Beyond Insurance Coverage: The Impact of Medicaid Expansion on Colorectal Cancer Surgery in the Midwest

The Affordable Care Act's Medicaid Expansion increased insurance coverage nationally; its impact on colorectal cancer surgery access and outcomes remains unclear, particularly in rural regions with structural barriers. This study evaluated whether Medicaid Expansion was associated with changes in colorectal cancer surgery utilization, access to elective surgery, and short-term outcomes within eight Midwestern states.

A population-based difference-in-difference analysis used State Inpatient Databases from 2010-2022, including four expansion and four late or non-expansion states. Adults aged 18-64 years who underwent colorectal cancer resection were included. Primary outcomes included state-level surgical utilization rates and elective surgery rates per 100,000 population. Secondary outcomes included in-hospital mortality and length of stay.

Among 42,634 resections, 69.5% occurred in expansion states. Colorectal cancer surgical utilization rates did not increase following Medicaid expansion in either state group, regardless of rurality or insurance type. Elective surgery rates did not increase among rural patients in either group. Among rural uninsured patients, rates declined significantly more in Medicaid Expansion states, consistent with shifts in payer mix post expansion. Length of stay and in-hospital mortality remained low, with no significant differences by expansion status or rurality.

Medicaid Expansion was not associated with sustained improvements in colorectal cancer surgical utilization, access to elective surgery, or outcomes in the Midwest, including rural populations. Expanded insurance coverage alone may be insufficient to overcome structural barriers to timely colorectal cancer surgery. Further research is needed to uncover drivers of gaps in rural cancer care.