Purpose <p>Vibration-controlled transient elastographies (VCTEs) are used to surveil disease progression in metabolic dysfunction-associated steatotic liver disease (MASLD), but this test is not covered by Florida Medicaid. This study aims to quantify the number of MASLD adults in a tertiary care center who did not obtain VCTEs despite indications for one based on their fibrosis-4 (FIB-4) scores, estimate the downstream costs associated with lack of VCTE access, and extrapolate these findings to the broader Florida Medicaid population.</p> Methods <p>The study population was categorized into fibrosis risk groups based on their FIB-4 scores. For each insurance group (Medicaid, Medicare, and private), elastography studies and costs were collected and compared in patients who did or did not receive them. This data were then extrapolated to the statewide Medicaid MASLD population.</p> Results <p>Among 282 MASLD patients with Medicaid, 64 patients were categorized as “intermediate-risk” for fibrosis based on their FIB-4, but only 4 had VCTEs performed. The number of VCTEs performed was significantly lower in the Medicaid group in comparison to all “intermediate-risk” patients with Medicaid, Medicare, and private insurance [<i>χ</i>²(2, <i>N</i> = 622) = 19.8, <i>p</i> &lt; 0.001]. In the “intermediate-risk” Medicaid patients, the VCTE and non-VCTE groups averaged $86.74 ± 23.91 and $424.95 ± 63.49 per patient-year (<i>p</i> = 0.01), respectively, in elastography costs. When extrapolating these findings to the statewide Medicaid MASLD population, performing at least one VCTE could reduce downstream elastography costs by $136,020,921.51 ± 27,299,855.72 annually.</p> Conclusion <p>VCTEs are underutilized in MASLD patients with Medicaid and VCTE use is associated with significantly lower downstream healthcare costs.</p>