Date of Award

Spring 5-12-2017

Degree Type


Degree Name

Master of Public Health (MPH)


Public Health

First Advisor

Lee Rivers Mobley

Second Advisor

Eric Wright

Third Advisor

Katherine Masyn


INTRODUCTION: Since 2010, there has been a wave of hospital closures and mergers across the United States. These closures have likely impaired access to ambulatory care services for many communities, particularly those in which only one hospital is present. Given that decisions to expand Medicaid were state-specific, there may be differences in number and type of hospital closures between states that expanded and did not expand Medicaid

AIM: The present study aims to investigate the association between state level Medicaid expansion and short-term hospital closures from 2010-2016 using multilevel modeling of hospitals, counties, and states. This analysis aims to control for hospital differences, county demographics, and state insurance market factors.

METHODS: Hospital level data was obtained from the Center for Medicaid and Medicare Services. For contextual county effects, small area health insurance, income, and poverty estimates were included (U.S. Census 2013). State decisions on Medicaid expansion and state-level insurance market data was also assembled and analyzed. Multilevel models were estimated in STATA gllamm.

RESULTS: Medicaid non-expansion was not associated with a greater risk of hospital closure once included in the multilevel model. Further, rural vs. urban status was not predictive of hospital closure. Smaller hospitals, nonprofit hospitals, and hospitals with a history of ownership change were associated with closure risk. Critical access hospital status was a protective factor against closure.

DISCUSSION: Local, state, and federal policies supportive of small and nonprofit hospitals may be beneficial in preventing more hospital closures in the coming years. Further, in-depth financial research and increased awareness of both the historical and current trends in hospital closures is recommended for researchers and policymakers.

Available for download on Monday, April 30, 2018