“Study hospitals (Appendix 2) in states that expanded eligibility for the Medicaid program experienced considerable patient volume increases from Medicaid enrollment expansions, whereas they experienced little volume change from the ACA’s expansion of commercial coverage through the federal and state Marketplaces. Despite concerns that they might lose many newly insured patients to other providers, these study hospitals largely retained existing patients and gained new ones. The growth in patient volume was especially notable for outpatient care, and there were corresponding marked increases in the proportion of their patients with insurance coverage. The growth in outpatient visits reflects in part safety net hospitals’ active efforts to help uninsured patients enroll in coverage, expand primary care capacity, and improve their facilities and systems to attract or retain patients as they gained coverage. Respondents (the hospital executives and staff we spoke with for the study) reported that these changes both supported their patients and the hospitals’ overall financial health. The words of one hospital executive captured the sentiment of many: “The biggest success of the ACA is reducing our self-pay [uninsured] patients and getting people the health care that they need. That to me has been a great thing financially and a great thing for patients … we have anecdotal stories that people are accessing care and identifying issues and getting better.”

“In contrast, study hospitals in states that did not expand eligibility for Medicaid experienced, on average, more modest increases in patient volumes and no overall change in patient mix, with many of their patients remaining uninsured. On average, they experienced greater financial challenges compared to the hospitals in states that expanded Medicaid (“expansion state hospitals”); these challenges increased over the study period. Although hospitals in both types of states experienced some declines in their subsidies to support care for the uninsured, all of them are bracing for additional cuts.”

Source: Laurie Felland, Peter Cunningham, Annie Doubleday, and Cannon Warren. Final Report: Effects of the Affordable Care Act on Safety Net Hospitals. Prepared by Mathematica Research for the Department of Health and Human Services. November 2016. https://aspe.hhs.gov/pdf-report/effects-affordable-care-act-safety-net-hospitals