Policies increasing healthcare availability might decrease the cost of delaying accessing of care, leading to potential negative consequences if patients delay treatment. We analyze a policy designed to increase access to kidney transplantation through the use of time since dialysis inception to prioritize patients for transplant, which was piloted at 26 of the 271 kidney transplant centers in the United States in 2006 and 2007. We model the patient’s optimization problem comparing the benefits and costs of early waitlisting and predict that the policy change will lead to delayed waitlisting. To empirically test this prediction, we use difference-in-differences fixed effects panel regression techniques to analyze data on patients who began dialysis between 1/1/2000 and 12/31/2009. The results support the model’s prediction; patients on dialysis who waitlist for kidney transplantation increase pre-waitlist dialysis duration by 11.6 percent or approximately 76 days from a pre-policy mean of 652 days (SD = 654). With regard to waitlist outcomes, the policy is associated with a 4.5 percentage point decrease in the probability of receiving a deceased donor transplant, somewhat offset by 3.0 percentage point increase in the probability of receiving a live donor transplant. On the extensive margin, patients on dialysis decrease their likelihood of ever waitlisting by 1.5 percentage points. We find an increase in pre-waitlist dialysis time and a decrease in the likelihood of waitlisting at all, especially among populations likely to have experienced increased access to transplantation through the policy change: patients self-identifying as Black or Hispanic rather than Non-Hispanic White, and patients without private insurance. These results suggest that some individuals may not benefit if their access to care increases, if the increase in access sufficiently decreases the penalty of delaying accessing of care.

提高医疗保健可用性的政策可能会降低延迟获得护理的成本，如果患者延迟治疗，则会导致潜在的负面后果。我们分析了一项旨在通过利用透析开始以来的时间来增加肾移植机会的政策，以优先考虑接受移植的患者，该政策于 2006 年和 2007 年在美国 271 家肾移植中心中的 26 家试点。我们对患者的优化进行建模比较早期等候名单的收益和成本并预测政策变化将导致等候名单延迟的问题。为了对这一预测进行实证检验，我们使用差异固定效应面板回归技术来分析在 2000 年 1 月 1 日至 2009 年 12 月 31 日之间开始透析的患者的数据。结果支持模型的预测；等待肾移植的透析患者将等待名单前透析持续时间增加 11.6% 或从政策实施前的平均 652 天 (SD = 654) 增加约 76 天。关于候补名单结果，该政策与接受已故供体移植的概率降低 4.5 个百分点有关，但在一定程度上被接受活体供体移植的概率增加 3.0 个百分点所抵消。从广义上讲，透析患者的候补名单可能性降低了 1.5 个百分点。我们发现等待名单前透析时间的增加和等待名单的可能性降低，特别是在可能通过政策变化获得更多移植机会的人群中：自称为黑人或西班牙裔而非非西班牙裔白人的患者，以及没有私人保险的患者。这些结果表明，如果获得护理的机会增加，一些人可能不会受益，如果获得的增加足以减少延迟获得护理的惩罚。