Impact of the Affordable Care Act's Medicaid expansion on tertiary pediatric surgical care

Background: Many children gained insurance with the 2014 Affordable Care Act's (ACA) Medicaid Expansion (ME), yet its impact on access to pediatric tertiary surgical care remains unknown. We examined the effect of ME on rates of elective, ambulatory surgery (EAS), especially among publicly-insured and ethnoracial-minority patients. Methods: Surgical patients ≤18 years between 2012 and 2018 were identified using the Pediatric Health Information System. Interrupted time series analyses were conducted to predict the monthly proportion of publicly-insured patients and EAS rates in ME and nonexpansion states. Results: 3,270,842 patients were included. Nonexpansion states demonstrated a 1.10% (p<0.05) increase in the proportion of publicly-insured patients at ACA implementation, which then plateaued. No immediate change was observed in ME states, but there was an annual 1.08% (p<0.01) decrease in subsequent years. Publicly-insured EAS rates decreased by 1.09% (p<0.01) in nonexpansion states; no change was observed in ME states. A 3.36% (p<0.01) increase in EAS rates was observed in nonexpansion and ME states. The gap in EAS rates increased between private and publicly-insured patients in nonexpansion, but not ME states. Conclusions: Increased coverage for children in ME states was not associated with more access to tertiary pediatric surgical care; however, while nonexpansion states saw an increase in insurance-based disparities, ME states did not. Though insurance coverage is critical to access, other factors may be contributing to persistent disparities in access to pediatric surgical care.