Medicaid Expansion and Patient Safety Culture in USA Hospitals.

BACKGROUND: The Affordable Care Act (ACA) included provisions to improve access and patient safety. However, in some cases, improving access generated a rapid increase in demand, leading to a strain on the healthcare workforce, with potential impacts on patient safety. This study seeks to assess a potential trade-off between access and safety that could have resulted from Medicaid expansion, a key provision of ACA. To our knowledge, this is the first study that directly links Medicaid expansion to internal patient safety culture dynamics within hospitals. METHODS: We used a panel data model with hospital fixed effects to assess how different dimensions of patient safety culture were affected in hospitals located in states that expanded Medicaid. We also clustered standard errors by hospital to account for dependence among responses within a single facility and correct for heteroskedasticity, thus achieving more precise and reliable estimates. RESULTS: In small hospitals, Medicaid expansion is significantly associated with a reduced Teamwork Within Units dimension (-0.067, p < 0.01), a small but significant 1.7% decrease in a 1-to-5 Likert scale, while a negative association with Nonpunitive Response to Error dimension was observed in medium-sized hospitals (-0.045, p < 0.05) and in large hospitals (-0.064, p < 0.05). CONCLUSIONS: Public policies to improve healthcare access should plan around resources and capabilities to ensure patient safety. Small hospitals need additional support to manage the healthcare worker shortage that results from higher demand of healthcare services, while medium and large hospitals need to respond more in the areas of response to error.