Early impact of the Affordable Care Act Medicaid Expansion on Hospital Uncompensated Care and Revenues
We find that hospitals in Medicaid expansion states experienced increases in Medicaid discharges and revenue relative to hospitals in non-expansion states. Increases were more pronounced for hospitals in states with larger changes in income eligibility for low-income adults, and for disproportionate share hospitals, and Medicaid revenue increased more in counties with higher poverty and uninsured rates in 2013. Uncompensated care decreased in Medicaid expansion states relative to non-expansion states, but contrary to Medicaid discharges and revenue, the effect did not vary by disproportionate share status or county-level poverty or uninsured measures. Changes in Medicaid discharges and revenue, and uncompensated care did not vary by ownership status. Although uncompensated care fell for hospitals in Medicaid expansion states relative to non-expansion states, there was no relative change in hospital operating margins. However, operating margins fell for public hospitals relative to non-profit hospitals.
Our study provides the first estimates of the impact of the Affordable Care Act’s Medicaid expansion on payer mix, uncompensated care, and financial status measures by individual hospital characteristics for a near-census of general acute care hospitals. Our work shows that historic gains in coverage have translated into favorable changes in payer mix in the first year of the ACA’s major coverage expansions. While uncompensated care decreased, the lack of change in hospital operating margins suggest that Medicaid expansion does not result in immediate improvements in hospital finances. In fact, our results suggest that financial position may worsen for public hospitals.