Date of Award

2025

Degree Name

Healthcare Administration

College

College of Business

Type of Degree

M.S.

Document Type

Research Paper

First Advisor

Alberto Coustasse, Dr.PH. MD, MBA, MPH

Abstract

Introduction: In the United States, hospitals in rural areas have been under financial pressure and have been closing at an increasing rate.  This reduces access to care for rural citizens.  The Affordable Care Act of 2010 was passed in order to increase access to medical care, partially through an optional expansion of Medicaid coverage to a larger percentage of the population.  As some states adopted the expansion and some states did not, an opportunity was created to examine the policy’s effect on rural hospital stability.

Purpose of the Study:  This study was designed to examine the effect of the Medicaid expansion policy on rural hospital financial health, the closure rate of rural hospitals, and the access to care in rural areas.

Methodology: A literature review was conducted using PRISMA guidelines. From an initial set of 434 citations—412 from academic databases and 22 from government or policy sources—53 full texts were reviewed. Twenty empirical studies that directly addressed financial outcomes, closure patterns, or access measures were included in the final analysis. The Donabedian Model was used to frame the review, allowing the studies to be interpreted through the lens of structural factors, care processes, and resulting outcomes.

Results:  The results of the literature review showed that Medicaid expansion was correlated with lower levels of uncompensated care and improved operating margins for rural hospitals.  In states that expanded Medicaid, hospitals were less likely to close, and most of the closures between 2014 and 2024 occurred in states that did not expand Medicaid.  Studies showed that states that did expand Medicaid experienced either slower declines or small improvements in access to emergency and inpatient services compared with states that did not expand Medicaid.

Discussion/Conclusion: Medicaid expansion under the ACA did appear to have contributed to greater financial stability for rural hospitals and a lower likelihood of closure, along with decreased loss of access to care in rural areas.  While Medicaid expansion did help, rural hospitals continue to face financial challenges, and other policy solutions should be explored to maintain access to care in rural areas. 

Subject(s)

Health services administration.

Health facilities -- Business management.

Medicaid.

Health insurance -- Law and legislation -- United States.

Poor -- Medical care -- United States.

Health services accessibility.

Rural health.

Rural health services.

Rural hospitals.

Hospitals -- Finance.

Hospital closures.

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