Safety-net hospitals (SNH) have had challenges in providing high-quality care as they operate under limited financial resources. While Medicaid expansion has led to improvements in finances, whether it has improved hospital quality is not clear. This study aims to assess the changes in quality after Medicaid expansion.

 This cohort study with difference-in-difference analysis included a total of 811 SNHs, of which 316 belonged to non-expansion states and 495 to expansion states. Time-varying indicators of Medicaid expansion were put into consideration. The primary outcome of the study was hospital quality measured by patient-reported experience, healthcare-associated infections, and patient outcomes.

 The findings suggested that there were no significant changes in patient-reported experience, readmissions, healthcare-associated infections, and mortality. Modest differential increases in the adoption of electronic health records among SNHs in expansion states were recorded; however, they were not statistically significant. Subgroup analysis comparing SNHs with higher and lower baseline margins showed that there was an isolated differential improvement in heart failure readmissions among SNHs with lower baseline operating margins in expansion states.

 The research concluded that little evidence with low statistical significance was available on quality improvement among SNHs in expansion states compared with SNHs in non-expansion states.