Project Summary Lack of insurance coverage and individual income have been associated with considerable disparities in cancer care for patients with solid organ malignancies, including later stage disease at time of presentation, decreased probability of undergoing cancer-directed surgery, and decreased survival. However, much less is understood about upstream geospatial determinants of health that influence access to and receipt of care for the 20% of Americans that live in rural communities. Furthermore, the degree to which recent health policy changes have impacted cancer care delivery for patients living in rural and socioeconomically vulnerable communities remains unclear. To address these gaps, Dr. Loehrer plans to conduct a population-based observational and quasi-experimental cohort study to evaluate the influence of rural residence, community- level socioeconomic deprivation, and their interaction with insurance coverage on presentation with and management of solid organ malignancies. Additionally, we will evaluate the degree to which Affordable Care Act associated insurance expansion influenced cancer care delivery across rural and socioeconomically diverse communities. The study capitalizes on the novel use of select state cancer registries with geographically linked measures of community-level socioeconomic deprivation. Multilevel quantitative methods, geovisualization, geocomputational approaches, spatiotemporal analyses, and econometric modelling will all be used to describe and visualize complex relationships between insurance coverage, rural residence, local community-level socioeconomic factors in addition to determining the influence of state-level insurance expansion on disparities in cancer care delivery. The study will provide important information on upstream geospatial drivers of cancer care disparities while also evaluating the heterogeneous influence of health policy on rural cancer disparities. Dr. Loehrer is a surgical oncologist and health services researcher at Dartmouth-Hitchcock Medical Center and The Dartmouth Institute for Health Policy and Clinical Practice. His clinical practice includes care for patients with skin, soft-tissue, and liver malignancies while his academic focus is at the intersection health policy, social determinants of health, and equity of cancer care delivery. His long-term career goal is to become an innovative and independently funded health policy researcher with a focus on vulnerable populations. The research plan presented complements both career development and training plans that are focused on geospatial methodologies and application. The award will lay the methodological and policy foundation for follow-up studies on state-specific waivers in Medicaid delivery that are too early to be evaluated at present.