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This study examines  the early effects of the ACA on 10 safety net hospitals, both in states that expanded income eligibility for Medicaid under the ACA and those that did not. This primarily qualitative research study, was conducted between September 2013 and March 2016.

Safety net hospitals in states that expanded Medicaid under the ACA are treating significantly more insured and fewer uninsured patients than in 2013.This shift has helped the hospitals financially. In contrast, the hospitals in states that did not expand Medicaid typically experienced little change in their patient mix and increased financial challenges. Overall, hospitals in both types of states experienced little effect from new Marketplace coverage, faced declining subsidies, and are bracing for additional cuts, although experience varied within the study set. The study also identified a number of challenges that safety net hospitals face in adapting to payment and delivery system reforms; several of the study hospitals have made progress in developing integrated delivery systems capable of assuming financial risk, but others lag behind.