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DID THE AFFORDABLE CARE ACT’S MEDICAID EXPANSION HAVE A SUSTAINABLE IMPACT ON ACCESS TO COLORECTAL CANCER SURGERY IN THE MIDWEST?
Jillian Timperley^*1, Mark Pedersen¹, Danielle B. Dilsaver¹, Alexander Hall¹, Awinder Singh¹, Scott R. Reetz¹, James Hazen¹, Jennifer F. Tseng², Ryan W. Walters¹, Waddah Al-Refaie^1
1Creighton University School of Medicine, Omaha, NE; ²Boston University, Boston, MA

Introduction
The Affordable Care Act’s (ACA) Medicaid Expansion (ME) has led to increased access to healthcare, including surgical cancer care, in urban states. However, nearly 30% of the nation’s rural population reside in the Midwest. Although ME has improved access to care for many low-income Americans, its impact on access to colorectal cancer (CRC) surgery for residents in the Midwest is largely under-investigated. This 9-state, population-based study aims to examine the impact of ACA’s ME on the utilization rates of CRC surgery among residents in the Midwest and whether it affected its rural residents.
Methods
Data were abstracted from State Inpatient Databases which variably spanned from 2010 to 2022 (5 expansion and 4 late or non-expansion Midwest states). Medicaid-eligible adults (18-64 years) who underwent CRC surgical resection were included, stratified by state-level expansion status. Interrupted time series models were estimated to assess changes in utilization defined as the rate of CRC surgical resections per 100,000 state population. Adjusted models controlled for state-level annual proportion of race, biological sex, income quartile, elective procedure, and mean age and comorbidity burden. Separate models were estimated by insurer and patient rurality.
Results
There were 45,700 CRC surgical resections, of which 32,697 (71.5%) occurred in expansion states. Three distinct trajectories with interruptions emerged: pre-expansion (2010-2013), expansion implementation (2014-2015), and post-expansion (2016-2022). The overall year-over-year trends in CRC surgery utilization remained relatively consistent in both expansion and non-expansion states; however, there was a transient statistically significant increase in utilization from 2013 to 2014 in expansion states (15.5 to 17.8 per 100,000; Figure 1). In Medicaid beneficiaries, the increase in utilization observed in 2014 was not sustained (Figure 2). There was an increase beginning in 2016 in self-pay patients in expansion states (rate ratio: 1.08, 95% CI: 1.00-1.18, p = .038) with the difference in utilization between expansion and non-expansion states widening through 2022 (Figure 2). Finally, within rural patients, there were no statistically significant differences in utilization within expansion or non-expansion states (Figure 2). Adjusted model results were substantively identical.
Conclusion
ME under the ACA did not lead to sustained increases in CRC surgery utilization among Medicaid beneficiaries in the Midwest overall or among its rural residents. There was a steady rise in the number of uninsured across the Midwest during this era of expanded coverage. This points to additional barriers to equitable surgical care. A deeper exploration of other factors limiting the impact of ACA ME in the Midwest and its rural residents is needed.

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