Spillover Theory: Unintended Consequences of Provisions in the Affordable Care Act

Objective: To examine spillovers from a federal policy, managed care market, and community perspective. Data Sources/Study Setting: We studied spillovers from a federal policy and managed care market perspective using the Health Care Utilization Project’s (HCUP) State Inpatient Database (SID). American Hospital Association (AHA) data, Interstudy Commercial Managed Care, and Area Health Resource File (AHRF). Medicare Advantage county-level payment schedules originate from CMS. We examined community uninsurance spillovers using 2011-2015 Medical Expenditure Panel Survey (MEPS), the Area Health Resource File (AHRF), and the Small Area Health Insurance Estimator (SAHIE). Study Design: Ordinary Least Squares (OLS) and difference-in-difference regression analyses were used to examine a federal policy spillover on hospital readmissions. We used OLS and instrumental variable (IV) estimation to examined Medicare Advantage (MA) spillovers on Medicare fee-for-service (FFS) hospital readmissions. We used logistic regression to examine community uninsurance spillovers on the privately insured. Principal Findings: After the HRRP, Medicare FFS saw a decrease in 30-day preventable condition- and all-cause readmissions. Medicare Advantage saw a positive spillover after the HRRP. MA market penetration has no effect on Medicare FFS hospital readmissions. High community uninsurance rates are associated with less access to behavioral health related outpatient/office-based and prescription utilization. Conclusions: HRRP had a positive spillover on MA hospital all-cause readmissions. MA market penetration has no effect on Medicare FFS readmissions. High levels of community uninsurance are associated with poorer access to outpatient/office-based and prescription behavioral related services