Medicaid expansion associated with lower death rates in young adults with kidney failure

Among young adults with kidney failure, the expansion of Medicaid following the Affordable Care Act signed into law in 2010 was associated with substantial declines in one-year death rates, researchers from Brown University found in a new study.

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."

Shailender Swaminathan, lead author, adjunct professor of health services, policy and practice at the Brown University School of Public Health

The researchers found that for young adults with kidney failure, Medicaid expansion led to improvements in pre-dialysis care, increased use of dialysis and longer dialysis sessions - all factors that can improve long-term health outcomes. The study, published in JAMA Pediatrics, focused on young adults for two main reasons.

"Young adults have historically been underinsured, but the Medicaid expansions under the Affordable Care Act were able to address that issue quite quickly," Swaminathan said. "Thus, we were able to find a large shift in health insurance coverage for young adults before and after Medicaid expansions. Second, unlike for older adults, benefits of Medicaid for young adults can potentially accrue over multiple years."

Prior to the Affordable Care Act, young adults had the highest rates of uninsurance of any age group in the United States. This was driven by several factors, including the loss of childhood eligibility for Medicaid coverage at age 19 and disproportionate employment in jobs that do not offer health insurance.

In 2010, the Affordable Care Act expanded Medicaid coverage for lower-income adults and required insurers to cover dependents on their parents' employer-provided insurance plans until age 26. As a result, uninsurance rates for young adults ages 19 to 25 fell from 31.5% in 2009 to 13.1% in 2023 - the biggest change among any age group.

To find out how the expansion affected the mortality rates of young adults, the Brown research team zeroed in on the high-risk population of young adults with kidney failure, whose death from heart disease is 500 times greater than that of their peers. The team studied 7,139 patients, comparing young adults affected by Medicaid expansion (ages 19 to 23) with adolescents whose eligibility was unchanged (ages 14 to 18). The study period extended from 2010 through 2019.

They found that one-year mortality among 19- to 23-year-olds initiating dialysis declined by a statistically significant 1.8 percentage points after insurance expansion.

Health insurance coverage and access is one of the central health policy issues currently facing the country, said study author Dr. Amal Trivedi, a professor of health services, policy and practice at Brown. Between 5 million and 10 million Americans are projected to lose Medicaid coverage by 2028 as a result of H.R.1 (the One Big Beautiful Bill Act) signed into law in July 2025.

"As we approach these issues, it's important to keep in mind that Medicaid expansion was associated with substantial reductions in mortality among young adults with kidney failure initiating dialysis," Trivedi said. "This suggests that expanded health insurance coverage may improve survival and care quality in this high-risk population."

The research was funded by the National Institute of Diabetes and Digestive and Kidney Diseases (R01DK113298, R01DK129388) and the National Institute of Minority Health and Health Disparities (R01MD017080).