Barriers beyond Medicaid: A Midwest study on pancreatic surgery access in the post-Affordable Care Act era

The Affordable Care Act (ACA) Medicaid expansion (ME) has improved access to cancer surgery in urban states. However, its impact in the Midwest, home to a large rural population, remains understudied. Pancreatic surgery requires access to high-volume hospitals (HVH), often found in urban areas. This study examined the effect of ME on pancreatic surgery in the Midwest.

Data from State Inpatient Databases (2010-2022) of 9 Midwest states that were expansion or non/late-expansion states from Medicaid-eligible patients who underwent pancreatectomy for neoplasm were included. Interrupted time-series models were estimated for pancreatic surgery rates per 100,000 people across the pre-expansion (2010-2013) and post-expansion (2014-2022) periods, stratified by expansion status, and were evaluated separately by payer, rurality, and HVH status (≥20 pancreatic cases/y).

A total of 10,168 pancreatectomies were identified, of which 75% occurred in expansion states; 39% were performed in rural patients and 79% at HVH. The ACA did not significantly increase pancreatic surgery rates (expansion states, P =.325; non-expansion states, P =.904). Among Medicaid beneficiaries, surgery rates showed a slight increase before ME in non-expansion states but not within other payer types. The growth in the use of HVH preceded the ACA and continued along this trajectory after ME (expansion states, P =.356; non-expansion states, P =.413).

Medicaid beneficiaries in the Midwest did not experience increased rates of pancreatic surgery after ME, suggesting that insurance coverage alone is insufficient to increase receipt of surgical care. Future investigations should examine barriers beyond healthcare coverage that may limit rural patients' ability to receive pancreatic surgery in the Midwest.