Haderxhanaj, Laura T. MPH, MS; Gift, Thomas L. PhD; Loosier, Penny S. PhD, MPH; Cramer, Ryan C. JD, MPH; Leichliter, Jami S. PhD
Sexually transmitted diseases (STDs) continue to be a public health problem and are the most commonly reported infectious diseases in the United States.1,2 Some curable bacterial STDs are associated with sequelae in women, including chronic pelvic pain, pelvic inflammatory disease, infertility, and ectopic pregnancy; however, many infections are asymptomatic.1–3 Chlamydia infections are the most commonly reported notifiable disease in the United States, with 610.6 cases per 100,000 women reported for 2010.3 Gonorrhea cases, the second most commonly reported disease in the United States, have recently increased.4 To reduce the negative health impacts of STDs and identify asymptomatic infections, it is important that women receive timely STD services including screening, treatment, and counseling.2,3
One example of STD services is screening for chlamydia, recommended routinely by the US Preventive Services Task Force for sexually active young women and other women at high risk for infection, although few studies have focused on recent trends of these services at the national level.5 The Healthcare Effectiveness Data and Information Set measure for chlamydia screening examined trends in the United States and found that screening increased from 29.8% in 2002 to 41.6% in 2007 among sexually active young women (age, 16–25 years) enrolled in private health insurance and Medicaid.1 Although the trends increased, chlamydia screening in the United States remains at suboptimal levels, even among insured women. Similarly, chlamydia testing rates increased significantly from 220 tests per 1000 person-years in 1997 to 270 tests per 1000 person-years in 2007 among women (age, 15–44 years) enrolled in a private health plan.6 However, data in both studies are limited to medical claims and exclude uninsured women.
One national study that included uninsured women found a statistically significant increase in use of STD services among women from 1995 (7.6%) to 2002 (12.6%),7 but recent trends are unknown. Given the potential sequelae of STDs in women and the changing health care system in the United States, it is important to monitor trends in the receipt of STD services including patterns of use and payment for services. Thus, the purpose of this study is to examine recent trends in the receipt of STD services among reproductive-aged women using a national survey from 2002 to 2006–2010.
MATERIALS AND METHODS
The National Survey of Family Growth (NSFG) is a nationally representative, cross-sectional, in-person, household survey of noninstitutionalized men and women aged 15 to 44 years in the United States.8–10 We analyzed data from the 2002 and 2006–2010 NSFG. In 2006 to 2010, the NSFG changed to continuous administration where interviews were conducted from June 2006 to June 2010.8 The 2006 to 2010 continuous interviewing process contained the same primary sampling units as the 2002 survey.8
Given STD sequelae, analyses were restricted to women only. In the 2002 NSFG, 7643 women were interviewed, and in 2006 to 2010, 12,279 women were interviewed.9,10 In 2002, the NSFG response rate for women was 80%, and in 2006 to 2010, the response rate was 78%.9,10 The NSFG was approved by the Centers for Disease Control and Prevention National Center for Health Statistics Ethics Review Board. Participants provided informed consent; subsequent to parental consent, adolescent respondents provided assent.
We analyzed the demographic characteristics, health insurance, and visit-related variables of women reporting receipt of STD services in the 12 months before interview. Receipt of STD services was ascertained by asking women if they had received counseling for or been tested or treated for an STD in the past 12 months, with a dichotomized response (yes or no). The demographic characteristics included in analyses were age (15–19, 20–24, or 25–44 years), race/ethnicity (Hispanic, non-Hispanic white, non-Hispanic black, or non-Hispanic other), and poverty-income ratio. The poverty-income ratio was calculated from the household income as a percentage of the federal poverty level (FPL; recoded as 0–132% or ≥133%).
Two health insurance variables were included in analyses. The first variable, current health insurance status, categorized women into 4 insurance groups: (1) private health insurance or Medi-Gap (“private”); (2) Medicaid, Children’s Health Insurance Program, or state-sponsored health plan (“Medicaid”); (3) Medicare, military health care, or other government health care (“Medicare”); or (4) currently covered only by a single-service plan, only by the Indian Health Service, or currently not covered by health insurance (“no insurance”). Respondents chose from health insurance options, which included the name of the Medicaid program specific to their state (eg, Medi-Cal in California). The second health insurance variable identified if women had a gap in health insurance coverage in the past 12 months (yes or no).
Visit-related variables included the self-reported type of clinic where women reported receipt of the STD service (recoded as “private doctor/HMO,” “public clinic,” “family planning,” or “nonprimary care” location) and payment method for the STD service (Medicaid, private insurance, out-of-pocket, or no payment required). The nonprimary care location for the type of clinic that a respondent received STD services includes employer or company clinic, school or school-based clinic, hospital outpatient clinic, hospital emergency department, hospital regular room, urgent care, urgi-care, walk-in facility, or some other place. Payment method for the STD service was a “mark all that apply” variable that we recoded into a categorical variable with priority given to responses in the following order: Medicaid, private insurance, out-of-pocket, or no payment required. Medicaid was prioritized because STDs are higher among this population.11 The final visit-related variable included in our analyses was whether or not the clinic where the respondent received STD services was the regular place for their medical care with 4 response options: (1) yes, regular place; (2) yes, regular place but go to more than 1 place regularly; (3) usually go somewhere else; or (4) not the usual place for medical care. The place for regular medical care was applicable for women who reported receipt of STD services in the following clinics only: community health clinic, community clinic, or public health clinic; family planning or Planned Parenthood; school or school-based clinic; or hospital outpatient clinic.
We further analyzed the place where women reported receipt of STD services in the past 12 months by demographic characteristics and health insurance variables. Then, the payment methods for STD services were analyzed by demographics and health insurance variables. Finally, we analyzed payment methods for STD services by the place where the service was received and whether or not the women had a copay.
Analyses were conducted using SAS-callable SUDAAN, release 11.0.0 (Research Institute, Research Triangle Park, NC) to account for the complex sample design, multistage sample procedures, and sampling weights.12,13 Analyses were weighted to represent US women aged 15 to 44 years.14 Cochran-Mantel-Haenszel and χ2 tests were conducted to compare receipt of STD services in the past 12 months over time, from 2002 to 2006–2010.
Receipt of STD services reported by women in the past 12 months increased from 12.6% in 2002 to 16.0% in 2006 to 2010 (P < 0.001; Table 1). However, receipt of STD services did not significantly increase from 2002 to 2006–2010 among certain subgroups of women including the following: adolescents aged 15 to 19 years (P = 0.592); women who identified as “other” (non-Hispanic) racial/ethnic groups (P = 0.924); women currently enrolled in Medicare, military, or other government health insurance plans (P = 0.117); or among women who were not currently enrolled in health insurance (P = 0.302). In post hoc analyses (data not show in tables), among sexually active (reported sex in the past 12 months) respondents only, adolescents who reported receipt of STD services did not significantly increase from 2002 to 2006–2010 (27.2%–28.2%; P = 0.701). Among women who reported receiving STD services in the past 12 months, visit-related characteristics did not significantly increase over time for the place where the STD service was received (P = 0.202) or for the clinic being the regular place for medical care (P = 0.077), but there were significant differences in payment method (P = 0.021) from 2002 to 2006–2010 (Table 1).
Trends in the type of health care provider or clinic where women received STD services were examined by demographics (Table 2). Among women receiving STD services from a private doctor/HMO, the percentage who had private insurance decreased from 74.6% in 2002 to 66.8% in 2006 to 2010, whereas the percentage who had Medicaid increased from 12.8% in 2002 to 19.7% in 2006 to 2010 (P = 0.020). However, among these women, there were no significant differences by age, race/ethnicity, poverty-income ratio, or health insurance gap in the past 12 months. For women receiving STD services at a public or family planning clinic, there were no statistically significant differences by race/ethnicity, poverty-income ratio, health insurance status, and health insurance gap in the past 12 months. However, as compared with 2002, fewer adolescent women (15–19 years) but more young adult women (20–24 years) reported using a public clinic (P = 0.038) for STD services. Findings for women who received STD services at a family planning clinic were similar to those for public clinic. For nonprimary care locations (eg, employer or company clinic, school or school-based clinic, hospital outpatient clinic, hospital emergency department, hospital regular room, urgent care, urgi-care, walk-in facility, or some other place) where women received STD services, there were no significant differences between 2002 and 2006–2010 for all characteristics measured (age, race/ethnicity, poverty-income ratio, health insurance status, and health insurance gap in past 12 months).
Owing to sample sizes for the nonprimary health care setting where women reported receiving STD services, we were unable to statistically compare the health insurance status among women who received STD services at different clinics during the same time frame. However, there seemed to be different patterns in health insurance status among women attending public clinics or family planning clinics and those who received STD services from private doctors/HMOs (Table 2). In 2006 to 2010, only 27.1% of women attending public health clinics and 35.7% attending family planning clinics were currently enrolled in private health insurance as compared with 66.8% of women attending a private doctor/HMO. Also in 2006 to 2010, approximately half of women who attended public clinics (43.4%) and family planning clinics (54.4%) for STD services had a gap in health insurance status in the past 12 months compared with only 23.7% who attended a private doctor/HMO.
Finally, trends in reported methods of payment for STD services from 2002 to 2006–2010 were examined by demographic and visit-related variables (Table 3). Among women who reported using Medicaid as the payment method for STD services, there was a slight decrease in the percentage who had a household income less than 133% of FPL (73.8% in 2002 to 65.5% in 2006–2010; P = 0.061). Also among these women, receipt of services at a public clinic significantly decreased (36.8% in 2002 to 25.4% in 2006–2010; P = 0.019), with smaller increases for receipt of services at private doctors/HMOs, family planning, and nonprimary care locations. There were no significant differences for women who paid for STD services with Medicaid by the remaining demographics. Conversely, for women who paid for STD services with private insurance, the only significant difference across time was an increase in having a copay from 2002 (61.3%) to 2006–2010 (70.1%) (P = 0.012). There were no other differences across time for women who paid with private insurance. Also, there were no significant differences among women who paid out of pocket or who reported that no payment was required.
We found that the number of reproductive-aged women who reported receiving STD services in the past 12 months increased from 2002 to 2006–2010, continuing an earlier trend in increased use of STD services observed from 1995 to 2002.7 Increases in receipt of STD services were observed for all payer types; however, these increases were not statistically significant for Medicare recipients or the uninsured. More than half of uninsured Americans have incomes less than 200% of the FPL,15 and low-income patients tend to be disproportionately affected by STDs such as chlamydia.11 Therefore, it is important for private providers and HMOs to be aware of the needs of this subpopulation, especially in a changing health care system.
In addition, there was no increase in receipt of STD services among adolescents (15–19 years), nor was there a significant increase among sexually active adolescents (reported sex in the past 12 months). These findings are important because adolescents have the highest burden of STDs.2 Although the Centers for Disease Control and Prevention recommends screening sexually active women younger than 26 years for chlamydia on an annual basis, screening remains at suboptimal levels.2,16–18 Furthermore, we found a significant decrease in adolescents who reported that they received services in public clinics and a nonsignificant declining trend for family planning clinics; however, the percentage of adolescents who received STD services at private providers, family planning clinics, and nonprimary care clinics did not change.
The health care setting where women receive STD services is important, especially public and family planning clinics. Among the women reporting STD services in public, family planning, school, or hospital outpatient clinics having a usual place for medical care decreased but did not significantly differ from 2002 to 2006–2010. Similar findings are seen in the National Health Interview Study, where having a usual place for medical care decreased from 2003 to 2010 among Americans of all ages.19 Thus, public clinics may serve as a “safety net” for STD services.20 Furthermore, there may be anonymity and confidentiality concerns with STD screening,21,22 and at least one study found that women seek services from family planning clinics for confidentiality reasons including receiving services without using insurance.23
Our findings also highlight the insurance status of reproductive-aged women who received STD services at different health care settings. First, there was a significant increase in the number of reproductive-aged women with Medicaid who received STD services from private providers or HMOs in 2006 to 2010. Furthermore, of women who reported using Medicaid to pay for their service, fewer reported receiving services from a public clinic. Finally, a substantial proportion of women who received STD services from public or family planning clinics did not have health insurance in either time frame.
It is important for public and private providers to be aware of how having insurance coverage changes women’s access to, payment of, and health seeking behaviors for STD services. As of May 2013, the Congressional Budget Office estimated that in 2014, the first year in which many of the Affordable Care Act’s provisions will be inaugurated, the effect of the law will reduce the nonelderly uninsured population by 14 million persons.24 The law is projected to further reduce the number of persons uninsured in subsequent years; after 5 years postimplementation in 2019, 30 million nonelderly Americans, including undocumented immigrants, will remain uninsured.24 In addition, some states have proposed, or have begun, to close their publicly funded clinics that specialize in STD-related services because of budgetary shortfalls, eliminating a safety net for STD services.25 We found that approximately 1 in 5 women sought STD services in these safety net clinics.
Finally, we found a significant increase in copays for women who paid for their STD service using private insurance. In 2006 to 2010, 7 in 10 privately insured women paid a copay for their STD service. The Affordable Care Act provision mandating first dollar coverage of certain recommended preventive services (not including treatment) may alleviate this burden on women, particularly for some STD screening and counseling services.26 By 2012, 41% of workers were covered by employer-sponsored health plans that expanded preventive services because of the Affordable Care Act.27 However, the requirement applies only to non–grandfathered private plans, so cost sharing remains for some individuals with private insurance.28
There are some limitations to this study. The survey item for receipt of STD services included 3 topics (STD counseling, testing, or treatment); therefore, it was not possible to examine only women who received an STD test. In addition, the variable was self-reported, and it is possible that some women may not always know when they are tested for an STD if the visit occurred during other preventive services such as birth control, annual pelvic examinations, or Papanicolaou testing. However, there is no evidence that the self-report bias has changed over time. Because it is not possible to parse out the specific STD service (counseling, testing, or treatment), we are not able to determine which visits were for preventive services rather than for treatment. Finally, given relatively small sample sizes, we were not able to look at other clinic types such as school-based clinics and hospital emergency departments.
This study presents the most recent, national-level trends for receipt of STD services among reproductive-aged women. Although self-reported receipt of STD services in the past 12 months significantly increased among women of childbearing age from 2002 to 2006–2010, less than 1 in 5 women (age, 15–44 years) and less than 1 in 3 young adult women (age, 20–24 years) received STD services. In addition, less than 1 in 6 adolescents (age, 15–19 years) overall and 1 in 4 sexually active adolescents received STD services. Our findings highlight important changes in the use and payment of STD services among reproductive-aged women and may be useful for health care providers (public and private), health departments, and public health programs.
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