Trends in hospital ED closures nationwide and across Medicaid expansion, 2006-2013

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 would experience a reduced rate of ED closure compared with states that did not. We compiled a national census of EDs from 2006 through 2013 from federal databases and manually confirmed each closure. We used difference-in-differences regression on this longitudinal panel to compare the probability over time that a hospital was in operation in expansion states to nonexpansion states. The number of hospitals grew every year nationally and in nonexpansion states. In expansion states, the number fell from 2027 in 2009 to 2019 in 2010, not surpassing the 2009 peak until 2012. In regression estimates, hospitals in expansion states were 2.2% (95% confidence interval, 0.3%-4.1%) less likely to be in operation after 2010 compared with the trend in nonexpansion states. States that expanded Medicaid experienced increased, rather than reduced, ED closure rates from 2010 through 2013. The financial benefits of the Affordable Care Act may be poorly targeted to the hospitals most vulnerable to closure.