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.

Thesis (PhD)--Stellenbosch University, 2014. / ENGLISH ABSTRACT: The growing burden of mental illnesses in low- and middle-income countries, such as Uganda, necessitates effective interventions to promote mental and social well-being among their populations. Mood disorders contribute more substantially to the global burden of mental illnesses than do other forms of mental disorders. The substantial global burden of mental illnesses is projected to grow more rapidly in low- and middle-income countries than in high-income countries in the future. Because experiences of and responses to mood disorders are invariably patterned by social and cultural contexts, as argued in the growing field of cross-cultural psychiatry, health care systems, especially in low- and middle-income countries, need to design and deliver culturally relevant interventions that effectively deal with this problem. However, there is generally a paucity of suitable evidence to guide the planning and delivery of such interventions in countries like Uganda. As a response to the apparent knowledge and research gaps regarding experiences of mood disorders and care in Western Uganda, I conducted a qualitative study involving outpatients and their care providers, that is, outpatients’ families, psychiatric health workers, religious healers and traditional healers. Using purposive and snow ball sampling techniques, I selected participants, that is, outpatients as well as psychiatric health workers, outpatients’ families, religious healers and traditional healers involved in the care of the outpatients from the Mbarara Regional Referral Hospital (MRRH) and the “Greater Mbarara” region, respectively. The aim of this study is to explore explanatory models that outpatients and care providers in Western Uganda use in responding to mood disorders. I analysed the data collected in the fieldwork using ATLAS.ti 6.2, a computer-software programme designed to support qualitative data analysis. Results from the study indicate that outpatients and their care providers hold complex, diverse and contradictory explanatory models regarding mood disorders and care, which are shaped by their unique social and cultural contexts. Additionally, poor relationships and communication between patients and their care providers, especially between outpatients and psychiatric health workers, are strongly evident; structural barriers significantly hinder the provision and utilisation of care; care is generally inadequate, although it is conceptualised broadly to include biomedical, popular and folk treatments; and outpatients generally exhibit inconsequential (weak) agency in managing distress, which is primarily caused by mood disorders and care-seeking challenges. The results of the current study suggest several implications regarding mental health practice, training, policy and research. / AFRIKAANSE OPSOMMING: Weens die toenemende geestesiektelas in lae- en middelinkomstelande soos Uganda word intervensies vereis om die geestelike en maatskaplike welsyn van die bevolkings van daardie lande te bevorder. Gemoedsteurings maak ’n groter deel van die wêreldwye geestesiektelas uit as ander vorme van geestesongesteldheid. Die beduidende wêreldwye geestesiektelas sal in die toekoms na verwagting vinniger in lae- en middelinkomstelande as in hoë-inkomstelande toeneem. Aangesien ervarings van én reaksies op gemoedsteurings meestal deur maatskaplike en kulturele kontekste beïnvloed word, soos die groeiende dissipline van transkulturele psigiatrie beweer, moet gesondheidsorgstelsels, veral dié in lae- en middelinkomstelande, kultureel tersaaklike intervensies ontwerp en voorsien wat hierdie probleem doeltreffend hanteer. Tog is daar oor die algemeen ’n skaarste aan geskikte bewyse om die beplanning en voorsiening van sulke intervensies in lande soos Uganda te rig. In antwoord op die klaarblyklike kennis- en navorsingsleemtes met betrekking tot ervarings van gemoedsteurings en sorg in Wes-Uganda het ek ’n kwalitatiewe studie onder buitepasiënte en hul versorgers – met ander woorde hul familie, psigiatriese gesondheidswerkers, geloofsgenesers en tradisionele genesers – onderneem. Die steekproef het bestaan uit pasiënte en hul familielede, psigiatriese gesondheidswerkers sowel as geloofs- en tradisionele genesers wat gemoeid is met die versorging van buitepasiënte by die streeksverwysingshospitaal Mbarara (MRRH) én in die Mbarara-distrik onderskeidelik. Die doel met die studie was om te verken watter verklarende modelle pasiënte en versorgers in Wes-Uganda gebruik om op gemoedsteurings te reageer. Die data wat met die veldwerk ingesamel is, is ontleed met behulp van die rekenaarsagteware ATLAS.ti 6.2, wat ontwerp is om kwalitatiewe dataontleding te ondersteun. Die resultate van die studie toon dat buitepasiënte en hul versorgers oor komplekse, uiteenlopende en teenstellende verklarende modelle met betrekking tot gemoedsteurings en sorg beskik, wat deur hul unieke maatskaplike en kulturele kontekste gevorm word. My navorsing dui daarop dat swak verhoudings en kommunikasie tussen pasiënte en hul versorgers, veral tussen buitepasiënte en psigiatriese gesondheidswerkers, aan die orde van die dag is; dat strukturele versperrings die voorsiening en benutting van sorg beduidend verhinder; dat sorg oor die algemeen onvoldoende is, hoewel dit volgens die algemene begrip biomediese, populêre én volksbehandelings insluit, en dat buitepasiënte meestal ontoereikende (swak) vermoëns toon om nood wat uit gemoedsteurings en uitdagings in die soeke na sorg spruit, te hanteer. Die studie sit uiteindelik ook verskeie belangrike implikasies vir geestesgesondheidspraktyke, -opleiding, -beleid en -navorsing uiteen.