Insurance Type as an Independent Factor of Surgical Delay After Anterior Cruciate Ligament Injury

Background: Anterior cruciate ligament reconstruction (ACLR) is time-sensitive, as surgical delays exceeding 120 days are associated with an increased risk of secondary meniscal injury. Insurance type is a known determinant of health care access; however, its specific impact on time to ACLR is poorly characterized. Purpose: To determine the effect of insurance type on the known increased risk of surgical delay >120 days in patients undergoing ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: A dual-center retrospective cohort study was conducted, including 2030 patients (age, 9-73 years) who underwent primary ACLR between 2013 and 2023 at 2 centers. Patients were stratified by insurance type: private (n = 1619), public (n = 362), self-pay (n = 27), and workers’ compensation (n = 22). The primary outcome was surgical delay, defined as >120 days from injury to surgery. This threshold was selected a priori based on institutional data linking this threshold to increased risk of secondary meniscal injury. Multivariable logistic regression, including 2008 patients (private, public, and self-pay), was used to estimate adjusted odds ratios (aORs) with 95% CIs for the risk of delay. The model compared patients with public insurance and self-pay status to those with private insurance (the reference group) and was adjusted for confounding effects of patient age, biological sex, and injury type (sports-related vs nonsports-related). The multivariable logistic regression was restricted to patients with private, public, and self-pay insurance; the workers’ compensation cohort was omitted from this analysis due to sample size considerations. Results: Descriptive statistics revealed substantial differences in median wait times by insurance type: privately insured patients (median, 55 days [interquartile range, IQR, 90.5]), publicly insured patients (median, 106 days [IQR, 247]), self-pay patients (median, 145 days [IQR, 420]), and workers’ compensation (median, 97.5 days [IQR, 136]). Multivariable logistic regression confirmed that insurance type was a significant factor for surgical delay (>120 days). Compared with patients with private insurance, those with public insurance were 1.86 times more likely (95% CI, 1.43-2.43; P < .001), and self-pay patients were 2.75 times more likely (95% CI, 1.25-6.27; P = .013) to experience surgical delay. Conclusion: This study demonstrates that insurance status is a significant independent factor of delayed ACLR. Patients with public or self-pay insurance experience significantly longer wait times and are at markedly higher risk of surgical delays exceeding 120 days compared with privately insured patients, highlighting a substantial inequity in access to timely orthopaedic sports medicine care.