Insurance, Region, and Ethnicity Drive Gaps in Liver Transplant Access

Patients with end-stage liver disease who are insured by Medicaid, live in the western US, are Hispanic or Latino, or have unmet social needs face disparities in access to liver transplant and related care, according to 6 studies presented Saturday at The Liver Meeting 2026.¹ One analysis found that some high-volume transplant centers listed almost no Medicaid-insured patients over a decade.

The oral abstract session, “Health Equity in Transplant and Advanced Liver Disease,” was moderated by Cristal Brown, MD, assistant professor in the Department of Internal Medicine at the University of Texas at Austin Dell Medical School, and Karn Wijarnpreecha, MD, MPH, a transplant hepatologist at Mayo Clinic in Jacksonville, Florida. Presenters examined how insurance, geography, race and ethnicity, social needs, and sex are associated with access to transplant and outcomes in advanced liver disease.

Medicaid Listing for Liver Transplant Varies Widely by Center

Russell Rosenblatt, MD, assistant professor of medicine at Weill Cornell Medicine and medical director of living donor liver transplant at NewYork-Presbyterian Hospital in New York, New York, presented an analysis of whether Medicaid-insured patients have equal access to the liver transplant waitlist across centers.¹ A prior study coauthored by Rosenblatt found that Medicaid use on the waitlist rose from 19.4% to 26.1% in states that expanded Medicaid under the Affordable Care Act but fell from 13.4% to 12.1% in states that did not.²

The new study used Organ Procurement and Transplantation Network (OPTN) data from 2014 to 2024 on adults in states with at least 3 transplant centers that either expanded Medicaid in 2014 or never expanded it. Of 104,167 listed patients, 63,290 (60.8%) were in 20 expansion states with 90 centers, and 40,877 (39.2%) were in 13 nonexpansion states with 49 centers. Medicaid covered 24.7% of listed patients in expansion states vs 10.6% in nonexpansion states (P < .001). Among small centers performing fewer than 50 transplants per year, Medicaid listing was similar (18% vs 17%; P > .05), but it differed significantly at medium centers (21% vs 13%; P = .02) and at large centers performing more than 100 per year (24% vs 10%; P < .001).

In Texas, a nonexpansion state, the 2 largest centers each listed 0.2% Medicaid-insured patients, and the center with the highest share (18.2%) listed 222 patients over the study period. In California and New York, both expansion states, Medicaid accounted for 31.2% and 29.6% of listings, respectively. Rosenblatt noted the study could not assess referral patterns or center intent.

“I want to be clear that I'm not assuming center intent, and this is not saying that any center does not want to or any doctor does not want to help a patient who has Medicaid,” Rosenblatt said. “I think the system is set against Medicaid patients and incentivizes centers to not list them because they’re afraid of losing money, and that, to me, is the driver of this.”

Rosenblatt described himself as “a strong proponent of insurance for all of our patients” and said Medicaid expansion “would help our patients and incentivize centers to accept Medicaid patients in general.”

Asked during the question-and-answer period whether programs could model how many Medicaid patients they can afford to list, he pointed to a lack of cost transparency at transplant centers. “I think a lot of it has to do with actually being transparent about money,” he said.

Access to Transplant for Alcohol-Associated Liver Disease Lags in the West

Alcohol-associated liver disease (ALD) is now the leading indication for liver transplant in the US, but there are regional differences in access to transplant, explained Sharmitha Yerneni, MD, an internal medicine resident at NewYork-Presbyterian/Columbia University Irving Medical Center.³ She cited the federal OPTN Final Rule, which went into effect in 2000 and states that place of residence or listing should not be a major determinant of access.

“Essentially, where one lives should not dictate whether one has access to a liver transplantation or not,” Yerneni said.

The researchers compared 48,820 transplant waitlist registrations for ALD with 262,909 ALD-related deaths from 2011 to 2024, using a listing-to-death ratio as a population-level measure of access. The Northeast had a ratio of 0.31, and the West had 0.12, a 2.6-fold difference. United Network for Organ Sharing regions 2 and 6 differed 4-fold, and Maryland (0.63) had more than 15 times the ratio of Alaska (0.04). States with greater social deprivation tended to have lower access (r = –0.40).

“These findings suggest that socioeconomic disadvantage may contribute to geographic disparities in transplant access, potentially through barriers related to health care access, insurance, transportation, and social support,” Yerneni said.

Access varied more for alcohol-associated hepatitis than for alcohol-associated cirrhosis (coefficient of variation, 84.5% vs 59.3%; P < .001), which Yerneni said may reflect differences in referral or center selection criteria. The analysis was observational and population-based, and the team is in the process of repeating the analysis using transplant referral regions, Yerneni said.

Responding to an internist from Alaska who said high rates of alcohol-associated hepatitis among Alaska Native and American Indian populations may drive the western gap, Yerneni said the causes are “very multifactorial and not necessarily just attributed to the proximity” of transplant centers.

Hepatorenal Syndrome Deaths Rose During COVID-19, Then Fell

Jagadish Koyi, MD, an internal medicine resident at Integris Health in Oklahoma City, Oklahoma, presented national trends in deaths from hepatorenal syndrome (HRS) from 2018 to 2024 using CDC death-certificate data.⁴

Of 3395 deaths with HRS listed as the underlying cause, annual deaths peaked at 550 in 2021, and the COVID-19 era averaged 11.8% more deaths per year than the prepandemic period. By 2024, the annual count of 419 was the lowest in the study period. Adults aged 35 to 44 years (rate ratio [RR], 1.51; 95% CI, 1.09-2.08) and men (RR, 1.14; 95% CI, 1.03-1.27) drove the surge, and the share of HRS deaths among adults aged 25 to 44 years rose from 4.6% in 2019 to 11.2% in 2024.

Rates in the most rural counties were 2.9 times those of large central metropolitan areas, and the South accounted for 1368 deaths (40%). Deaths at home rose from 10.5% in 2018 to 19.8% in 2023, and 15% of decedents with known education held a bachelor’s degree. “HRS is a clinical problem. It is a social one too,” Koyi said.

“For a condition where survival is measured in weeks, distance from a hepatologist or a transplant center matters,” he added. He noted that the decline after 2021 coincided with the 2022 FDA approval of terlipressin but described that timing as “a context and not as a cause.”

Because the analysis captured only deaths with HRS as the underlying cause, it reflects roughly 1 in 10 HRS-related deaths. Koyi called for earlier detection of kidney injury, alcohol use treatment integrated into hepatology care, and expanded telehepatology.

“If we focus on the young, the rural, and the underserved, we can keep that curve going down,” he said.

Unmet Social Needs Linked to Frailty in Compensated Cirrhosis

One-quarter of adults with compensated cirrhosis had at least 1 unmet core health-related social need (housing, food, transportation, or utilities), and 8.3% had 2 or more.⁵ Ani Kardashian, MD, MS, assistant professor of clinical medicine at the Keck School of Medicine of the University of Southern California in Los Angeles, presented the results of a cross-sectional analysis of 1183 adults with compensated cirrhosis from 10 sites in the Liver Cirrhosis Network Cohort Study. Frailty affected 20% of participants with any unmet core need vs 9.1% of those without one.

After adjustment for demographics, body mass index, alcohol use, comorbidities, cirrhosis etiology, and disease severity, 1 unmet core need was associated with higher odds of frailty (OR, 1.89; 95% CI, 1.20-3.00; P = .006), as were 2 or more (OR, 3.88; 95% CI, 2.29-6.56; P < .001). Two or more needs were also associated with minimal hepatic encephalopathy (OR, 1.69; 95% CI, 1.07-2.67; P = .024).

Because the design was cross-sectional, the direction of the relationship could not be established. “My hypothesis is that it’s bidirectional,” Kardashian said, noting that patients with chronic illness may be unable to work, which adds to household financial strain.

“If one in four of our patients with compensated cirrhosis have an unmet need, then at the very least we should try to identify the patients that are at high risk and refer them to our social workers and our case managers,” Kardashian said.

Asked how clinicians can screen without causing patients shame, she recommended building standardized questions into routine intake in the electronic medical record. “I think standardizing it as much as possible actually normalizes these questions,” she said.

Latino Candidates Less Likely to Receive Living Donor Liver Transplant

Tulio L. Correa, MD, an internal medicine resident at the University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania, presented a competing-risk analysis of living donor liver transplant among adults listed from 2014 to 2024.⁶ Living donor transplant was received by 2.7% of Hispanic or Latino candidates vs 3.8% of non-Hispanic White candidates, and the 3-year cumulative incidence was 2.9% vs 4.3%. After adjustment, Latino ethnicity remained associated with lower receipt of a living donor transplant (subdistribution HR, 0.86; 95% CI, 0.76-0.96).

Latino candidates were more likely to have less than a high school education (21% vs 2%) and less likely to be employed or to be US citizens, according to the presentation. Correa said living donation “depends on social and family structures and networks to identify a willing donor,” and that potential donors may be limited by immigration concerns, lack of insurance, out-of-pocket costs, and metabolic disease.

“If we want to achieve equity in living donor transplantation, we need projects and ideas to better address these barriers, including donor identification, financial burden, and donor eligibility,” Correa said. In response to an audience question, he said the analysis did not adjust for transplant center, and that state- and center-level analyses are planned for the manuscript, which is under minor revision. He also pointed to cultural barriers, saying that education and “talking early to these patients about this possibility” are important.

Men Face Higher Mortality After Liver Transplant

Women made up 33% of the liver transplant waitlist in 2006 and 41% in 2025, according to research on sex differences among 214,827 liver transplant candidates with chronic liver disease in the Scientific Registry of Transplant Recipients from 2006 to 2025, presented by Maria Stepanova, PhD, of the Center for Outcomes Research in Liver Diseases in Washington, DC.⁷ By 2025, ALD was the leading etiology in both sexes, accounting for 53% of listings among men and 39% among women, followed closely in women by metabolic dysfunction-associated steatohepatitis (36%).

Women had higher crude waitlist mortality (11% vs 9%), but the difference did not hold within etiology groups. “After adjustment, we found that male sex, candidate sex, was not independently associated with adverse waitlist outcomes within any individual liver disease etiology,” Stepanova said.

After transplant, survival “was nearly identical at one year, but then it gradually separated with longer follow-up,” she said, and 5-year mortality was 22% in men vs 20% in women (adjusted HR, 1.12; 95% CI, 1.09-1.14). Public insurance was also associated with higher posttransplant mortality in both sexes, with an adjusted HR for Medicaid vs private insurance of 1.12 in men and 1.21 in women.

“After accounting for other risk factors, sex was not independently associated with waitlist outcomes, but after transplantation, male sex was independently associated with higher mortality across several major [chronic liver disease] etiology subgroups,” Stepanova concluded.

References

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

2. Wahid N, Lee J, Rosenblatt R, et al. Affordable Care Act Medicaid expansion associated with increased liver transplant waitlist access without worsening mortality. Liver Transpl. 2024;30(1):20-29. doi:10.1097/LVT.0000000000000221

3. Yerneni S, Rosenblatt R, Palte E, Cullaro G, Verna E, Im GY. Geographic disparities leave patients in the Western US with unequal access to liver transplant for alcohol-associated liver disease. Abstract presented at: The Liver Meeting 2026; November 5-9, 2026; Denver, Colorado. Abstract 0125.

4. Kodali NA, Gundapaneni SRC, John SS, et al. Hepatorenal syndrome mortality in the United States, 2018-2024: pre-COVID, COVID-era, and post-COVID national trends and disparities. Abstract presented at: The Liver Meeting 2026; November 5-9, 2026; Denver, Colorado. Abstract 0126.

5. Kardashian A, Smith A, Kan A, et al; LCN Cohort Study Group. Burden of health-related social needs are independently associated with frailty and minimal hepatic encephalopathy in compensated cirrhosis: a Liver Cirrhosis Network study. Abstract presented at: The Liver Meeting 2026; November 5-9, 2026; Denver, Colorado. Abstract 0129.

6. Correa TL, Sierra L, Parraga X, et al. Hispanic/Latino liver transplant candidates have lower access to living donor liver transplantation in the United States: a national competing-risk analysis. Abstract presented at: The Liver Meeting 2026; November 5-9, 2026; Denver, Colorado. Abstract 0124.

7. Henry L, Stepanova M, Germani G, et al. Sex disparities in the liver transplant journey: from candidacy to long-term outcomes in a 20-year US cohort. Abstract presented at: The Liver Meeting 2026; November 5-9, 2026; Denver, Colorado. Abstract 0128.