Kidney Transplant Access Lower in Medicare Advantage

Medicare Advantage enrollees with end-stage kidney disease (ESKD) had substantially lower rates of kidney transplant and wait-listing than beneficiaries in traditional Medicare during the first 3 years after the 21st Century Cures Act expanded Medicare Advantage eligibility to this population, according to a cohort study published in JAMA.

The 21st Century Cures Act opened Medicare Advantage enrollment to individuals with ESKD, but evidence on whether Medicare Advantage plans affect access to kidney transplant—a treatment associated with better survival and quality of life than maintenance dialysis—has been limited. Investigators compared kidney transplant and incident wait-listing rates between Medicare Advantage and traditional Medicare beneficiaries with ESKD from January 1, 2021, through December 31, 2023, adjusting for demographic characteristics, dual Medicare-Medicaid eligibility, duration of ESKD, socioeconomic status, and hospital referral region.

The retrospective cohort included 630,848 Medicare beneficiaries aged 18 to 74 years with ESKD who had not received a kidney transplant in the prior 3 years (mean age, 57.9 years; 40.9% female; 35.2% Black; 19.4% Hispanic). Over 14.8 million person-months of follow-up, Medicare Advantage beneficiaries had lower kidney 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). Incident wait-listing was also lower among Medicare Advantage enrollees (3.05 vs 4.64 per 1000 person-months; aRR, 0.77; 95% CI, 0.75-0.78).

The gap in transplant rates was widest among the youngest beneficiaries, aged 18 to 44 years, and remained stable across each calendar year studied (aRRs ranging from 0.70 to 0.71 in 2021, 2022, and 2023). Among beneficiaries already wait-listed at baseline or added to a wait list during the study, Medicare Advantage enrollees still had lower transplant rates than traditional Medicare beneficiaries (16.59 vs 20.85 per 1000 person-months; aRR, 0.91; 95% CI, 0.90-0.92).

The study authors concluded that policy oversight may be needed to monitor access to kidney transplant for the growing population of Medicare Advantage beneficiaries with ESKD.

Source: Shah AD, Dana BA, Brazier JF, et al. Medicare Advantage enrollment and access to kidney transplant after the 21st Century Cures Act. JAMA. Published online September 21, 2026. doi:10.1001/jama.2026.14391