Timely access to acute care services can be lifesaving in medical emergencies such as acute myocardial infarction, stroke, sepsis, and trauma. For decades, the primary approach to maintain or improve access to acute care hospitals for patients with medical emergencies has been to implement organizational approaches such as regionalization of acute care.  In contrast, relatively little attention has been paid to the role of insurance reform, sources of hospital revenue, and the financial sustainability of hospitals providing emergency services. Signed into law in 2010, the Patient Protection and Affordable Care Act (ACA) included provisions for states to receive enhanced matching federal funds to expand eligibility for Medicaid up to 138 percent of the federal poverty level for adults. As of December 2017, 19 states had not expanded coverage to those newly eligible under the ACA. Evidence suggests that the decision not to adopt Medicaid expansion has contributed to hospital closures in those states. However, the extent to which hospital closures have affected access to care is not known. As hospital closures could occur in areas with duplication of services or in areas with declining populations, fewer hospitals does not necessarily translate to decreased population access. At the same time, closures of safety-net hospitals specifically may constitute a practical loss of access for some patients, even if other nearby hospitals remain open, as underinsured persons may be dissuaded from accessing services because of the potential for high out-of-pocket expenses.