Health Care Disparities Persist Across Liver Diseases

Insurance type and race were associated with liver disease disparities at nearly every step of care studied, from cancer surveillance to transplant listing to new and curative drug therapies, according to 4 studies presented at The Liver Meeting 2026. The American Association for the Study of Liver Diseases’ annual meeting is being held in Denver, Colorado, this year.^1-4 In the studies, Medicaid coverage was linked to lower odds of guideline-interval hepatocellular carcinoma (HCC) surveillance and to lower representation on transplant waiting lists at high-volume centers.^1,2

Medicaid and Other Social Factors Tied to HCC Surveillance Gaps

Researchers from UT Southwestern Medical Center, Baylor College of Medicine, and the Michael E. DeBakey VA Medical Center prospectively enrolled 1326 patients with cirrhosis from 4 US health systems, all with at least 1 outpatient visit in the prior year, and surveyed them about education, income, insurance, health literacy, housing, and barriers to liver care.¹ Although 61.4% completed annual surveillance imaging, only 25.9% completed semiannual surveillance, and the median proportion of time covered was 65.5% (IQR, 33.5%-85.2%).

In multivariable analysis, Medicaid insurance (OR, 0.55; 95% CI, 0.34-0.86), Spanish language (OR, 0.64; 95% CI, 0.42-0.98), female gender (OR, 0.73; 95% CI, 0.58-0.93), and the highest quartile of self-reported barriers to liver care (OR, 0.60; 95% CI, 0.44-0.82) were associated with lower odds of semiannual surveillance, while a college education was associated with higher odds (OR, 1.50; 95% CI, 1.15-1.96).

“Addressing barriers to liver care and a focus on underinsured patients belonging to high-risk subgroups may improve surveillance utilization and early-stage HCC detection,” the authors wrote.

Medicaid Patients Underrepresented on Liver Transplant Lists

An analysis of 114,778 adults listed for liver transplant at 142 centers in 33 states from 2014 to 2024 found that Medicaid-insured patients made up 23.6% of listings in states that expanded Medicaid in 2014 vs 10.0% in states that never expanded (P < .001).² The gap was widest at the highest-volume centers (23.2% vs 9.8%), and transplant volume alone did not explain the variation.

In one nonexpansion state, 2 large centers with a combined 2800 listings each had 0.2% Medicaid-insured patients, while a smaller center had 26.6%. Waitlist mortality was lower among privately insured patients in both expansion and nonexpansion states.

“This gap is even more pronounced in the highest-volume [liver transplant] centers, further exacerbating disparities,” the authors wrote.

Liver Disease Disparities in Resmetirom and Hepatitis C Treatment

A retrospective comparison of 747 patients with metabolic dysfunction–associated steatotic liver disease who received resmetirom (Rezdiffra; Madrigal Pharmaceuticals) and 169,839 who did not found that Black patients accounted for 5% of resmetirom users vs 9% of comparators (P = .0008).³ The authors cautioned that this “should be interpreted as a modest access signal, not proof of independent prescribing inequity,” given higher rates of unknown race documentation and limited socioeconomic data.

In a systematic review and meta-analysis of 12 US observational studies including 660,513 patients with chronic hepatitis C, Black patients (pooled OR, 0.88; 95% CI, 0.80-0.98) and Hispanic patients (pooled OR, 0.74; 95% CI, 0.57-0.96) had lower odds than White patients of starting direct-acting antiviral therapy.⁴ Heterogeneity across studies was substantial, though the direction of effect was largely consistent.

Three of the studies were retrospective, and the resmetirom comparison was unadjusted and did not account for fibrosis stage, payer status, or treatment eligibility. The meta-analysis pooled observational studies with high heterogeneity, and the surveillance study, while prospective, included only patients already connected to care. None of the studies has yet been published in a peer-reviewed journal.

The resmetirom investigators called for adjusted studies to evaluate payer status, specialty access, geography, and eligibility “to ensure that MASH-directed therapy does not widen existing liver-disease disparities.”³

References

1. Al-Hasan M, Rich N, Quirk L, et al. Social determinants of health and HCC surveillance receipt in patients with cirrhosis: a multicenter cohort study. Paper presented at: The Liver Meeting 2026; November 5-9, 2026; Denver, Colorado. Abstract 0121.

2. Rosenblatt R, Goldberg D. Having insurance is not enough: Medicaid insured patients still lack equitable access to listing for liver transplant. Paper presented at: The Liver Meeting 2026; November 5-9, 2026; Denver, Colorado. Abstract 0127.

3. Ezeano C, Kanu I, Boateng S, et al. New therapy, old equity questions: racial disparities in resmetirom use for MASLD. Poster presented at: The Liver Meeting 2026; November 5-9, 2026; Denver, Colorado. Abstract 3564.

4. Syed A, Zahid MD, Akinditan V, Hasan S, Bari K. Unequal access to curative therapy: racial and ethnic disparities in direct-acting antiviral treatment for chronic hepatitis C in the United States. Paper presented at: The Liver Meeting 2026; November 5-9, 2026; Denver, Colorado. Abstract 0120.