Introduction: Medicaid expansion is associated with improved survival outcomes among pediatric liver transplant (LT) recipients. The association between citizenship status, Medicaid expansion, and survival outcomes has not been studied.

Methods: Pediatric liver-only transplants from 2009-2022 in the UNOS database were identified and divided based on state Medicaid expansion (ME) status and citizenship status at the time of LT. Kaplan-Meier (KM) survival analysis and Cox regression were used to evaluate 10-year survival outcomes. Propensity score matching (PSM) and a sensitivity analysis with states providing Medicaid coverage regardless of immigration status were performed.

Results: Our final study population consisted of 7107 patients, of which 4154 (58.4%) were transplanted prior to ME and 2953 (41.6%) were transplanted after ME. There were 6930 citizens (pre-ME n=4073, post-ME n= 3102) and 177 non-citizens (pre-ME n=84, post-ME n=58). Kaplan-Meier survival curves demonstrated significantly improved 10-year OS (p<0.001) and GS (p<0.001) for citizens after ME. No significant differences in 10-year OS (0.790) and GS (p=0.870) were observed for non-citizens. On multivariable cox regression, there was an improved hazard of 10-year OS (aHR 0.77, p=0.002) and GS (aHR 0.70, p<0.001) for citizens after ME. For non-citizens, there was a non-significant trend toward improved hazards of 10-year OS (aHR 0.98, p=0.966) and GS (aHR 0.95, p=0.913) after ME. These findings persisted after matching and on sensitivity analysis.

Conclusions: Medicaid expansion is associated with improved survival for citizens, while no significant improvement was observed for non-citizens. Citizenship status is an important driver of survival in pediatric LT after ME.