Background & aims: Given the evolving epidemiology of liver disease, escalating healthcare costs, and persistent racial health disparities, evaluating the Affordable Care Act (ACA)-the most substantial U.S. healthcare reform to date-is critical for informing future policy. We conducted a systematic review to assess the impact of the ACA and its Medicaid Expansion (ME) provision on access to care, survival, and racial and ethnic disparities among patients with chronic liver disease (CLD).
Methods: We reviewed studies published between 2010 and 2025 that included adults with CLD and evaluated ACA/ME effects on access to services, survival or mortality, or disparities in outcomes. Studies compared ME and non-Medicaid Expansion (NME) states during pre- and post-ACA periods. Risk of bias was assessed using a validated tool.
Results: Twenty-seven studies met inclusion criteria across 4 clinical categories: hepatitis C virus (n = 4), liver transplantation (n = 10), hepatocellular carcinoma (n = 9), and cirrhosis or CLD (n = 5). Twenty-three studies reported improved outcomes associated with ACA/ME. Difference-in-difference analyses showed liver transplantation listing increased by 1.8% to 6.0% in ME vs NME states; early-stage hepatocellular carcinoma diagnosis increased by 5.4%, and cirrhosis-related mortality rose more slowly in ME states (0.5-1.0 per 100,000 vs 1.4-10.4 per 100,000). Most studies were at low-to-moderate risk of bias and used causal inference methods.
Conclusions: The ACA, particularly ME, improved access, survival, and equity among Medicaid-eligible adults with CLD. Individuals in NME states would likely benefit from expansion, and future liver health policy should consider these findings to reduce disparities.
Keywords: Affordable Care Act; Hepatocellular Carcinoma; Liver Transplantation; Medicaid Expansion.
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