ACA expansion linked to better liver disease outcomes
The analysis is believed to be the first of its kind.
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01/07/2026
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by Doug Brunk
The Affordable Care Act (ACA), especially its Medicaid expansion (ME), has helped people with chronic liver disease who qualify for Medicaid get better access to care, live longer, and experience fewer health disparities, according to a new review.
“The findings are especially timely as several states still have not expanded Medicaid and millions of patients are losing coverage following the unwinding of pandemic-era continuous enrollment,” the study’s senior author, Lauren D. Nephew, MD, MSCE, Assistant Professor of Medicine in the Division of Gastroenterology and Hepatology and the Assistant Vice Chair of Health Equity at Indiana University School of Medicine, told GI & Hepatology News. “Liver disease disproportionately affects socially marginalized populations. Demonstrating that Medicaid expansion improves early cancer detection, transplant access, survival, and equity provides strong evidence that insurance policy is a powerful lever for improving liver-related outcomes at the population level and for reducing health disparities.”
In what the authors describe as the first analysis of its kind, reported in Clinical Gastroenterology and Hepatology, Dr. Nephew and colleagues reviewed studies published between 2010 and 2025 that included adults with chronic liver disease and evaluated ACA/ME effects on access to services, survival and mortality, and disparities in outcomes. They focused on 27 studies that compared outcomes between ME and non–Medicaid Expansion (NME) states before and after ACA implementation and used the validated Cochrane Risk of Bias in non-Randomized Studies of Interventions tool to assess the quality of studies included.
The 27 studies spanned four clinical categories: hepatitis C virus, liver transplantation, hepatocellular carcinoma, and cirrhosis or chronic liver disease. Twenty-three studies reported improved outcomes associated with ACA/ME and most met criteria for low-to-moderate risk of bias and used causal inference methods. Difference-in-difference analyses identified the following trends for each clinical category:
HCV studies showed improved access to direct-acting antiviral therapy in ME states. Expansion states consistently reported higher direct-acting antiviral prescription rates and Medicaid reimbursement levels compared with NME states.
Liver transplantation listing increased by 1.8% to 6% in ME versus NME states. Black and Hispanic patients experienced significantly larger increases in Medicaid-supported waitlisting in ME states, suggesting partial mitigation of long-standing access barriers. However, improvements in transplant rates were not observed across racial subgroups.
Findings on early-stage diagnosis of hepatocellular carcinoma and receipt of curative therapy were mixed, likely due to differences in data sources and analytic methods, with some studies showing improved early detection and surgical treatment in ME states and others finding no significant stage shift.
However, survival outcomes improved more consistently in ME than in NME states after ACA implementation (median overall survival, 7.3 months versus 4.5 months, respectively), with particularly large gains among non-Hispanic Black patients and rural populations.
Of the five studies that examined chronic liver disease and cirrhosis, ME was associated with lower emergency department readmissions, shorter hospital stays, and reduced hospitalization costs. At the population level, mortality related to chronic liver disease continued to increase nationwide, but the rate of increase was substantially slower in ME states. Difference-in-differences analyses showed mortality growth of 0.5–1 per 100,000 in ME states versus 1.4–10.4 per 100,000 in NME states, translating into hundreds of potentially preventable deaths annually.
Dr. Nephew characterized the consistency of ACA benefit across different clinical domains as striking. “Seeing such alignment across transplantation, oncology, and chronic disease management reinforces that insurance coverage fundamentally shapes access and outcomes,” she said. “The equity gains were [also] notable. Several studies demonstrated narrowing racial and ethnic disparities, particularly for Black and Hispanic patients in transplant access and cancer survival.”
She added, the findings underscore that insurance access is a core determinant of timely, high-quality care, not a peripheral factor in clinical outcomes. “Providers should recognize that their patients face systemic barriers that cannot be overcome solely through individual clinical decision-making and think through what options they have at the clinic and health-system level to mitigate insurance barriers,” Dr. Nephew said. “More broadly, the results empower clinicians and professional societies to engage in policy advocacy, recognizing that coverage decisions directly affect survival and equity for patients with liver disease.”
The study was funded by grants from the National Institute on Minority Health and Health Disparities and the National Institute of Diabetes and Digestive and Kidney Diseases. The authors had no disclosures to report.
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7 Key Takeaways
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Can detect 12 chemical agents, including industrial toxins.
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Provides rapid, simultaneous identification through image analysis.
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Future developments include a machine learning-enabled reader device.
The guidelines emphasize four-hour gastric emptying studies over two-hour testing. How do you see this affecting diagnostic workflows in practice?
Dr. Staller: Moving to a four-hour solid-meal scintigraphy will actually simplify decision-making. The two-hour reads miss a meaningful proportion of delayed emptying; standardizing on four hours reduces false negatives and the “maybe gastroparesis” purgatory that leads to repeat testing. Practically, it means closer coordination with nuclear medicine (longer slots, consistent standardized meal), updating order sets to default to a four-hour protocol, and educating front-line teams so patients arrive appropriately prepped. The payoff is fewer equivocal studies and more confident treatment plans.
Metoclopramide and erythromycin are the only agents conditionally recommended for initial therapy. How does this align with what is being currently prescribed?
Dr. Staller: This largely mirrors real-world practice. Metoclopramide remains the only FDA-approved prokinetic for gastroparesis, and short “pulsed” erythromycin courses are familiar to many of us—recognizing tachyphylaxis limits durability. Our recommendation is “conditional” because the underlying evidence is modest and patient responses are heterogeneous, but it formalizes what many clinicians already do: start with metoclopramide (lowest effective dose, limited duration, counsel on neurologic adverse effects) and reserve erythromycin for targeted use (exacerbations, bridging).
Several agents, including domperidone and prucalopride, received recommendations against first-line use. How will that influence discussions with patients who ask about these therapies?
Dr. Staller: Two points I share with patients: evidence and access/safety. For domperidone, the data quality is mixed, and US access is through an FDA IND mechanism; you’re committing patients to EKG monitoring and a non-trivial administrative lift. For prucalopride, the gastroparesis-specific evidence isn’t strong enough yet to justify first-line use. So, our stance is not “never,” it’s just “not first.” If someone fails or cannot tolerate initial therapy, we can revisit these options through shared decision-making, setting expectations about benefit, monitoring, and off-label use. The guideline language helps clinicians have a transparent, evidence-based conversation at the first visit.
The guidelines suggest reserving procedures like G-POEM and gastric electrical stimulation for refractory cases. In your practice, how do you decide when a patient is “refractory” to medical therapy?
Dr. Staller: I define “refractory” with three anchors.
1. Adequate trials of foundational care: dietary optimization and glycemic control; an antiemetic; and at least one prokinetic at appropriate dose/duration (with intolerance documented if stopped early).
2. Persistent, function-limiting symptoms: ongoing nausea/vomiting, weight loss, dehydration, ER visits/hospitalizations, or malnutrition despite the above—ideally tracked with a validated instrument (e.g., GCSI) plus nutritional metrics.
3. Objective correlation: delayed emptying on a standardized 4-hour solid-meal study that aligns with the clinical picture (and medications that slow emptying addressed).
At that point, referral to a center with procedural expertise for G-POEM or consideration of gastric electrical stimulation becomes appropriate, with multidisciplinary evaluation (GI, nutrition, psychology, and, when needed, surgery).
What role do you see dietary modification and glycemic control playing alongside pharmacologic therapy in light of these recommendations?
Dr. Staller: They’re the bedrock. A small-particle, lower-fat, calorie-dense diet—often leaning on nutrient-rich liquids—can meaningfully reduce symptom burden. Partnering with dietitians early pays dividends. For diabetes, tighter glycemic control can improve gastric emptying and symptoms; I explicitly review medications that can slow emptying (e.g., opioids; consider timing/necessity of GLP-1 receptor agonists) and encourage continuous glucose monitor-informed adjustments. Pharmacotherapy sits on top of those pillars; without them, medications will likely underperform.
The guideline notes “considerable unmet need” in gastroparesis treatment. Where do you think future therapies or research are most urgently needed?
Dr. Staller: I see three major areas.
1. Truly durable prokinetics: agents that improve emptying and symptoms over months, with better safety than legacy options (e.g., next-gen motilin/ghrelin agonists, better-studied 5-HT4 strategies).
2. Endotyping and biomarkers: we need to stop treating all gastroparesis as one disease. Clinical, physiologic, and microbiome/omic signatures that predict who benefits from which therapy (drug vs G-POEM vs GES) would transform care.
3. Patient-centered trials: larger, longer RCTs that prioritize validated symptom and quality-of-life outcomes, include nutritional endpoints, and reflect real-world medication confounders.
Our guideline intentionally highlights these gaps to hopefully catalyze better trials and smarter referral pathways.
Dr. Staller is with the Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston.