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Figure 1
Number of open hospital EDs over time
Trends in (A) Number of hospitals open over time, (B) broken down by state Medicaid expansion status, and (C) percentage of number of hospitals open over time relative to 2006 baseline, by state Medicaid expansion status.
Abstract
Study Hypothesis
Low reimbursement from the uninsured has been claimed to threaten hospital finances and even hospital emergency department (ED) closure. We hypothesized in advance of beginning data collection that states that expanded Medicaid ("expansion states") under the 2010 Patient Protection and Affordable Care Act (ACA) would experience a reduced rate of ED closure compared to states that did not.
Methods
We compiled a national census of EDs from 2006 through 2013 from federal databases and manually confirmed each closure. We employed difference-in-differences regression on this longitudinal panel to compare the probability over time that a hospital was in operation in expansion states to non-expansion states.
Results
The number of hospitals grew every year nationally and in non-expansion states. In expansion states the number fell from 2,027 in 2009 to 2,019 in 2010, not surpassing the 2009 peak until 2012. In regression estimates, hospitals in expansion states were 2.2% (95% CI: 0.3 – 4.1%) less likely to be in operation after 2010 compared to the trend in non-expansion states.
Conclusions
States that expanded Medicaid experienced increased, rather than reduced, ED closure rates from 2010 through 2013. The financial benefits of the ACA may be poorly targeted to the hospitals most vulnerable to closure.
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Findings from this project, although not these specific results, were presented at the American Economics Association meeting, San Francisco CA, January 5, 2015.
The authors received no grant funding and have no COI to declare.
ABF and VEP conceived the study, designed the analysis, supervised the conduct of the trial and data collection, managed the data, including quality control, provided statistical advice on study design and analyzed the data. DDO and VEP verified hospital closures and provided substantial input into the inclusion/exclusion criteria and search strategy. ABF drafted the manuscript, and all authors contributed substantially to its revision. ABF takes responsibility for the paper as a whole.
