Reply to Vale et al. Comment on "Zhong et al. Sugar-Sweetened and Diet Beverage Consumption in Philadelphia One Year after the Beverage Tax. Int. J. Environ. Res. Public Health 2020, 17, 1336".

Thank you for the opportunity to respond to the recent letter to the editor regarding our paper "Sugar-Sweetened and Diet Beverage Consumption in Philadelphia One Year after the Beverage Tax" [...].

Racial Disparities in Payment Source of Opioid Use Disorder Treatment among Non-Incarcerated Justice-Involved Adults in the United States.

BACKGROUND: Research has documented a low rate of opioid use disorder (OUD) treatment utilization among individuals involved in the criminal justice system. However, racial disparities in sources of payment for OUD treatment have not been examined in the existing literature. AIM OF THE STUDY: Although substance use disorder (SUD) treatment is relatively rare for all criminal justice system involved racial-groups, previous research has indicated that, among individuals with SUD, members of racial minority groups receive treatment at lower rates than their non-Hispanic White counterparts. Given the alarming rise of OUD in the US and the association between source of payment and utilization of health care services, this study seeks to quantify racial disparities in sources of payment for OUD treatment among individuals with criminal justice involvement. METHOD: Using data from the 2008-2016 National Survey of Drug Use and Health (NSDUH), this study analyzes data on non-incarcerated individuals with OUD who have had any criminal justice involvement in the previous 12 months. An extension of the Blinder-Oaxaca decomposition method for non-linear models is implemented to determine the extent that differences in OUD treatment utilization across non-Hispanic Blacks and non-Hispanic Whites are explained by observed and measurable characteristics and/or unobserved factors. RESULTS: Results indicate that non-Hispanic Whites are more likely to have their OUD treatment paid by a court (10%) relative to non-Hispanic Blacks (4.0%). Black-White differences in measurable factors explain 87% of the disparity, while the rest is attributed to unobserved factors. Non-Hispanic Blacks are more likely to have their OUD treatment paid by public insurance (77% vs 36%) than non-Hispanic Whites and only 72% of this disparity can be explained by observed characteristics. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Our findings indicate racial disparities in sources of payment for OUD treatment among the criminal justice-involved population. Expansion of health insurance coverage and access to substance use disorder treatments would be beneficial for reducing health care disparities. IMPLICATIONS FOR HEALTH POLICY: Equitable treatment options in the criminal justice system that incentivize OUD treatment availability may help address racial disparities in sources of payment among the criminal justice-involved population with OUD. IMPLICATIONS FOR FURTHER RESEARCH: Future research should focus on understanding the main factors driving the court's treatment decisions among the criminal justice system involved individuals.

Sugar-Sweetened and Diet Beverage Consumption in Philadelphia One Year after the Beverage Tax.

In January 2017, Philadelphia (Pennsylvania) implemented an excise tax ($ 0.015/ounce) on sugar-sweetened and diet beverages. This study is a general population-based study to report on the longer-term impacts of the tax on within-person changes in consumption 12 months after implementation. A quasi-experimental difference-in-difference design was used to contrast Philadelphia vs. nearby comparison cities (Trenton, New Jersey; Camden, New Jersey; and Wilmington, Delaware) at baseline (December 2016-January 2017) vs. 12-month follow-up (December 2017-February 2018). A random-digit-dialing phone survey was administered to a population-based cohort. Analyses assessed changes in 30-day consumption frequency and ounces of sugar-sweetened and diet beverages (and a substitution beverage, bottled water) in the analytic sample (N = 515). After 12 months, relative to the comparison group, Philadelphians were slightly more likely to decrease their frequency of sugar-sweetened beverage consumption (39.2% vs. 33.5%), and slightly less likely to increase their frequency of sugar-sweetened beverage consumption (38.9% vs. 43.0%). The effects of the tax estimated in the adjusted difference-in-difference analysis were very small (for example, changes in monthly sugar-sweetened beverage consumption in Philadelphia relative to comparison cities was -3.03 times or -51.65 ounces) and confidence intervals were very wide. Results suggested that, one year after implementation, there was no major overall impact of the tax on general population-level consumption of sugar-sweetened or diet beverages, or bottled water. Future studies should test whether the tax's effect differs in vulnerable sub-populations.

The Effects of the Affordable Care Act on Health Care Access and Utilization Among Asian American Subgroups.

OBJECTIVES: We examined changes in health care access and utilization associated with the Patient Protection and Affordable Care Act (ACA) for different Asian American subgroups relative to non-Latino whites (whites). RESEARCH DESIGN: Using 2003-2017 California Health Interview Survey data, we examined changes in 4 health care access measures and 2 utilization measures among whites and 7 Asian American subgroups. We estimated the unadjusted and adjusted percentage point changes on the absolute scale from the pre-ACA to post-ACA periods. Adjusted estimates were obtained from multivariable logistic regression models that controlled for predisposing, enabling, and need factors. We also estimated the pre-ACA to post-ACA changes between whites and Asian American subgroups using a difference-in-difference approach. RESULTS: After the ACA was implemented, uninsurance decreased among all Asian American subgroups, but improvements in disparities relative to whites in these measures were limited. In particular, Koreans had the largest absolute reduction in uninsurance (-16.8 percentage points) and were the only subgroup with a significant reduction in terms of disparities relative to whites (-10.1 percentage points). However, little or no improvement was observed in the other 3 access measures (having a usual source of care, delayed medical care in past year, or delayed prescription drug use in past year) and 2 utilization measures (having a physician visit or emergency department visit in past year). CONCLUSIONS: Despite coverage gains among Asian American subgroups, especially Koreans, disparities in access and utilization persisted across all Asian American subgroups.

Association of Medicaid Expansion With Health Insurance Coverage Among Persons With a Disability.

Importance: Although nearly 1 in 5 persons in the United States has a physical or mental disability, little is known about the association of the Patient Protection and Affordable Care Act (ACA) with health insurance coverage among persons with a disability. Objective: To determine the association of Medicaid expansion with health insurance coverage among persons with a disability. Design, Setting, and Participants: Cross-sectional analysis of adults eligible for Medicaid expansion (aged 26-64 years with incomes up to 138% of the federal poverty level), using a triple-differences (difference-in-difference-in-difference) approach to compare the pre-ACA with post-ACA trend in health insurance rates by disability status between expansion and nonexpansion states using nationally representative, repeated cross-sectional sample data obtained from the American Community Survey in the United States from January 1, 2010, to December 31, 2016. Time was defined as either pre-ACA (January 1, 2010, to December 31, 2013) or post-ACA (January 1, 2014, to December 31, 2016). Treatment status was defined as whether a state implemented Medicaid expansion after January 1, 2014. States that expanded Medicaid between January 1, 2014, to December 31, 2016, were classified as the treatment group, and states that did not expand Medicaid during the study period were classified as the control group. Data were analyzed from December 12, 2018, to May 21, 2019. Main Outcomes and Measures: Self-reported health insurance coverage (uninsured, Medicaid, private) and self-reported disability status (≥1 condition limiting activity, including cognitive, ambulatory, self-care, independent living, and sensory difficulties). Results: Of 2 549 376 Medicaid-eligible adults, 1 348 620 (52.9%) were female; 1 218 602 (47.8%) were non-Hispanic white, 497 128 (19.5%) were non-Hispanic black, 211 598 (8.3%) were Hispanic, and 206 499 (8.1%) were of other race/ethnicity; and 619 498 (24.3%) reported at least 1 disability. The percentage of persons without health insurance was greatest for persons without a disability who lived in a nonexpansion state before the ACA's Medicaid expansion provision went into effect (236 645 of 426 387 [55.5%]), and the smallest proportion of persons without health insurance was reported for persons with a disability living in an expansion state after the ACA went into effect (19 552 of 176 145 [11.1%]). Triple-differences analysis suggested that Medicaid expansion was associated with a decrease in the uninsured rate for both persons with a disability (7.1% - 16.2% = -9.1%) and without a disability (21.2% - 34.9% = -13.7%) and that Medicaid expansion was associated with a 4.6% decrease in the uninsurance rate for persons without a disability and a 2.6% decrease in persons with a disability (P < .001). Although Medicaid expansion was associated with an increase in Medicaid coverage for both persons with a disability (49.3% pre-ACA to 62.3% post-ACA; change, 13.0%) and persons without a disability (21.6% pre-ACA to 40.3% post-ACA; change, 17.7%), the triple difference-estimated Medicaid coverage was -4.7% for persons with a disability and 0.4% for persons without a disability, a difference of 5.1% (P < .001). Medicaid expansion was associated with a 3% higher private insurance rate for persons with a disability than for persons without a disability. Conclusions and Relevance: Medicaid expansion appeared to be associated with lower uninsurance rates and higher Medicaid and private insurance coverage for persons with a disability. This study's findings suggest that the reduction in the uninsured rate and gains in Medicaid coverage were greater for persons without a disability than for persons with a disability.

Insurance-Based Disparities In Access, Utilization, And Financial Strain For Adults With Psychological Distress.

Limited provider participation within Medicaid and narrow provider networks on health insurance Marketplaces pose potential barriers to accessing and using the health care system for people with behavioral health needs. We compared employer-sponsored insurance, Medicaid, and Marketplace coverage for people with psychological distress across three domains of health care: access, utilization, and financial strain. We found evidence that adults with psychological distress reported greater difficulty accessing health care relative to those without such distress, regardless of insurance source. Among adults with psychological distress, Medicaid enrollees were more likely to use care and less likely to experience health-related financial strain than those enrolled in employer-sponsored insurance were. However, people with Marketplace coverage were more likely to experience barriers across all domains, relative to people with the other two coverage sources. Policy makers should be cognizant of the participation of providers within Medicaid and the Marketplaces and work to make network breadth more transparent.

Racial and Ethnic Disparities in Provider-Related Barriers to Health Care for Children in California After the ACA.

The aim of this study was to examine disparities in provider-related barriers to health care by race and ethnicity of children in California after the implementation of the Affordable Care Act (ACA). California Health Interview Survey child (0-11 years) survey data from 2014 to 2016 were used to conduct multivariable logistic regressions to estimate the odds of reporting any provider-related barrier, trouble finding a doctor, child's health insurance not accepted by provider, and child not being accepted as a new patient. Compared with parents of non-Latino white children, parents of non-Latino black, Latino, Asian, and other/multiracial children were not more likely to report experiencing any of the 4 provider-related barrier measures. The associations between children's race and ethnicity and parents' reports of provider-related barriers were nonsignificant. Findings demonstrate that there are no significant racial/ethnic differences in provider-related barriers to health care for children in California in the post-ACA era.

Health Care Access and Utilization Among U.S. Immigrants Before and After the Affordable Care Act.

We examine changes in health insurance coverage and access to and utilization of health care before and after the national implementation of the Patient Protection and Affordable Care Act (ACA) among the U.S. adult immigrant population. Data from the 2011-2016 National Health Interview Survey are used to compare adult respondents in 2011-2013 (before the ACA implementation) and 2014-2016 (after the ACA implementation). Multivariable logistic regression analyses are used to compare changes over time. This study shows that the ACA has closed the coverage gap that previously existed between U.S. citizens and non-citizen immigrants. We find that naturalized citizens, non-citizens with more than 5 years of U.S. residency, and non-citizens with 5 years or less of U.S. residency reduced their probability of being uninsured by 5.81, 9.13, and 8.23%, respectively, in the first 3 years of the ACA. Improvements in other measures of access and utilization were also observed.

Disparities in Pediatric Provider Availability by Insurance Type After the ACA in California.

OBJECTIVE: To examine insurance-based disparities in provider-related barriers to care among children in California in the wake of changes to the insurance market resulting from the Affordable Care Act. METHODS: Our sample included 6514 children (ages 0 to 11 years) from the 2014-2016 California Health Interview Survey. We examined parent reports in the past year of 1) having trouble finding a general provider for the child, 2) the child not being accepted by a provider as a new patient, 3) the child's health insurance not being accepted by a provider, or 4) any of the above. Multivariable models estimated the associations of insurance type-Medi-Cal (Medicaid), employer-sponsored insurance, or privately purchased coverage-and parent reports of these problems. RESULTS: Approximately 8% of parents had encountered at least one of these problems. Compared with parents of children with employer-sponsored insurance, parents of children with Medi-Cal or privately purchased coverage had over twice the odds of experiencing at least one of the barriers. Parents of children with Medi-Cal had over twice the odds of being told a provider would not accept their children's coverage or having trouble finding a general provider and 3times the odds of being told a provider would not accept their children as new patients. Parents of children with privately purchased coverage had over 3times the odds of being told a provider would not accept their children's coverage. CONCLUSIONS: Our study found significant disparities in provider-related barriers by insurance type among children in California.

Insurance Coverage and Utilization Improve for Latino Youth but Disparities by Heritage Group Persist Following the ACA.

OBJECTIVE: Latino youth experience worse access to and utilization of health care compared with non-Latino "white" youth, with inequities persisting following the implementation of the Affordable Care Act (ACA). To better understand these disparities, we examine changes in youth's access and utilization associated with the ACA for different Latino heritage groups relative to whites. STUDY DESIGN: We use 6 years (2011-2016) of National Health Interview Survey data to examine Latino youth's insurance coverage and health care utilization by heritage group, nativity, and parental language. The dependent measures of utilization included well-child, emergency department, and physician visits. We used multivariable logistic regression models to estimate the odds of each dependent measure and interacted heritage group and time period [2011-2013 (pre-ACA) versus 2014-2016 (post-ACA)] to examine how changes associated with the ACA varied by group. RESULTS: Insurance coverage and well-child visits improved among youth overall following implementation of the ACA. Although Mexican and Central or South American youth experienced the largest absolute increase in coverage, they still had high levels of uninsurance post-ACA (9.9% and 9.1%, respectively). Disparities in coverage between Puerto Rican and white youth improved, while disparities in well-child visits between Mexican and white youth worsened. Little to no movement was observed in disparities by nativity and parental language. CONCLUSIONS: Most disparities in insurance and utilization across Latino heritage groups and white youth persisted post-ACA despite significant gains within groups. Although disparities for Puerto Rican youth have improved, Mexican and Central or South American youth continue to experience disparities.

Health Care Access and Physical and Behavioral Health Among Undocumented Latinos in California.

BACKGROUND: This paper provides statewide estimates on health care access and utilization patterns and physical and behavioral health by citizenship and documentation status among Latinos in California. METHODS: This study used data from the 2011-2015 California Health Interview Survey to examine health care access and utilization and physical and behavioral health among a representative sample of all nonelderly Latino and US-born non-Latino white adults (N=51,386). Multivariable regressions estimated the associations between the dependent measures and citizenship/documentation status among Latinos (US-born, naturalized citizen, green card holder, and undocumented). RESULTS: Adjusted results from multivariable analyses observed worse access and utilization patterns among immigrant Latinos compared with US-born Latinos, with undocumented immigrants using significantly less health care. Undocumented Latinos had lower odds of self-reporting excellent/very good health status compared with US-born Latinos, despite them having lower odds of having several physical and behavioral health outcomes (overweight/obesity, physician-diagnosed hypertension, asthma, self-reported psychological distress, and need for behavioral health services). Among those reporting a need for behavioral health services, access was also worse for undocumented Latinos when compared with US-born Latinos. CONCLUSIONS: Patterns of poor health care access and utilization and better physical and behavioral health are observed across the continuum of documentation status, with undocumented immigrants having the worst access and utilization patterns and less disease. Despite fewer reported diagnoses and better mental health, undocumented Latinos reported poorer health status than their US-born counterparts.

Access-To-Care Differences Between Mexican-Heritage And Other Latinos In California After The Affordable Care Act.

We examined changes in health insurance coverage and access to and use of health care among adult (ages 18-64) Latinos in the US before (2007-13) and after (2014-16) implementation of the main provisions of the Affordable Care Act. Data from the California Health Interview Survey were used to compare respondents in the two periods. We used multivariable and decomposition regression analyses to investigate the role of documentation status in access disparities between Mexicans and other Latinos in California. Our findings show that after the implementation of these provisions in California, insurance coverage increased for US- and foreign-born Latinos, including undocumented Latinos. Our decomposition analyses show that after implementation, disparities between Mexicans and other Latinos declined with respect to having coverage and a usual source of care. Without the implementation of these provisions in 2014, these disparities would have been 5.76 percent and 0.31 percent larger, respectively. In contrast, legal documentation status was positively associated with disparities between Mexicans and other Latinos in having coverage and physician visits. If Mexican Latinos had had the same share of undocumented immigrants as other Latinos, disparities in health insurance coverage would have declined by 24.17 percent.

The Affordable Care Act Attenuates Financial Strain According to Poverty Level.

We use data from the 2011-2016 National Health Interview Survey to examine how the Patient Protection and Affordable Care Act (ACA) has influenced disparities in health care-related financial strain, access to care, and utilization of services by categories of the Federal Poverty Level (FPL). We use multivariable regression analyses to determine the ACA's effects on these outcome measures, as well as to determine how changes in these measures varied across different FPL levels. We find that the national implementation of the ACA's insurance expansion provisions in 2014 was associated with improvements in health care-related financial strain, access, and utilization. Relative to adults earning more than 400% of the FPL, the largest effects were observed among those earning between 0% to 124% and 125% to 199% of the FPL after the implementation of the ACA. Both groups experienced reductions in disparities in financial strain and uninsurance relative to the highest FPL group. Overall, the ACA has attenuated health care-related financial strain and improved access to and the utilization of health services for low- and middle-income adults who have traditionally not met income eligibility requirements for public insurance programs. Policy changes that would replace the ACA with less generous age-based tax subsidies and reductions in Medicaid funding could reverse these gains.

Association between Medicaid Expansion under the Affordable Care Act and Preemptive Listings for Kidney Transplantation.

BACKGROUND AND OBJECTIVES: Before 2014, low-income individuals in the United States with non-dialysis-dependent CKD had fewer options to attain health insurance, limiting their opportunities to be preemptively wait-listed for kidney transplantation. We examined whether expanding Medicaid under the Affordable Care Act was associated with differences in the number of individuals who were pre-emptively wait-listed with Medicaid coverage. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Using the United Network of Organ Sharing database, we performed a retrospective observational study of adults (age≥18 years) listed for kidney transplantation before dialysis dependence between January 1, 2011-December 31, 2013 (pre-Medicaid expansion) and January 1, 2014-December 31, 2016 (post-Medicaid expansion). In multinomial logistic regression models, we compared trends in insurance types used for pre-emptive wait-listing in states that did and did not expand Medicaid with a difference-in-differences approach. RESULTS: States that fully implemented Medicaid expansion on January 1, 2014 ("expansion states," n=24 and the District of Columbia) had a 59% relative increase in Medicaid-covered pre-emptive listings from the pre-expansion to postexpansion period (from 1094 to 1737 listings), compared with an 8.8% relative increase (from 330 to 359 listings) among 19 Medicaid nonexpansion states (P<0.001). From the pre- to postexpansion period, the adjusted proportion of listings with Medicaid coverage decreased by 0.3 percentage points among nonexpansion states (from 4.0% to 3.7%, P=0.09), and increased by 3.0 percentage points among expansion states (from 7.0% to 10.0%, P<0.001). Medicaid expansion was associated with absolute increases in Medicaid coverage by 1.4 percentage points among white listings, 4.0 percentage points among black listings, 5.9 percentage points among Hispanic listings, and 5.3 percentage points among other listings (P<0.001 for all comparisons). CONCLUSIONS: Medicaid expansion was associated with an increase in the proportion of new pre-emptive listings for kidney transplantation with Medicaid coverage, with larger increases in Medicaid coverage among racial and ethnic minority listings than among white listings.

Experiences in Care According to Parental Citizenship and Language Use Among Latino Children in California.

OBJECTIVE: To assess differences in health care access, utilization, and experiences among Latino children in California according to parental citizenship status and language use. METHODS: Data are from the 2011 and 2012 California Health Interview Survey public use child files. A total of 2841 interviews of parents of Latino children younger than the age of 12 years were conducted. Analyses were conducted to determine the associations between access (usual of source of care, delay in receiving needed care, health insurance), utilization (physician visits in past year, emergency department visits), and experiences (doctor listens, doctor explains instructions clearly, communication via telephone or e-mail) according to parental citizenship status and household language use after adjusting for confounders. RESULTS: In multivariate analyses, there were no significant differences in access to care according to parental citizenship status. Children with 2 noncitizen parents had fewer doctor visits and were less likely to go to the emergency department in the past year than those with 2 citizen parents. Among children with 1 or 2 noncitizen parents, their parents reported worse experiences in care than those with 2 citizen parents. Similar results were observed for language use. Parents of children in bilingual and Spanish-only households were less likely to report that their children's doctors explained things clearly, and parents in Spanish-only households were less likely to communicate via telephone or e-mail than those in English-only households. CONCLUSIONS: Health policy should focus on provider-parent communication to ensure health care equity for Latino children whose parents are not citizens or do not speak English.

Insurance Type and Access to Health Care Providers and Appointments Under the Affordable Care Act.

BACKGROUND: Millions of adults have gained insurance through the Affordable Care Act (ACA). However, disparities in access to care persist. OBJECTIVE: This study examined differences in access to primary and specialty care among patients insured by private individual market insurance plans (both on-exchange and off-exchange) and Medicaid compared with those with employer-sponsored insurance. RESEARCH DESIGN: Using data from the 2014 and 2015 California Health Interview Survey, logistic regression analyses were used to calculate the odds of being unable to access primary care providers, access specialty care providers and receive a needed doctor's appointment in a timely manner, with insurance type serving as the independent variable. Interaction terms examined if the expiration of the ACA's optional Medicaid primary care fee increase in 2014 modified any of these associations. RESULTS: Findings showed poorer access to providers among those insured through Medicaid and the individual market (whether purchased through the state's health insurance exchange or off-exchange) relative to employer-based insurance. Poor access to primary care providers was seen among private coverage purchased via exchanges, relative to private coverage purchased on the individual market. In addition, findings showed that reduction of Medicaid fees coincided with reduced ability to see primary care providers. However, a similar trend was seen among those with employer-based coverage, which suggests that this change may not be attributable to reductions in Medicaid fees. CONCLUSION: Despite ACA-related gains in insurance coverage, those with on-exchange and off-exchange individual private insurance plans and Medicaid encounter more barriers to care than those with employer-based insurance.

Insurance Coverage and Well-Child Visits Improved for Youth Under the Affordable Care Act, but Latino Youth Still Lag Behind.

OBJECTIVE: To examine whether there have been changes in insurance coverage and health care utilization for youth before and after the national implementation of the Patient Protection and Affordable Care Act (ACA) and to assess whether racial and ethnic inequities have improved. METHODS: Data are from 64,565 youth (ages 0-17 years) participants in the 2011 to 2015 National Health Interview Survey. We conducted multivariate logistic regression analyses to determine how the period after national implementation of the ACA (years 2011-2013 vs years 2014-2015) was associated with health insurance coverage and utilization of health care services (well-child visits, having visited an emergency department, and having visited a physician, all in the past 12 months), and whether changes over the pre- and post-ACA periods varied according to race and Latino ethnicity. RESULTS: The post-ACA period was associated with improvements in insurance coverage and well-child visits for all youth. Latino youth had the largest absolute gain in insurance coverage; however, they continued to have the highest proportion of uninsurance post national ACA implementation. With regard to health care equity, non-Latino black youth were less likely to be uninsured and Latino youth had no significant improvements in insurance coverage relative to non-Latino white youth after national ACA implementation. Inequities in health care utilization for non-Latino black and Latino youth relative to non-Latino white youth did not improve. CONCLUSIONS: Insurance coverage and well-child visits have significantly improved for all youth since passage of the ACA, but inequities persist, especially for Latino youth.

Examining EMTALA in the era of the patient protection and Affordable Care Act.

BACKGROUND: Little is known regarding the characteristics of hospitals that violate the Emergency Medical Treatment and Labor Act (EMTALA). This study addresses this gap by examining EMTALA settlements from violating hospitals and places these descriptive results within the current debate surrounding the Patient Protection and Affordable Care Act (ACA). METHODS: We conducted a content analysis of all EMTALA Violations that resulted in civil monetary penalty settlements from 2002-2015 and created a dataset describing the nature of each settlement. These data were then matched with Thomson Healthcare hospital data. We then present descriptive statistics of each settlement over time, plot settlements by type of violation, and provide the geographic distribution of settlements. RESULTS: Settlements resulting from EMTALA violations decreased from a high of 46 in 2002 to a low of 6 in 2015, a decline of 87%. Settlements resulting from violations most commonly occurred for failure to screen and failure to stabilize patients in need of emergency care. Settlements were most common in hospitals in the South (48%) and in urban areas (74%). Among Disproportionate Share Hospitals (DSH) with a violation, the majority (62%) were located in the South or in urban areas (65%). Violating hospitals incurred annual settlements of $31,734 on average, for a total $5,299,500 over the study period. CONCLUSIONS: EMTALA settlements declined prior to and after the implementation of the ACA and were most common in the South and in urban areas. EMTALA's status as an unfunded mandate, scheduled cuts to DSH payments and efforts to repeal the ACA threaten the financial viability of safety-net hospitals and could result in an increase of EMTALA violations. Policymakers should be cognizant of the interplay between the ACA and complementary laws, such as EMTALA, when considering changes to the law.