The Effect of the ACA Medicaid Expansion on Safety Net Hospital Utilization in California.

Researchers: Peter Cunningham, Ph.D. and Lindsay M. Sabik, Ph.D.

Funding Source: Robert Wood Johnson Foundation and State Health Access Reform Evaluation (SHARE) Program


The objective of this project is to examine the effects of the Medicaid expansions in California prior to 2014 on inpatient and emergency department utilization of safety net hospitals.  With the expansion of health insurance coverage through the Affordable Care Act, safety net hospitals are expected to experience increased demand for care, as well as an improved payer mix that will reduce uncompensated care.      Whether safety net hospitals are able to increase patient revenue depends in part on whether uninsured patients who gain coverage continue to use safety net hospitals, or whether they choose to go elsewhere for their care.

Study design

The research will examine changes in safety net hospital utilization in California between 2010 and 2013 (which expanded Medicaid prior to 2014), and compare the changes to nearby states that did not expand Medicaid prior to 2014.   The primary data source for this project will be the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) and the State Emergency Department Databases (SEDD) sponsored by the Agency for Healthcare Research and Quality.   These data include the universe of inpatient stays and emergency department visits across all payers in participating states.  

Intended policy outcomes

It is crucial for policymakers to understand the extent of changes in utilization of safety net hospitals in response to the ACA coverage expansions because the assumed increase in patient revenue is essential to offset reductions in Medicare and Medicaid Disproportionate Share Hospital payments beginning in 2016.   If there is no such increase in patient revenue, the financial viability of safety net hospitals would be threatened, along with the access to care of  newly covered Medicaid beneficiaries and the remaining uninsured population.

The Affordable Care Act and Safety Net Hospitals

Principal Investigator: Peter Cunningham, Ph.D.

Funding Source: Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services


The objective of this project is to understand the effects of the Affordable Care Act (ACA) on the nation’s safety net hospitals. The ACA creates opportunities and challenges for safety net hospitals. With the expansion in Medicaid and the health plan marketplaces, safety net hospitals are expected to benefit from increased patient revenues and reduced uncompensated care. But many safety net hospitals are concerned that these gains may not be sufficient to offset planned reductions in Medicaid and Medicare Disproportionate Hospitals Share payments, which might affect their ability to care for patients who remain uninsured. Demand for safety net hospital services will be affected by the rollout of new insurance products, as well as by new innovative payment and delivery systems.  

Study design

The project will involve case studies to five safety net hospitals in the United States. Hospitals will be purposively selected based on a number of criteria, including the potential size of the insurance coverage expansion in the community, the type of safety net hospital (e.g., public, academic medical center, private not-for-profit), the financial position of the hospital prior to ACA implementation and other community characteristics. Case studies will involve interviews with hospital executives, practitioners and other knowledgeable persons in the community. Hospital financial data will be obtained from these interviews as well as municipal repositories. The project also includes a quantitative component, which involves building a database of all safety net hospitals in the U.S. using multiple sources. The data will be used to estimate the impact of various ACA provisions on safety net hospital utilization and revenues, and to track changes over time.    

Intended policy outcomes

The project will inform federal policymakers as to the experience of safety net hospitals with the Affordable Care Act. Of special interest to policymakers will be whether expansions in public and private health insurance coverage increase patient revenues and decrease uncompensated care, which is necessary to offset the expected reductions in Medicaid and Medicare Disproportionate Hospital payments. Along with this, policymakers are interested in whether safety net hospitals are able to retain their previously uninsured patients who gain coverage or whether these patients choose to use other providers in the community.  Finally, policymakers are interested in how innovations in payment and the delivery of care affect safety net hospitals and whether these innovations help them to adapt to other changes related to the ACA.

State Innovation Models: Round Two of Funding for Design and Test Assistance

Co-Investigator: Andrew J. Barnes, Ph.D.

Funding Source: Centers for Medicaid and Medicare Services

The Virginia Center for Health Innovation received funding from the Centers for Medicare and Medicaid Services to design models to reform the health care delivery systems that serve Medicaid beneficiaries in the Commonwealth.  In his role as a co-investigator, Dr. Andrew Barnes collaborated with behavioral health service providers including Community Service Boards, hospitals, homeless shelters, and local and regional jails in the communities of Richmond, Chesterfield, Henrico, Middle Peninsula, Northern Neck, and Williamsburg to determine the potential for delivery system reforms to improve outcomes and lower costs.

Improving Adolescent Obesity Treatment: Exploring the Role of Parents

Principal Investigator: Jessica LaRose, Ph.D.

Funding Source: 

Sub-Study on the Ethical, Legal and Social Issues, in Relation to the RFP GTEx

Principal Investigator: Maghboeba Mosavel, Ph.D.

Funding Source: 

Cancer Research Resources & Collaboration in Integrated Health Care Systems

Principal Investigator: Jennifer Elston Lafata, Ph.D.

Funding Source: Kaiser Foundation Research Institute

This NCI-funded Scholars Program is a 26-month training program that aims to help junior investigators develop research independence using CRN resources to conduct population-based multi-site and multi-disciplinary studies that leverage the network's strengths. Scholars are expected to work toward becoming a Principal Investigator (PI) on a successful investigator-initiated grant, and being first author on a peer-reviewed, published article reporting original research. The Program curriculum is based on principles of adult learning, in which participants identify their own needs and faculty act as facilitators.

A Post-Visit Patient portal Tool to Promote Colorectal Cancer Screening

Principal Investigator: Jennifer Elston Lafata, Ph.D.

Funding Source: National Institutes of Health/National Cancer Institute

The purpose of the proposed project is to develop and evaluate a post physician office visit colorectal cancer screening decision support and assistance tool, e-Assist. The evaluation is designed to provide cross-cutting information on how and in what contexts e-Assist impacts patient’s colorectal cancer screening perceptions, screening intentions, and screening use as well as how to ensure that, if effective, the tool can be implemented in diverse clinic settings.

An Interactive Preventive Health Record to Increase Colorectal Cancer Screening

Principal Investigator: Jennifer Elston Lafata, Ph.D.

Funding Source: NCI 
Summary: This study is developing and evaluating the effectiveness of a theory-based MyCRCS+ intervention, which will be integrated into an existing interactive preventive health record.