Assessing the Impact of Medicaid Policy Changes

Research center:
Lead researcher:
Project funded:
September 2015
Project completed:
November 2017

This project has two major components. One is an analysis of enrollment into the Medicaid program in each of 40 states since the enactment of the Patient Protection and Affordable Care Act of 2010 (ACA). Using county-level data obtained from the states, the analysis explored rural-urban differences in enrollment as a percent of total population. States that expanded the Medicaid program were analyzed separately from those that did not, and the two groups were compared. The other project component was an assessment of the impact of disproportionate share hospital (DSH) payments on rural hospitals, with critical access hospitals addressed as a subset of all rural hospitals. Effects varied, given the variation in state policies allocating DSH payments, as the percent of revenues represented by DSH payments.

Research Questions

  1. What has been the change in Medicaid enrollment in rural counties? How do states compare based on expansion v non-expansion, and within each of those two groups?
  2. What are the rural/urban differences in enrollment into Medicaid since implementation of the Patient Protection and Affordability Act (ACA), within and across states (and comparing within and across categories of expansion and non-expansion)?
  3. What might explain differences across states, including county characteristics, state political environment and resources, and use of waivers?
  4. What is the impact of Medicaid DSH payment on rural hospitals, by state?


  • Changing Rural and Urban Enrollment in State Medicaid Programs
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 01/2017
    Medicaid enrollment growth in 36 states is analyzed by rural and expansion status, pre- and post-Affordable Care Act (ACA). Enrollment growth was larger in expansion states but did take place in most states, with significant state-level variation in both groups. Metropolitan areas generally had higher growth than micropolitan and rural areas.
  • Distribution of Disproportionate Share Hospital Payments to Rural and Critical Access Hospitals
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 11/2017
    This policy brief provides information about the potential impact of scheduled changes in Medicaid Disproportionate Share Hospital (DSH) payment on hospitals in 47 states. We expect variation across states, because of differences in state policies allocating DSH payments, as well as geographic variation by census region.