Date of Award
Spring 2023
Document Type
Dissertation
Degree Name
Doctor of Philosophy (PhD)
Department
Public Health
First Advisor
Friedman, Abigail
Abstract
Millions of Americans experienced some form of mental illness in 2020. To make matters worse, many of these individuals also experience barriers to care. Many of these challenges arise from supply side barriers, that is, a constraint in the mental health workforce. This dissertation evaluates two policies relevant to mental health in the US: (1) Medicaid expansion under the Affordable Care Act and (2) granting nurse practitioners (NPs) full practice authority (FPA). Chapter 1 offers an overview of the current mental health landscape in the US. It provides a discussion of what the US mental health workforce looks like, barriers to care stemming from both the supply and demand side, and existing policy approaches for targeting these barriers. Chapter 2 examines the relationship between ACA’s Medicaid expansions and poor mental health. Specifically, it examines whether the relationship varies by a state’s ex-ante mental health workforce capacity (supply side constraints). While insurance expansions alleviate cost-related barriers, and increase demand for care, their benefits may be muted without an increase in supply to meet the demand. Using nationally representative survey data from the Behavioral Risk Factor Surveillance System (BRFSS) between 2010 to 2019, I find that mental health improvements linked to the Medicaid expansions are driven by states with a more robust mental health workforce. Given evidence that workforce constraints hinder mental health improvements from Medicaid expansion, Chapter 3 examines a potential policy lever for addressing these constraints. I leverage state-level variation on whether NPs had FPA. FPA grants NPs the authority to prescribe independently and hold important implications for the provision of pharmacotherapy for mental illnesses. Two-way fixed effect estimates, using 2011 to 2019 years of the restricted use National Survey on Drug Use and Health, suggest that granting FPA to NPs improves mental health access and reduces reports of severe psychological distress/serious mental illness and suicidal ideation. However, these benefits are still limited to states with a more robust mental health workforce and those with individuals who are more advantaged in terms of socio-demographic and economic characteristics. Finally, chapter 4 investigates supply-side responses to NPs gaining FPA. Specifically, whether suppliers of mental health treatment (i.e., mental health facilities) shift their treatment offerings following a policy shift that increases the number of authorized independent prescribers in a state. Prescribers are critical to the provision of pharmacotherapy and certain evidence-based treatment models such as assertive community care (ACT). To study supplier behavior, I utilize data from the National Mental Health Services Survey (N-MHSS). Consistent with chapter 3’s finding, this study finds that granting NPs FPA is linked with an increased likelihood of facilities offering psychotropic medication treatment, ACT, and both. However, increases in offerings of psychotropic medication are not consistent across states; increases are driven by less rural states. On the other hand, the number of facilities offering ACT and ACT with prescribing increases consistently across the board following FPA policies.
Recommended Citation
Xu, SiQing, "Policy Approaches to Address Supply of Mental Health Treatment in the US" (2023). Yale Graduate School of Arts and Sciences Dissertations. 989.
https://elischolar.library.yale.edu/gsas_dissertations/989
