The extent of the increase in demand for care will also depend in part on decisions that states make in implementing the reforms. Of particular importance is whether state governments decide to expand Medicaid coverage to adults— which is no longer mandatory, based on the Supreme Court’s 2012 decision on the constitutionality of the ACA. As of this writing, 30 states including the District of Columbia have decided to proceed with the expansion, 15 states currently oppose expansion, and 6 are undecided (Kaiser Family Foundation, State Health Facts). Moreover, a number of states that have decided not to expand Medicaid have large numbers of uninsured people who might otherwise have gained insurance coverage through the Medicaid expansions. Thus, the decision not to expand Medicaid in a state is likely to substantially limit the increase in demand for care at safety net hospitals.
Another potentially mitigating factor that may affect the size of the increase in demand at any specific hospital is whether the hospital is included in qualified health plans as an “essential community provider.” The ACA requires that qualified health plans sold in the marketplaces have a “sufficient number and geographic distribution of essential community providers (which includes public and nonprofit hospitals), where available, to ensure reasonable and timely access to a broad range of such providers for low-income, medically underserved individuals.” Although this generally includes safety net providers, not all safety net providers need to be included in plan networks, and states will still have considerable discretion in identifying the specific providers that must be included in a qualified health plan. For example, under the “safe harbor” standard, CMS requires that plans include a minimum of 20 percent of available essential community providers in their network, whereas only 10 percent of available essential community providers are required under the “minimum expectation” requirement (CMS-CCIIO 2013). Movement by some health plans toward narrower network insurance products could further serve to exclude some safety net hospitals, especially those that are perceived to be high cost (Christianson et al. 2011b). Exclusion from plan networks would seriously affect safety net hospitals’ ability to retain and attract patients who are newly insured through the health insurance marketplaces.