Defense Date


Document Type


Degree Name

Doctor of Philosophy


Healthcare Policy & Research

First Advisor

Peter Cunningham

Second Advisor

Cathy Bradley

Third Advisor

Gerard Moeller

Fourth Advisor

Andrew Barnes


This dissertation examines policy and individual barriers to behavioral health (BH) service utilization. The full reach of federal policies like the Affordable Care Act (ACA) and the Comprehensive Addiction and Recovery Act (CARA) may be limited by state policies and the supply of the workforce available to deliver these services. Further, individual factors, such as low health insurance literacy, may influence patterns of behavioral healthcare utilization. Despite efforts to increase access to behavioral health services, treatment rates remain low, suggesting that barriers remain. To explore the effectiveness of these policies and examine remaining barriers, this dissertation explores three main research questions:

  1. Does mental health services utilization increase more in Medicaid expansion states, and does MH workforce supply moderate this relationship?
  2. Does buprenorphine dispensing increase to a greater extent after CARA in states where nurse practitioners have a broad scope of practice relative to states with a narrow scope of practice?
  3. Does health insurance literacy affect subsequent behavioral health services utilization and self-reported unmet need for mental health services?

We find evidence of greater increases in mental health (MH) service visits in Medicaid expansion states but little difference between counties with mental health workforce shortage and areas with adequate supply. Following CARA, buprenorphine dispensing increases overall. Increases are greater in states where state laws grant nurse practitioners (NP) more practice autonomy. Finally, we find evidence that low health insurance literacy is associated with an increased probability of reported unmet MH needs and less access to mental health specialist services.


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