The STD Clinic in the Age of Healthcare Reform

Young Man in Waiting Room
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STD clinics are safety net providers. They provide necessary care, often for free, in many communities across the United States. (If you need help finding one...) They also provide expert care in a medical area where many doctors are uncomfortable. That's why some people find it worrisome that the role of the STD clinic may be changing in the age of health reform.

The Affordable Care Act, also known as ObamaCare or the ACA, has shifted the role of the STD clinic.

However, the role played by STD clinics has not changed as much as many people might expect. It's true that, under the ACA, many more people have health insurance. It's also true that free STD testing and treatment coverage is mandated for certain populations. Unfortunately, coverage isn't mandated for everyone. Furthermore, there are people who won't use their insurance for STD services even when they can. That's why there is unquestionably still a role for STD clinics in sexual health care.

Why Patients Continue to Prefer STD Clinics After the Affordable Care Act

A number of researchers have investigated why patients continue to visit STD clinics, even when they have other options for care. One large study found that there were several reasons why people preferred to visit an STD clinic. Even though approximately 60 percent of people in that study had access to other care, they still chose the STD clinic for their sexual health care.

Their reasons included access to same-day appointments, the ability to walk-in for care, doctor expertise, and low cost. In other words, STD clinics felt like a safer, convenient, and more affordable place to get care.

The majority of people who go to STD clinics tend to be young, male, and non-White.

Around half are uninsured. Many are men who have sex with men. Perhaps unsurprisingly, these are all groups who often have trouble with, or are reluctant to access, traditional preventative care. For many of them, the STD clinic is a place where sexual health care comes with a lower risk of judgment. STD clinics are also a place where they can quickly and easily get help for urgent, uncomfortable needs.

Insurance, Privacy, and STD Clinic Access

One of the major reasons that people choose to go to an STD clinic rather than see their doctor is that they perceive these clinics as a more confidential place to get care. They don't need to worry about their doctor judging them for their sexual behaviors or their sexual partners. They know that everyone else in the waiting room is there for a similar reason. They can often remain anonymous or unidentified, if they need to. There is an interesting side effect of this desire for privacy when talking about sexual health. Many people are reluctant to use health insurance at STD clinics.

Several studies have found that only around half of people with insurance are willing to use that insurance at an STD clinic. That's true whether or not they have to pay a fee for care.

While the overarching reason for not wanting to use insurance is generally a concern about privacy, the specific reasons vary. They might be worried about records being sent to their homes. They may not want their insurance company to know they're getting tested. If they have employer based health insurance, they may be (inaccurately) concerned that their employers will have access to their records. Those who receive coverage through a parent or spouse may be worried that that person may see their bills.

Still, privacy concerns are not the only reason people don't want to use insurance at STD clinics.

Another reason that people may prefer not to use their insurance is concern about out of pocket costs. People may also have concerns that if their insurance company knows about an STD that it could affect their premiums or access to care. Although the affordable care act prohibits refusing coverage because of a preexisting condition, that risk was a reality for many years. Unfortunately, removing the protection for preexisting conditions went back on the table in the congressional health reform debates of 2017. Despite widespread popular approval, there is no guarantee that it will remain part of U.S. healthcare law.

How Health Care Reform Has Changed STD Clinic Funding

The ways in which health reform has mandated insurance coverage has affected the way that all health care, including that received at an STD clinic, is funded. The money used to expand Medicaid and increase insurance options had to come from somewhere. Some of it was shifted from funds that had previously been used to pay for other patient care—such as at public STD clinics. Some clinics have closed or reduced hours. Others have instituted a flat fee for care.

Massachusetts was the first state to mandate health insurance coverage. That has given researchers a unique opportunity to look at how that affected STD clinics in the state. What they found spoke to the interaction between privacy and money that impacts so much STD care.

On one hand, when more people had insurance coverage, many of them did use it. There was a shift where a significant fraction of patients started to go to their primary care doctor for treatment. On the other hand, a lot of people continued to go to the STD clinic. Furthermore, even once a 75 dollar fee went into place, half of all clinic patients chose to pay it rather than use insurance. Given the high rates of coverage in the state, it's likely that most of them did have insurance as an option. They just chose not to use it.

The Need for STD Clinics Is Not Going Away

Increasing insurance coverage is generally thought to improve access to care. Still, the unique privacy concerns associated with sexual health care may make it something of an exception to the rule. There has unquestionably been an increase in the use of insurance for STD screening, treatment, and prevention. However, it looks like fears around STD stigma and privacy may mean that there will always be gaps where people look for more confidential care.

Many of those gaps are best filled by publicly funded STD clinics. People may not want to use their insurance to get tested. They may not wanting to visit their doctors to talk about an infection. But they still need a place to go for their sexual health care.

Sources:

Drainoni ML, Sullivan M, Sequeira S, Bacic J, Hsu K. Health reform and shifts in funding for sexually transmitted infection services. Sex Transm Dis. 2014  Jul;41(7):455-60. doi: 10.1097/OLQ.0000000000000135.

Gift TL, Haderxhanaj LT, Torrone EA, Behl AS, Romaguera RA, Leichliter JS. Estimating the Size and Cost of the STD Prevention Services Safety Net. Public Health Rep. 2015 Nov-Dec;130(6):602-9.

Hoover KW, Parsell BW, Leichliter JS, Habel MA, Tao G, Pearson WS, Gift TL. Continuing Need for Sexually Transmitted Disease Clinics After the Affordable Care Act. Am J Public Health. 2015 Nov;105 Suppl 5:S690-5. doi: 10.2105/AJPH.2015.302839.

Pathela P, Klingler EJ, Guerry SL, Bernstein KT, Kerani RP, Llata L, Mark HD, Tabidze I, Rietmeijer CA; SSuN Working Group.. Sexually transmitted infection clinics as safety net providers: exploring the role of categorical sexually transmitted infection clinics in an era of health care reform. Sex Transm Dis. 2015 May;42(5):286-93. doi: 10.1097/OLQ.0000000000000255.

Pearson WS, Cramer R, Tao G, Leichliter JS, Gift TL, Hoover KW. Willingness to Use Health Insurance at a Sexually Transmitted Disease Clinic: A Survey of Patients at 21 US Clinics. Am J Public Health. 2016 Aug;106(8):1511-3. doi: 10.2105/AJPH.2016.303263.

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