Advantage eligibility to individuals with end-stage kidney disease (ESKD), with limited evidence about access to transplant in Medicare Advantage plans. Objective: To compare kidney transplant and wait-listing rates between Medicare Advantage and traditional Medicare beneficiaries with ESKD in the first 3 years after the 21st Century Cures Act. Design, Setting, and Participants: Retrospective cohort study of Medicare beneficiaries aged 18 to 74 years with ESKD who had not received kidney transplant in the prior 3 years from January 1, 2021, through December 31, 2023. Exposure: Enrollment in Medicare Advantage vs traditional Medicare. Main Outcomes and Measures: The primary outcome was kidney transplant. The secondary outcome was incident (new) wait-listing. Models adjusted for demographic characteristics, dual Medicare-Medicaid eligibility, duration of ESKD, socioeconomic status, and hospital referral region. Results: The study population included 630 848 Medicare beneficiaries with ESKD (mean age, 57.9 [SD, 11.0] years; 40.9% female; 35.2% Black; and 19.4% Hispanic). Over 14.8 million person-months, Medicare Advantage beneficiaries had lower transplant rates than those in traditional Medicare (2.51 vs 4.60 per 1000 person-months; adjusted rate ratio [aRR], 0.71; 95% CI, 0.69-0.72). Absolute differences were widest among the youngest beneficiaries (aged 18-44 years) and were stable across calendar years (aRRs: 0.71 [95% CI, 0.68-0.73] in 2021; 0.70 [95% CI, 0.68-0.73] in 2022; and 0.70 [95% CI, 0.68-0.72] in 2023). Incident wait-listing was also lower in Medicare Advantage (3.05 vs 4.64 per 1000 person-months; aRR, 0.77; 95% CI, 0.75-0.78). Among beneficiaries wait-listed at baseline or placed on a wait list during observation, Medicare Advantage enrollees had lower transplant rates (16.59 vs 20.85 per 1000 person-months; aRR, 0.91; 95% CI, 0.90-0.92). Conclusions and Relevance: In the first 3 years following the 21st Century Cures Act, Medicare Advantage beneficiaries with ESKD had substantially lower transplant and wait-listing rates than traditional Medicare beneficiaries. Policy oversight may be needed to monitor access for this critical, high-value treatment for kidney failure among the rapidly growing Medicare Advantage population.