JAMA Pediatr
Medicaid expansion cut dialysis deaths in young adults
Clinical Takeaway: Insurance coverage may affect survival in young adults with kidney failure. Coverage disruptions could worsen outcomes in patients who depend on consistent dialysis access and predialysis care.
Young adults with kidney failure face an exceptionally high risk of early death, yet they have historically also had some of the highest rates of uninsurance. Many lose stable insurance coverage just as they age out of pediatric Medicaid eligibility. This study examined whether Affordable Care Act Medicaid expansion changed survival and dialysis care during that transition into adulthood.
This study found that Affordable Care Act Medicaid expansion was associated with lower 1-year mortality among young adults initiating dialysis. Mortality in patients ages 19 to 23 fell from 3.6% before expansion to 2.1% afterward. This translated to about two fewer young adults dying within a year of starting dialysis for every 100 patients treated. For adolescents whose Medicaid eligibility was not affected, mortality rates slightly increased, though the difference was not statistically significant.
The analysis included 7,139 patients in expansion states between 2010 and 2019 and compared outcomes in young adults ages 19 to 23, who were directly affected by Medicaid expansion, with adolescents ages 14 to 18, whose eligibility remained largely unchanged. Medicaid coverage increased from 37% to 49% in the older group, while uninsurance rates fell from 19% to 8%.
The survival improvement coincided with measurable differences in dialysis care delivery. Young adults were more likely to receive predialysis nephrology care, undergo hemodialysis sessions lasting at least 4 hours, and start peritoneal dialysis after expansion. The study did not find changes in catheter use at dialysis initiation or kidney transplant rates.
The findings arrive as Medicaid coverage losses are again expected to affect millions of Americans after recent federal policy changes. Young adults with kidney failure represent a particularly vulnerable group because dialysis requires intensive, continuous care with little margin for interruption. The results suggest that insurance coverage affects more than access alone and may influence the quality and timing of kidney care before and after dialysis initiation.
“The biggest takeaway from this study is that health insurance is critically important for survival among individuals with a high and constant need for medical care,” said Shailender Swaminathan, PhD, adjunct professor of health services, policy and practice at the Brown University School of Public Health.
Source: Swaminathan S. JAMA Pediatr. 2026 May 11. Medicaid Expansion and 1-Year Mortality Among Young Adults Initiating Dialysis