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

BackgroundHeart 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. MethodsAdults aged 18-64 undergoing first-time HT between 10/2018 and 3/2024 were identified in the UNOS database. Patients surviving [&ge;]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. ResultsAmong 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). ConclusionsPublic 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. What is KnownO_LIPost-heart-transplant outcomes differ by insurance type, with publicly insured recipients generally experiencing worse long-term survival and higher complication rates than privately insured recipients. C_LIO_LIPrior transplant analyses often treat insurance as a static exposure rather than a time-varying trajectory spanning waitlist, transplant, and follow-up. C_LIO_LIInsurance transitions ("churn") are detrimental: in pre-Affordable Care Act and the 2018 allocation change cohorts, private to public switch within 1-year associates with higher mortality. C_LIO_LISocioeconomic disadvantage independently correlates with poorer post-transplant outcomes beyond clinical risk. C_LI What the Study AddsO_LIThis is the first national, post-2018 allocation analysis to model insurance as a time-varying trajectory across the waitlist, transplant hospitalization, and the first post-transplant year. C_LIO_LIContinuous public insurance and insurance instability (multiple coverage transitions) are each independently associated with higher adjusted risks of mortality and graft failure than continuous private insurance. C_LIO_LIThe direction of churn is clinically meaningful: a private to public switch increases graft-failure risk, whereas public to private associates with lower mortality and graft failure rates compared with remaining on public insurance C_LIO_LIDefines a distinct and actionable morbidity profile linked to continuous public coverage--longer hospitalizations and higher rates of dialysis, acute rejection, and treatment for rejection, along with the highest incidence of primary graft dysfunction -- pinpointing concrete targets for perioperative pathways, discharge planning, and payer-continuity interventions. C_LIO_LINeighborhood socioeconomic distress independently predicts mortality and graft failure above and beyond clinical covariates and insurance trajectory, highlighting structural levers for quality-improvement and policy. C_LI