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So…you want to know the impact of the Affordable Care Act in the 15 years since Congress passed it, do you?
Well, the correct answer is: There is no correct answer.
The story of American health care since the passage of the ACA in 2010 is not a single narrative, but a patchwork of regional tales defined by state-level political choices. Nowhere is this clearer than in the Kansas City metropolitan area, thanks in part to the state line that bisects it, and to the policy contrasts between Jefferson City and Topeka.
The Kansas-Missouri border provides sharp relief to see the divergent paths from a key aspect of ACA: optional Medicaid expansion by the states. Missouri embraced it in 2021 after a voter mandate; the Kansas Legislature has persistently rejected said expansion. Thus, we have two parallel health-care universes within a single, broader economic community. This split has fundamentally reshaped the insurance market, hospital finances, and the very delivery of care, offering a stark, real-time case study of the ACA’s legacy.
The National Backdrop
Nationally, the ACA’s impact is measured by two dominant, and somewhat divergent trends. First, an undeniable triumph: the dramatic expansion of coverage. The uninsured rate for non-elderly Americans plummeted from 16 percent in 2010 to under 9 percent by 2022. To the cynics, ACA got it about half-right (irrespective of its cost impact). To the pragmatist, it means more than 20 million people secured health insurance, primarily through Medicaid expansion and subsidized federal marketplace plans.
Second, a more complex story has unfolded on costs: while the law successfully slowed the growth of Medicare spending and national health expenditures by 2020 through payment reforms, premiums in the individual market remained volatile, and overall health-care spending continued its relentless climb, albeit at a slower pace.
The law’s true test, however, has always been at the state level. Medicaid expansion, a voluntary provision after a 2012 Supreme Court ruling, became the great fault line. Expansion states saw their uninsured rates drop precipitously, uncompensated-care burdens lighten for hospitals, and federal dollars pour into health-care economies. Non-expansion states, largely in the South and Midwest, remained outliers, with deeper coverage gaps, more fragile rural hospitals, and the paradoxical outflow of their residents’ federal tax dollars to other states.
Kansas City: A Natural Experiment
The Kansas City region is a perfect natural experiment. It shares a media market, a work force, and interconnected communities. A resident in Johnson County, on the Kansas side, and another in adjacent Jackson County, Missouri, may work for the same company and cheer for the same Chiefs, but they inhabit profoundly different health-care ecosystems.
On the Missouri Side: The decision to expand Medicaid, though delayed until 2021, triggered an immediate and profound shift. Nearly 300,000 low-income Missourians gained coverage. For Kansas City-area hospitals like University Health’s Truman Medical Center (the city’s essential safety-net hospital) and the sprawling Saint Luke’s Health System, this meant a seismic financial change.
The metrics tell the story: cost for uncompensated care plunged. While the data available to date shows Truman’s admissions holding relatively steady from 2017-2024 (around 15,000 annually), its financial footing transformed. The hospital could now bill Medicaid for services previously provided for free. This stability is reflected in its growing outpatient visits, which surged from 329,870 in 2016 to 397,019 in 2024—a sign of a population moving from emergency-room crisis care to managed, preventive visits.
The region’s largest provider, The University of Kansas Health System (which operates the main campus in Kansas City but a broader footprint with St. Francis in Topeka and Liberty Hospital), showcases the scale of growth enabled by a more insured population. Its mind-boggling revenue growth—from $3.96 billion in 2013 to $17.51 billion in 2024—is a regional phenomenon fueled by expansion, acquisitions, and a shift to high-value specialty care.
Its work force exploded, with Full-Time Equivalent employees jumping from 5,369 in 2013 to 14,061 in 2024, and physicians more than doubling from 586 to 1,256 in the same period. This isn’t just growth; it’s the construction of a regional health-care titan, buoyed by revenue from insured patients on both sides of the state line.
Elsewhere on the Kansas Side: The story is one of resilience against persistent headwinds. Kansas’ refusal to expand Medicaid left an estimated 150,000 people in a “coverage gap”—too poor for Marketplace subsidies, but ineligible for traditional Medicaid. This policy choice directly exacerbated the national trend of rural hospital stress. While the available data focus on major metro hospitals in the metro area, the strain is felt statewide. Kansas has seen multiple rural hospital closures, a fate largely—but not entirely—avoided by rural Missouri hospitals post-expansion.
For major Kansas-side providers like AdventHealth and Overland Park Regional Medical Center, the strategy has been adaptation. They serve a generally wealthier suburban population less reliant on Medicaid, but they still absorb the cost of the uninsured. Their financial growth, while strong, has been more reliant on other factors: attracting commercially insured patients, expanding high-margin outpatient services (Advent-Health’s outpatient visits leapt from 195,417 in 2013 to 695,904 in 2024), and leveraging national system affiliations for economies of scale. They have grown—adding physicians, nurses, and beds—but within a market con-strained by the state’s policy.
A Changing Insurance Market
This divide has fundamentally reshaped the regional insurance market.
The Medicaid Pivot: In the Kansas City MSA, Medicaid is no longer just a program for children and pregnant women on the Missouri side. It is a major, stable payer for working adults in hospitality, retail, and construction. This has given Missouri-side hospitals a more predictable revenue stream and reduced their reliance on cost-shifting to private insurance plans—a practice that historically raised premiums for everyone.
The Employer Market Squeeze: The Kansas-side market, with its higher uninsured rate, likely experiences greater hidden cost-shifting. Hospitals must still cover uncompensated emergency care, costs that are ultimately baked into higher charges for private insurers. This creates subtle upward pressure on premiums for businesses, exacerbating the challenge of rising employer-sponsored insurance costs.
The Individual Marketplace: The bifurcation is crystal clear here. A 40-year-old in Kansas City, earning $25,000, may qualify for expanded Medicaid and pay nothing. An identical resident across the state line in Wyandotte County falls into the coverage gap and likely remains uninsured. For those with slightly higher incomes who qualify for subsidies, the markets function similarly, but the risk pool in Kansas is likely smaller and potentially less healthy, contributing to more volatile premium pricing over the years.
Delivery System Transformation
The ACA’s incentives for value and coordination accelerated trends visible in the Kansas City data across all hospitals, regardless of state:
• Vertical and Horizontal Consolidation: The rise of behemoths like The University of Kansas Health System (affiliating with Liberty Hospital and acquiring Olathe Health) and the dominance of national chains like HCA Midwest Health (operating Research, Overland Park, Centerpoint, etc.) and Saint Luke’s (now part of BJC HealthCare) reflect a national drive for scale, bargaining power with insurers, and integrated service lines.
• The Outpatient Exodus: Perhaps the most dramatic trend in the data is the massive migration of care out of inpatient beds. Every single hospital reporting its annual figures to Ingram’s has, without exception, shown explosive growth in outpatient visits alongside flat or declining admissions.
Children’s Mercy, for example, saw outpatient visits grow from 370,321 in 2012 to 540,963 in 2024. North Kansas City Hospital’s visits rose from 225,686 to 262,130. Stormont Vail in Topeka jumped from 120,158 to 170,422.
This is the ACA-era model in action: reducing admissions through better outpatient management, performing surgeries in ambulatory centers, and leveraging technology for monitoring. It’s a shift that requires significant capital investment, but promises higher margins and aligns with value-based care.
The Work-Force Boom: The data uniformly show a health-care sector that has solidified its position as the region’s leading employer. Total FTEs across these major hospitals grew by tens of thousands from 2013 to 2024, adding legions of nurses, specialists, and advanced practitioners.
A decade and a half after the ACA became law of the land, the Kansas City region lives with two post-ACA realities. In Missouri, the system is moving toward the ACA’s ideal: a broader base of insured citizens, providing hospitals with more stable finances to invest in outpatient infrastructure and specialty care, and creating a modest buffer against medical debt for low-wage workers. In Kansas, the system operates under the pre-ACA status quo, augmented by the law’s reforms for those with employer or subsidized coverage, but still burdened by a significant uninsured population that strains providers and subtly taxes the insured.
The provided metrics—soaring revenues, a booming work force, and the dramatic pivot to outpatient care—show a health-care industry that is thriving in its economic capacity. But the human toll of the coverage gap can’t be measured. The Kansas City narrative strongly suggests that the ACA did not create a monolithic system. Instead, it provided the tools for states to craft their own health destinies. One side of the state line used those tools to build a broader safety net. The other side chose not to, and the divide between them is a living testament to the enduring, state-by-state politics of American health reform.
PUBLISHED DECEMBER 2025
