Key takeaways:

• Kidney transplant rates have been lower for Medicare Advantage beneficiaries in the first 3 years since the 21st Century Cures Act was passed.
• Younger and Hispanic beneficiaries faced the largest disparities.

Kidney transplant and wait-listing rates were lower for beneficiaries with Medicare Advantage vs. traditional Medicare, according to study data published in JAMA.

The 21st Century Cures Act, passed in 2021, permitted all individuals with end-stage kidney disease to enroll in Medicare Advantage plans, according to Ankur Shah, MD, MPH, associate professor of medicine at the Warren Alpert Medical School of Brown University, and colleagues. However, data exploring whether Medicare insurance type impacts access to kidney transplant have been limited, the researchers wrote.

Data derived from Shah AD, et al. JAMA. 2026;doi:10.1001/jama.2026.14391.

“Earlier work had shown that enrollment into Medicare Advantage for patients on dialysis was expanding rapidly, and we’ve begun seeing differences in our experience in clinical care, but we didn’t know if this anecdote was merely a perception or a sign of a larger pattern,” Shah told Healio.

In a retrospective cohort study, the researchers compared kidney transplant and wait-listing rates between beneficiaries with traditional Medicare and Medicare Advantage within the first 3 years after the 21st Century Cures Act’s passage (2021-2023). The data included 630,848 patients aged 18 to 74 years with ESKD (mean age, 57.9 years; 40.9% women; 35.2% Black).

Results showed Medicare Advantage beneficiaries, compared with traditional Medicare beneficiaries, had lower transplant rates (adjusted rate ratio [aRR] = 0.71; 95% CI, 0.69-0.72) and wait-listing rates (aRR = 0.77; 95% CI, 0.75-0.78).

In addition, kidney transplant rates were lower for Medicare Advantage beneficiaries who were wait-listed at baseline or during the study period (aRR = 0.91; 95% CI, 0.9-0.92).

Lower transplant rates for beneficiaries with Medicare Advantage vs. traditional Medicare persisted in each year since the 21st Century Cures Act’s introduction, including 2021 (aRR = 0.71; 95% CI, 0.68-0.73), 2022 (aRR = 0.7; 95% CI, 0.68-0.73) and 2023 (aRR = 0.7; 95% CI, 0.68-0.72).

Further subgroup analyses showed that the largest disparities in transplant rates were for beneficiaries aged 18 to 44 years with Medicare Advantage vs. traditional Medicare (aRR = 0.76; 95% CI, 0.73-0.79) and Hispanic enrollees with Medicare Advantage vs. traditional Medicare (aRR = 0.79; 95% CI, 0.76-0.82).

Overall, the findings suggest Medicare Advantage beneficiaries may have reduced access to kidney transplantation vs. traditional Medicare beneficiaries, according to the researchers.

Although the exact reasons cannot be determined from the study, a few possibilities may explain the discrepancy, according to Shah.

“On the plan side, narrow networks may limit which transplant centers patients can use,” he said. “Prior authorization can also add delays at each step of the long transplant pathway. Nephrologists should know which plan a patient is in and watch for plan-related delays during transplant referral and evaluation.”

Further research is needed to address research gaps regarding Medicare Advantage plan features and drop-offs in the transplant pathway, according to Shah.

“The most important gap is plan-level detail — we couldn’t observe each plan’s transplant center network, prior authorization rules or supplemental benefits, so we can’t yet say which plan features drive the differences or whether some plans perform as well as traditional Medicare,” he said. “Second, we need to know where in the pathway patients drop off. Our data begin at wait-listing, but the earlier steps, such as nephrologist referral, starting evaluation and finishing it are where a lot of attrition likely happens and where Medicare Advantage processes may matter most.”

For more information:

Ankur Shah, MD, MPH, associate professor of medicine and associate chief for research in the division of kidney disease and hypertension at the Warren Alpert Medical School of Brown University, can be reached at ankur_shah@brown.edu.