Association Between the 2014 Medicaid Expansion and US Hospital Finances

Importance: The Affordable Care Act expanded Medicaid eligibility for millions of low-income adults. The choice for states to expand Medicaid could affect the financial health of hospitals by decreasing the proportion of patient volume and unreimbursed expenses attributable to uninsured patients while increasing revenue from newly covered patients. Objective: To estimate the association between the Medicaid expansion in 2014 and hospital finances by assessing differences between hospitals in states that expanded Medicaid and in those states that did not expand Medicaid. Design and Setting: Observational study with analysis of data for nonfederal general medical or surgical hospitals in fiscal years 2011 through 2014, using data from the American Hospital Association Annual Survey and the Health Care Cost Report Information System from the US Centers for Medicare P <. 001) in mean annual uncompensated care costs per hospital. Hospitals in states with Medicaid expansion experienced a 3. 2 million increase (95% CI, 0. 9 to 5. 6 million; P =. 008) in mean annual Medicaid revenue per hospital, relative to hospitals in states without Medicaid expansion. Medicaid expansion was also significantly associated with improved excess margins (1. 1 percentage points 95% CI, 0. 1 to 2. 0 percentage points; P =. 04), but not improved operating margins (1. 1 percentage points 95% CI, -0. 1 to 2. 3 percentage points; P =. 06). Conclusions and Relevance: The hospitals located in the 19 states that implemented the Medicaid expansion had significantly increased Medicaid revenue, decreased uncompensated care costs, and improvements in profit margins compared with hospitals located in the 25 states that did not expand Medicaid. Further study is needed to assess longer-term implications of this policy change on hospitals' overall finances.