Shailender Swaminathan
Visiting Professor, Economics
Key Factors
Query Was Medicaid growth below the Affected person Safety and Inexpensive Care Act (ACA) related to decrease charges of Medicare-financed hospitalizations amongst adults with incident kidney failure?
Findings On this cross-sectional research of 188 671 US adults aged 19 to 64 years with kidney failure initiating dialysis, the ACA Medicaid growth was related to a discount within the variety of Medicare-financed hospitalizations within the first 3 months after dialysis initiation.
Which means Findings of this research counsel that decreases in Medicare-financed hospitalizations could point out favorable spillover outcomes from the ACA’s Medicaid growth to Medicare by way of decreased spending on hospitalizations amongst a clinically complicated affected person inhabitants.
Significance Though Medicare gives medical health insurance protection for many sufferers with kidney failure within the US, Medicare beneficiaries who provoke dialysis with out supplemental protection are uncovered to substantial out-of-pocket prices. The supply of expanded Medicaid protection below the Affected person Safety and Inexpensive Care Act (ACA) for adults with kidney failure could enhance entry to care and cut back Medicare-financed hospitalizations after dialysis initiation.
Goal To look at the implications of the ACA’s Medicaid growth for Medicare-financed hospitalizations, medical health insurance protection, and predialysis nephrology care amongst Medicare-covered adults aged 19 to 64 years with incident kidney failure within the first 12 months after initiating dialysis.
Design, Setting, and Contributors This cross-sectional research used a difference-in-differences strategy to evaluate Medicare-financed hospitalizations amongst adults aged 19 to 64 years who initiated dialysis between January 1, 2010, and December 31, 2018, whereas coated by Medicare Half A (as much as 5 years postexpansion). Knowledge on sufferers had been obtained from the Renal Administration Data System’s Finish Stage Renal Illness Medical Proof Report, which incorporates knowledge for all sufferers initiating outpatient upkeep dialysis no matter medical health insurance protection, therapy modality, or citizenship standing, and these knowledge had been linked with claims knowledge from the Medicare Supplier Evaluation and Assessment. Knowledge had been analyzed from January to August 2022.
Publicity Dwelling in a Medicaid growth state.
Fundamental Outcomes and Measures Major outcomes had been variety of Medicare-financed hospitalizations and hospital days within the first 3 months, 6 months, and 12 months after dialysis initiation. Secondary outcomes included twin Medicare and Medicaid protection at 91 days after dialysis initiation and the presence of an arteriovenous fistula or graft at dialysis initiation for sufferers present process hemodialysis.
Outcomes The research inhabitants included 188 671 adults, with 97 071 residing in Medicaid growth states (imply [SD] age, 53.4 [9.4] years; 58 329 males [60.1%]) and 91 600 residing in nonexpansion states (imply [SD] age, 53.0 [9.6] years; 52 677 males [57.5%]). Within the first 3 months after dialysis initiation, Medicaid growth was related to a major lower in Medicare-financed hospitalizations (−4.24 [95% CI, −6.70 to −1.78] admissions per 100 patient-years; P = .001) and hospital days (−0.73 [95% CI, −1.08 to −0.39] days per patient-year; P < .001), relative reductions of 8% for each outcomes. Medicaid growth was related to a 2.58–share level (95% CI, 0.88-4.28 share factors; P = .004) enhance in twin Medicare and Medicaid protection at 91 days after dialysis initiation and a 1.65–share level (95% CI, 0.31-3.00 share factors; P = .02) enhance in arteriovenous fistula or graft at initiation.
Conclusions and Relevance On this cross-sectional research with a difference-in-differences evaluation, the ACA’s Medicaid growth was related to decreases in Medicare-financed hospitalizations and hospital days and will increase in twin Medicare and Medicaid protection. These findings counsel favorable spillover outcomes of Medicaid growth to Medicare-financed care, which is the first payer for sufferers with kidney failure.
Practically 800 000 individuals within the US have kidney failure, with Black and Hispanic or Latino populations and people with low family incomes disproportionately affected.1–3 Amongst individuals with kidney failure handled with dialysis, the interval instantly after initiating dialysis carries substantial threat of mortality, frequent hospitalizations, infections, and cardiovascular occasions.4–6 Though mortality charges have declined lately, reported mortality charges amongst sufferers with incident kidney failure had been 8% at 90 days and 22% at 1 12 months.7
Medicare is the first insurer for people within the US aged 65 years and older in addition to these youthful than 65 with disabilities who obtain Social Safety Incapacity Insurance coverage (SSDI). Medicare additionally gives medical health insurance protection for many sufferers with kidney failure, and protection begins at 91 days after initiating in-center hemodialysis or on the time of enrolling in coaching for home-based dialysis. In 2017, Medicare fee-for-service spending for all beneficiaries with kidney failure was roughly $36 billion (or 6% of complete spending).1 Nonetheless, Medicare beneficiaries who provoke dialysis with out supplemental protection (eg, Medigap plans, employer-sponsored retiree advantages, or Medicaid) are uncovered to substantial out-of-pocket prices, and Medicare Half D prescription drug protection requires premiums and value sharing.8,9 As a part of the Affected person Safety and Inexpensive Care Act (ACA), states had the choice of increasing Medicaid eligibility to adults with low family incomes, and as of April 2022, 38 states and the District of Columbia have performed so.10 Medicaid growth has had favorable outcomes for sufferers with kidney illness, together with will increase in medical health insurance protection, Medicaid-covered preemptive listings for kidney transplantation, and 1-year survival after dialysis initiation.11,12 State Medicaid growth selections and Medicaid generosity (eg, ranges of state Medicaid protection) are related to decrease kidney failure incidence and elevated use of an arteriovenous fistula or graft at dialysis initiation.13,14
Along with offering help with Medicare premiums and value sharing,15 Medicaid growth could facilitate entry to predialysis nephrology take care of grownup sufferers initiating dialysis,8 thereby stopping issues and lowering the variety of Medicare-financed hospitalizations and hospital days instantly after dialysis initiation. These implications could also be evident amongst adults with low family incomes eligible for Medicaid after the ACA and for many who had been beforehand eligible for Medicaid however enrolled in this system after the ACA expansions, a phenomenon typically known as the woodwork or welcome mat impact. The purpose of the research was to look at the implications of Medicaid growth for Medicare-financed hospitalizations, medical health insurance protection, and receipt of predialysis nephrology care amongst Medicare-covered adults aged 19 to 64 years with incident kidney failure.
On this cross-sectional research, we used a difference-in-differences strategy to check adjustments within the variety of Medicare-financed hospitalizations, medical health insurance protection, and receipt of predialysis nephrology care over time in Medicaid growth vs nonexpansion states. The research inhabitants included individuals aged 19 to 64 years with kidney failure who initiated dialysis between January 1, 2010, and December 31, 2018, whereas coated by Medicare Half A. The research interval included 4 years throughout which sufferers initiated therapy earlier than Medicaid growth (2010-2013) and 5 years after growth (2014-2018). In keeping with earlier work, we thought-about growth states as those who applied the ACA’s Medicaid growth from 2014 and afterward and excluded 5 states that prolonged Medicaid eligibility to adults with low family incomes between 2010 and 2013 (eTable 1 within the Supplement).16,17 Every state’s postexpansion interval was outlined by its personal implementation date, which was January 1, 2014, for many states. The Brown College Institutional Assessment Board and the Facilities for Medicare & Medicaid Companies (CMS) Privateness Board authorized the research protocol and waived the requirement for knowledgeable consent as a result of solely deidentified knowledge had been used. The research adopted the Strengthening the Reporting of Observational Research in Epidemiology (STROBE) reporting guideline for cross-sectional research.
We used knowledge from the Renal Administration Data System’s Finish Stage Renal Illness Medical Proof Report (CMS 2728), which is accomplished for all individuals initiating outpatient upkeep dialysis no matter medical health insurance protection, therapy modality, or citizenship standing.18 As a result of CMS 2728 contains sufferers’ main mailing addresses, we geolocated sufferers into US Census tracts utilizing ArcGIS spatial mapping software program, model 10.5.1 (Esri).3,11,13,19 Hospitalizations had been assessed by linking the CMS 2728 knowledge to the Medicare Supplier Evaluation and Assessment, which incorporates details about all Medicare-financed hospitalizations, together with main diagnoses and variety of hospital days. Knowledge units had been linked utilizing sufferers’ Medicare beneficiary identifiers. We included sufferers with each conventional Medicare and Medicare Benefit as a result of the Medicare Supplier Evaluation and Assessment contains greater than 90% of hospitalizations for enrollees in Medicare Benefit.20,21 The 2009 to 2013 American Group Survey knowledge supplied the poverty fee in every affected person’s US Census tract.
The first outcomes had been the variety of Medicare-financed acute care hospitalizations and variety of acute care hospital days within the first 3 months, 6 months, and 12 months after initiation of dialysis. Secondary outcomes had been twin Medicare and Medicaid protection at 91 days after dialysis initiation, receipt of predialysis nephrology care, presence of arteriovenous fistula (AVF) or graft at dialysis initiation for sufferers present process hemodialysis, receipt of dwelling dialysis, and dialysis kind at initiation (hemodialysis vs peritoneal dialysis). We additionally assessed hospitalizations attributable to heart problems or infectious situations utilizing the US Renal Knowledge System’s strategy to categorise these situations.22 We attributed hospitalizations to the quarter of the affected person’s date of dialysis initiation.
Knowledge had been analyzed from January to August 2022. We used a linear regression mannequin with Huber-White strong SEs clustered on the state stage. Covariates included age, intercourse, race and ethnicity, main explanation for kidney failure, presence of congestive coronary heart failure, atherosclerotic coronary heart illness, different cardiac illness, hypertension, diabetes, diabetic retinopathy, most cancers, weight problems (physique mass index >30, calculated as weight in kilograms divided by top in meters squared), smoking standing, alcohol dependence, and hemoglobin and serum albumin ranges at dialysis initiation.11 The CMS 2728 specifies {that a} affected person’s race and ethnicity must be collected utilizing affected person self-report at therapy initiation and was categorised as Hispanic or Latino, non-Hispanic African American or Black, non-Hispanic Asian, non-Hispanic White, or non-Hispanic different race (American Indian or Alaska Native, Native Hawaiian or Pacific Islander, or different race). In keeping with earlier work, for observations lacking serum albumin and hemoglobin ranges, we used the imply worth of the covariates for nonmissing observations.11 All fashions included state and year-quarter mounted results. Analyses had been carried out in Stata, model 17 (StataCorp LLC) and used 2-tailed speculation testing with a significance threshold of P < .05.
We in contrast traits of individuals with kidney failure aged 19 to 64 years who had Medicare Half A at therapy initiation vs those that didn’t in the course of the research interval to evaluate the generalizability of our findings. To evaluate the validity of the difference-in-differences research design and to check the robustness of the findings, we carried out a number of sensitivity analyses (eAppendix within the Complement). First, we visually inspected preexpansion tendencies. Utilizing quarterly knowledge earlier than 2014, we then examined the statistical significance of an expansion-by-time development and individually used a categorical time specification. Second, we reran the analyses to incorporate states that expanded Medicaid earlier than January 1, 2014, or late-expanding states (eTable 1 within the Supplement). Third, we examined adjustments in affected person traits over time by state growth standing to account for potential shifts in affected person composition. Fourth, we used a Poisson mannequin to look at adjustments in variety of hospital days. Fifth, we ascertained the sensitivity of the outcomes to inclusion and exclusion of hemoglobin and serum albumin ranges within the risk-adjusted mannequin and included lacking hemoglobin and serum albumin ranges as an indicator variable. Sixth, we modeled the postperiod as an occasion research (evaluating annual adjustments in outcomes to a pooled preperiod), for which a state’s postexpansion interval was outlined by its personal implementation date (eTable 1 within the Supplement). Seventh, in exploratory analyses, we examined whether or not there have been differential adjustments in outcomes by age, intercourse, race and ethnicity, or area-level poverty (ie, residing in a US Census tract the place 20% or extra of the inhabitants was residing beneath the poverty threshold, which varies based mostly on the dimensions of the household and variety of youngsters within the family) by testing the importance of 3-way interactions amongst growth standing, time interval, and every attribute. As well as, to account for the competing threat of dying, we calculated mortality charges inside 3-month, 6-month, and 12-month durations after initiating therapy.
The research inhabitants included 188 671 adults aged 19 to 64 years who initiated dialysis whereas coated by Medicare Half A. Of this complete, 97 071 resided in Medicaid growth states (imply [SD] age, 53.4 [9.4] years; 58 329 males [60.1%] and 38 742 girls [39.9%]; 13.3% Hispanic or Latino, 26.4% non-Hispanic African American or Black, 3.4% non-Hispanic Asian, and 54.5% non-Hispanic White people and a pair of.5% non-Hispanic people of different races), and 91 600 resided in nonexpansion states (imply [SD] age, 53.0 [9.6] years; 52 677 males [57.5%] and 38 923 girls [42.5%]; 12.6% Hispanic or Latino, 40.2% non-Hispanic African American or Black, 1.0% non-Hispanic Asian, and 45.0% non-Hispanic White people and 1.2% non-Hispanic people of different races) (Table 1). The most typical unique cause for Medicare eligibility amongst each teams was incapacity insurance coverage advantages (59.5% in growth states, 51.9% in nonexpansion states) and incapacity and end-stage kidney illness (24.5% in growth states, 29.7% in nonexpansion states).
Major and Secondary Outcomes
Within the first 3 months after dialysis initiation, Medicaid growth was related to a major lower in Medicare-financed acute care hospitalizations (−4.24 [95% CI, −6.70 to −1.78] admissions per 100 patient-years; P = .001) and acute care hospital days (−0.73 [95% CI, −1.08 to −0.39] days per patient-year; P < .001), with relative reductions of 8% (Table 2, Figure 1). Medicaid growth was additionally related to important decreases in hospitalizations (−5.79 [95% CI, −10.36 to −1.23] admissions per 100 patient-years; P = .01) within the first 6 months after initiation of dialysis (eFigures 1 and a pair of within the Supplement).
Medicaid growth was related to a 2.58–share level enhance (95% CI, 0.88-4.28 share factors; P = .004) in twin Medicare and Medicaid protection at 91 days after dialysis initiation (a 6% relative enhance) (Table 2, Figure 2A). Though there have been no statistically important variations in receipt of predialysis nephrology care, dwelling dialysis, or dialysis kind (hemodialysis or peritoneal) by state growth standing (eFigures 3 and 4 within the Supplement), Medicaid growth was related to a major 1.65–share level enhance (95% CI, 0.31-3.00 share factors; P = .02) within the presence of an AVF or graft at dialysis initiation for sufferers present process hemodialysis (a 7% relative enhance) (Figure 2B).
Medicaid growth was related to a major discount within the variety of hospital days for cardiac situations within the 3 months after dialysis initiation (−0.13 [95% CI, −0.24 to −0.01] days per patient-year; P = .04) (Table 3; eFigures 5-7 within the Supplement). Medicaid growth was additionally related to important decreases within the variety of hospitalizations associated to infections at 3 months (−1.55 [95% CI, −2.41 to −0.68] admissions per 100 patient-years; P < .001), 6 months (−1.76 [95% CI, −3.06 to −0.46] admissions per 100 patient-years; P = .009), and 12 months (−3.23 [95% CI, −5.41 to −1.06] admissions per 100 patient-years; P = .004) after dialysis initiation (Table 3; eFigures 8-10 within the Supplement). Medicaid growth was additionally related to fewer hospital days for infection-related hospitalizations 3 months (−0.22 [95% CI, −0.34 to −0.09] days per patient-year; P = .001) and 6 months (−0.22 [95% CI, −0.40 to −0.04] days per patient-year; P = .02) after dialysis initiation.
A complete of 212 221 individuals (37.8%) aged 19 to 64 years with kidney failure who initiated dialysis had Medicare Half A protection (eTable 2 within the Supplement). There have been a number of variations in sociodemographic and medical traits between grownup individuals aged 19 to 64 years with kidney failure who initiated dialysis and had Medicare Half A protection in contrast with those that didn’t have such protection. Earlier than 2014, tendencies in outcomes weren’t statistically completely different by state growth standing for all outcomes besides variety of all-cause hospital days per patient-year inside 6 months and 12 months of dialysis initiation. We due to this fact didn’t examine the implications of Medicaid growth for these outcomes (eTable 3, eFigures 11-16 within the Supplement). There have been some adjustments within the traits of individuals with kidney failure over time in each growth and nonexpansion states, however these adjustments had been modest (eTable 4 within the Supplement). Estimates had been strong to completely different mannequin specs, though magnitudes of variations had been attenuated after we included states that expanded Medicaid earlier than 2014 (eTable 5 within the Supplement). Estimates utilizing Poisson fashions had been related in path and statistical significance, though the magnitude of variations was smaller in contrast with the primary mannequin. There was some variation in adjustments over time when respecifying the postperiod as an occasion research (eTable 6 within the Supplement). In exploratory analyses of differential outcomes by affected person sociodemographic traits, we noticed solely statistically bigger will increase in twin Medicare and Medicaid protection at 91 days after dialysis initiation amongst Hispanic or Latino sufferers (change by growth standing, 7.40 share factors) in contrast with White sufferers (change by growth standing, 1.81 share factors; 3-way interplay, 5.59 [95% CI, 3.32-7.86] share factors; P < .001) (eTables 7-15 within the Supplement). We didn’t establish statistically important adjustments in 3- and 6-month mortality charges by state growth standing; nonetheless, Medicaid growth was related to a considerably decrease 12-month mortality fee (0.55 [95% CI, −1.09 to −0.01] deaths per 100 patient-years; P = .04) (eTable 16 within the Supplement).
Amongst adults aged 19 to 64 years with kidney failure and Medicare protection who initiated dialysis, Medicaid growth was related to a lower in Medicare-financed hospitalizations 3 months after dialysis initiation and reduces within the variety of hospital days at 3 and 6 months after dialysis initiation. Medicaid growth was additionally related to will increase in twin Medicare and Medicaid medical health insurance protection, notably for Hispanic or Latino sufferers with kidney failure. Though there have been no important adjustments within the receipt of predialysis nephrology care, charges of dialysis initiation with an AVF or graft current amongst sufferers present process hemodialysis considerably elevated in states that expanded Medicaid. Constructing on earlier work, findings of the current research counsel that, amongst Medicare beneficiaries aged 19 to 64 years with incident kidney failure, Medicaid growth was related to a major lower in mortality charges 12 months after dialysis initiation.11
This research builds on the earlier literature in 3 methods: first, it gives new details about the implications of Medicaid growth for medical health insurance protection positive factors amongst these already eligible preexpansion. Earlier research indicated that Medicaid growth was related to will increase in Medicaid protection amongst sufferers with incident kidney failure.11,13 The current research pattern was composed of people that had Medicare protection at dialysis initiation, most of whom had been eligible for Medicare due to incapacity by way of SSDI. In most states earlier than implementation of the ACA, SSDI Medicare beneficiaries aged 19 to 64 years had been eligible just for supplemental Medicaid protection in the event that they concurrently obtained Supplemental Safety Revenue incapacity, which is strictly means examined for disabled people.23,24 The ACA expanded entry to Medicaid for SSDI recipients aged 19 to 64 years with low family incomes along with growing Medicaid participation amongst these already eligible for protection due to publicity, enrollment efforts, and different components, which is usually known as the woodwork or welcome mat impact.25,26 Current proof means that Medicaid growth was related to will increase in twin Medicare and Medicaid protection for older adults with low family incomes and people with disabilities.25 This research helps these estimates, suggesting that sufferers with incident kidney failure had pronounced will increase in twin Medicare and Medicaid protection after growth.
Second, the current research contributes new proof to the implications of Medicaid growth for adjustments in care use. Some coverage makers hypothesized that expanded Medicaid protection might cut back acute hospitalizations by bolstering entry to main care and different outpatient care. Most research, nonetheless, have advised that increasing Medicaid led to both elevated hospitalizations or no adjustments in hospitalizations.16,27–29 Findings of the current research, which used nationwide knowledge and targeted on a high-need and clinically complicated affected person inhabitants, counsel that Medicaid growth was related to important reductions in all-cause and infection-related hospitalizations. These outcomes align with previous work discovering that, amongst Medicare beneficiaries, notably these with continual situations, decrease value sharing could enhance entry to efficient outpatient care and generate offsetting reductions in acute hospitalizations.30,31 The current research’s findings counsel spillovers from the ACA’s Medicaid growth to Medicare within the type of well being advantages for Medicare enrollees and decreased spending on hospitalizations, the biggest supply of expenditures within the Medicare program.
Third, in contrast with different teams of Medicare beneficiaries, hospitalization charges are greater amongst individuals with kidney failure.32 There’s proof that the variety of annual admissions and hospital days for all-cause, cardiovascular, and infection-related hospitalizations have been declining amongst all sufferers with kidney failure since 2007, that are tendencies noticed in our research.22 For instance, between 2007 and 2016, hospitalization charges for all sufferers present process dialysis decreased by roughly 15%, with 1 research noting that the decreases may very well be affected by adjustments in medical care and insurance policies that incentivize use of ambulatory care providers.1,33 Findings of the current research counsel that, amongst sufferers aged 19 to 64 years initiating dialysis for incident kidney failure, reductions in hospitalizations and variety of hospital days had been extra pronounced for sufferers residing in states that expanded Medicaid. The relative 8% decreases related to Medicaid growth had been massive in magnitude contemplating the secular development between 2007 and 2016 was a 15% decline. This discovering is vital as a result of lowering hospitalizations among the many inhabitants with kidney failure is a medical and coverage precedence, together with public reporting on hospitalization charges for dialysis services. Moreover, Medicare is the first payer for care amongst individuals with kidney failure, and hospitalizations account for about 40% of Medicare expenditures for sufferers present process dialysis.22 Important decreases in 1-year mortality charges related to Medicaid growth assist previous findings11 and prolong this work to Medicare beneficiaries initiating dialysis therapy.
A number of research have evaluated the position of medical health insurance protection on entry to care, and twin Medicare and Medicaid protection could present further monetary safety to entry well being providers and medicines for sufferers with low family incomes who’re initiating dialysis.8,34 Though we didn’t establish important adjustments in receipt of predialysis nephrology care by Medicaid growth standing, it’s attainable that will increase in twin Medicare and Medicaid protection modified accessibility to prescribed drugs, main care, or different specialty care that mitigated the variety of hospitalizations and hospital days after dialysis initiation. The discovering that Medicaid growth was related to will increase in AVF could present a mechanism for the outcomes studied: placement of everlasting vascular entry has been related to fewer hospitalizations or emergency division use and decrease mortality amongst sufferers with kidney failure.35,36 Initiating hemodialysis with an AVF has been related to decrease mortality in contrast with initiating dialysis with a catheter.11,37
This research has a number of limitations. First, the research pattern was restricted to people who initiated dialysis whereas coated by Medicare Half A insurance coverage and might not be consultant of your entire inhabitants with kidney failure. It’s attainable adjustments related to Medicaid growth can be completely different for many who provoke therapy with out Medicare protection. Nonetheless, we discovered that just about 40% of adults aged 19 to 64 years initiating upkeep dialysis had Medicare Half A protection on the time of dialysis initiation. As well as, as a result of the CMS 2728 is accomplished for sufferers initiating upkeep dialysis, people who obtained solely dialysis for acute kidney failure and those that obtained dialysis within the hospital and died earlier than initiating outpatient therapy weren’t included within the evaluation. Second, we had been restricted to occasions that occurred after a affected person acquired Medicare protection, and we didn’t have knowledge on hospitalizations earlier than enrollment in Medicare. Third, it’s attainable that we had been unable to detect adjustments for subgroups due to smaller pattern sizes. Fourth, the research interval coincided with a number of adjustments in CMS guidelines round hospital stays (eg, Hospital Readmissions Discount Program in 2012, introduction of the Two-Midnight Rule in 2013), however it’s unlikely that these guidelines would differentially have an effect on states by growth standing. Fifth, though the difference-in-differences strategy and inclusion of state mounted results account for secular tendencies and potential state-specific coverage contexts, it’s believable that adjustments or variations in outcomes for sufferers who initiated therapy for kidney failure weren’t related to a state’s resolution to develop Medicaid. Sixth, for the end result analyzing adjustments in dialysis kind at initiation, it’s attainable that people switched their dialysis kind (hemodialysis vs peritoneal) after initiation. Seventh, we had been unable to evaluate variations in hospitalization-related out-of-pocket prices as a result of the info set didn’t embrace info resembling having supplemental protection or hospital networks (for Medicare Benefit beneficiaries). Nonetheless, further work to grasp the potential adjustments in out-of-pocket prices related to Medicaid growth amongst Medicare beneficiaries with kidney failure is warranted.
On this cross-sectional research, Medicaid growth was related to decreases in Medicare-financed hospitalizations and fewer acute care hospital days within the first 12 months after initiating dialysis, which is a high-risk interval, in addition to will increase in twin Medicare and Medicaid protection. This research means that there could have been favorable spillover outcomes of Medicaid growth to Medicare-financed care, which is the first payer for sufferers with kidney failure.
