question: BACKGROUND The Affordable Care Act (ACA) and subsequent Medicaid expansion has increased utilization of public health insurance. Living donor liver transplantation (LDLT) increases access to transplant and is associated with improved survival but consistently represents <5% of LT in the U.S. STUDY DESIGN National registry data were analyzed to evaluate the impact of insurance payor on waitlist mortality and LDLT rates at LDLT centers since implementation of the ACA. RESULTS Public insurance [Medicare RR 1.18 (1.13-1.22) p<0.001, Medicaid RR 1.22 (1.18-1.27) p<0.001], Latino ethnicity (p<0.001), and lower education level (p = 0.02) were associated with increased waitlist mortality at LDLT centers. LDLT recipients were more likely to have private insurance (70.4% vs. 59.4% DDLT, p<0.001), be Caucasian (92.1% vs. 83% DDLT, p<0.001), and have post-secondary education (66.8% vs. 54.1% DDLT, p<0.001). Despite 78% of LDLT centers being located in states with Medicaid expansion, there was no change in LDLT utilization among recipients with Medicaid (p = 0.196) or Medicare (p = 0.273). CONCLUSION Despite Medicaid expansion, registry data suggests that patients with public medical insurance may experience higher waitlist mortality and underutilize LDLT at centers offering LDLT. It is possible that Medicaid expansion has not increased access to LDLT. This article is protected by copyright. All rights reserved.