This dissertation examines the determinants of competition and consumer access in the health care market, and supply- and demand-side determinants of health care use under the Affordable Care Act (ACA). The first essay studies insurer entry into the federally-facilitated health insurance market under the ACA. Motivated by the fact that insurers’ service areas can be subsets of rating areas, and the substantial variation in plan composition within a rating area, I explore variations in the type of plans offered and insurers’ decisions to enter a rating area. I find that availability of medical providers, population size, and metropolitan status are important in insurers’ decisions to enter a rating area. Medical cost affects the entry of restricted network plans. The second essay examines how supply-side incentives affect treatment choice for depression. Using claims data from Florida’s Medicaid program, I find large variations in initiating antidepressant treatment among newly diagnosed patients with three plan types: Fee-for-Service (FFS), Primary Care Case Management (PCCMs) and Accountable Care Organizations (ACOs). Compared to FFS, PCCMs and ACOs are more likely to provide antidepressant but no office-based care. I use the control function approach to mitigate the self-selection bias and find that ACOs tend to use lower cost medication options. Despite the use of low-cost alternatives for ACOs, no differences are found in subsequent psychiatric hospitalization or emergency room visits among plans. Different provider contractual relationships may partially explain treatment choice differences. The third essay investigates whether the ACA policy of free preventive services affects utilization of preventive care. I use variation in commercially-insured enrollees to examine the demand and supply prices of four preventive services. Despite an average 53 percentage point decrease in demand prices for these services, the actual service use only increased by 17 percent from 2007 to 2011, possibly due to little or no change in prices paid to providers. Using risk adjustment tools to predict and control for patient underlying health status, I find similar changes in demand prices and rates of service use across six health plan types, consistent with preventive visits being provider rather than consumer choices.

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Little research has addressed the needs of Native American veterans. This study aims to provide a better understanding of Native American women veterans’ experiences using data from the Veteran Administration and Indian Health Services. Fifteen interviews were conducted with special attention to quality and quantity of health and mental health care services available to veterans, the barriers and local contextual factors in accessing and utilizing services, and potential solutions to service gaps for women veterans from two Montana reservations, the Northern Cheyenne and Flathead Confederated Salish and Kootenai Tribes. American Indians and Alaska Natives serve at a higher rate in the U.S military than any other population. Native American women veterans identified many barriers to accessing care, some of which include lack of information regarding eligibility and the type of services available. Many found the application process to be confusing and difficult. Other barriers included distance, cost of travel, and conflict with their work schedule. This research provides important data about Native American veterans who are often underrepresented in survey research and are a rapidly growing segment of the United States military and veteran population.

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Counselors are called to address barriers to human growth and development through advocacy (ACA, 2014), such as those posed by inequitable health care access for socially disadvantaged groups (CDC, 2013; IOM, 2011). Health care contributes to positive health outcomes (Healthy People 2020) and is therefore an important component of advancing health equity among marginalized populations, such as older sexual minority women (SMW) with disabilities. Despite evidence of disparate health care access and health outcomes, no research to date has explored the health needs or health care experiences of disabled older SMW. This study therefore sought to address this gap in the literature by: identifying current levels of health care access and barriers among older SMW with disabilities; exploring predictors of health care access among older SMW with disabilities; and identifying protective factors, such as social support and resilience, that moderate the relationship between health care access barriers and health outcomes. Results obtained from a sample of 208 respondents provided baseline data about health care access and barriers among older SMW with disabilities. Generally, respondents had a place to receive health care, but few had access LGBTQIA+-specific health services despite indicating that this type of health care was important to them. Only about half had accessed mental health services in the last six months, and people who had accessed mental health care perceived it to be easier to access than people who had not. Respondents most highly endorsed external barriers related to cost of health care, and they reported higher health care stereotype threat related to age and disability compared to gender and sexuality. External barriers to health care were predictive of most health care access indicators (e.g., utilization of general and specific health services, as well as health outcomes). Among internal barriers, sexuality- and disability-related health care stereotype threat emerged as predictors of health care access and health outcomes respectively. Similarly, acceptability of health services, accessibility of health services, and affordability of health services were specific external barrier categories that appeared to influence health care access and outcomes among older SMW with disabilities. Neither resilience nor social support moderated the relationship of external access barriers to physical or mental health outcomes. However, resilience had a significant independent relationship with physical health outcomes, and both resilience and social support had significant independent relationships with mental health outcomes. These findings illustrate the structural factors related to health care access and outcomes for older SMW with disabilities, as posited by health equity frameworks (Braveman, 2014). The most influential internal barriers related to health care stereotype threat, which may develop in response to minority stressors specific to health care settings. The findings of this study support lifespan perspectives on LGBTQIA+ health (Fredriksen-Goldsen, Simoni et al., 2014), as well as minority stress processes (Meyer, 2003), as frameworks for understanding LGBTQIA+ health in later life. Implications for counselors, counselor educators, community organizations, and policies are discussed. / Doctor of Philosophy / LGBTQIA+ older adults are at increased risk of negative health outcomes, but helping professions have limited resources for understanding their health care needs at present. Because nearly half of older sexual minority women (SMW) have disabilities, this study examined health care access and outcomes among older SMW with disabilities. This is relevant to counseling given the field's focus on social justice, advocacy, and equity, as well as the interconnected nature of physical and mental health. Across different ways of measuring health care access, external barriers related to health care systems and societal injustice were related to whether older SMW with disabilities could access health care. Health care stereotype threat, or internalized stigma related to experiences in health care, predicted health care access and health among disabled older SMW as well. These findings suggest that poor health care utilization and poorer health outcomes among older SMW with disabilities are the result of structural oppression rather than individual choices, which requires systemic interventions to correct. More research is needed to determine how counselors and other helping professionals can enhance strengths to support health among older SMW with disabilities.

Yes / Introduction Despite the interconnectedness of the European Union, there are significant variations in pregnant women’s legal status as migrants and therefore their ability to access maternity care. Limited access to maternity care can lead to higher morbidity and mortality rates in migrant women and their babies. This study aimed to investigate and compare maternal health access policies and the context in which they operate across European countries for women who have migrated and are not considered citizens of the host country. Methods The study adopted a mixed-methods research design exploring policies on migrant women’s access to maternity care across the migration regimes. Data were extracted from legal documents and research reports to construct a new typology to identify the inclusiveness of policies determining access to maternity care for migrant women. Results This study found inconsistency in the categorisation of migrants across countries and significant disparities in access to maternity care for migrant women within and between European countries. A lack of connection between access policies and migration regimes, along with a lack of fit between policies and public support for migration suggests a low level of path dependency and leaves space for policy innovation. Discussion Inequities and inconsistencies in policies across European countries affect non-citizen migrant women’s access to maternity care. These policies act to reproduce structural inequalities which compromise the health of vulnerable women and newborns in reception countries. There is an urgent need to address this inequity, which discriminates against these already marginalised women. / This article is based upon work from COST Action IS1405 BIRTH: “Building Intrapartum Research Through Health—An interdisciplinary whole system approach to understanding and contextualising physiological labour and birth” (http://www.cost.eu/COST_Actions/isch/IS1405), supported by EU COST (European Cooperation in Science and Technology). The work of Alena Pařízková was supported by project Migration and maternal health: pregnancy, birth and early parenting (The Czech Science Foundation, grant 16-10953S). Open access publishing supported by the National Technical Library in Prague.