Sexually transmitted diseases (STDs), including human immunodeficiency virus, syphilis, gonorrhea, and chlamydia, pose a significant public health burden in the United States,1 contributing to over US $15.6 billion in health care expenditures annually.2 A critical component of addressing STDs is ensuring access to health care for testing and treatment services. The Patient Protection and Affordable Care Act (ACA), signed into law in 2010, presented an opportunity for previously uninsured individuals to obtain insurance and health care access.3 Insurance exchanges began health insurance enrollment nationally in 2013, facilitating health insurance access to many who were previously uninsured. Expansion of state Medicaid programs under the ACA further increased health insurance coverage, although not all states have participated equally in the expansion.4
Implementation of the ACA has raised the possibility of reimbursement for preventive health care services in settings where these services have traditionally been provided at no cost to patients. Public STD clinics, which provide safety-net services for STD testing and treatment among high-risk populations, are one such setting.5 Historically, these clinics have been supported by state and local health departments and often provide services free of charge. Given limited public health resources along with Medicaid expansion, reimbursement of STD services through Medicaid and private insurers offers the opportunity to improve the financial sustainability of these services. However, little is known about the overall impact of the ACA on insurance coverage and acceptability of insurance utilization for STD care in states that have expanded Medicaid. Several potential factors in addition to insurance coverage may limit insurance utilization. These include the desire for anonymity, which patients may seek at public STD clinics.5–7 Out-of-pocket expenses, such as copays and deductibles, may also present barriers.5,7,8
In Rhode Island, the ACA with Medicaid expansion has resulted in one of the highest proportions of insurance coverage in the country, with over 95% of the state's population insured as of 2015.9 The Rhode Island STD Clinic is the only publicly funded STD clinic in the state and is a collaboration between the Rhode Island Department of Health and The Miriam Hospital, a major Brown University teaching affiliate. Insured patients are encouraged to use their insurance to cover the cost of laboratory services. The clinic provides services free of charge for those who are uninsured or unwilling to use their insurance. Increasing patient volume, limited financial resources, and Medicaid expansion have resulted in a movement to explore a more comprehensive payment-based system where third-party payers, both public and private, are billed for clinical services. The goal of the present study was to characterize insurance coverage and barriers to utilization among patients presenting for STD services in a Medicaid expansion state.
MATERIALS AND METHODS
The study site was the Rhode Island STD Clinic, located in Providence, Rhode Island. The clinic serves as a safety-net provider of STD care for the entire state with 2153 total visits in 2015. At the time of the study, the clinic billed third-party payers for laboratory services with consent from patients to do so. Medical provider time and treatment services were not billed for any patient encounters.
We reviewed insurance status and type among patients presenting for STD services between July and December 2015. All patients completed a demographic and behavioral questionnaire at intake based on standard Centers for Disease Control and Prevention surveillance questions. Demographics reviewed included age, gender, race, and ethnicity. Behaviors reviewed included the number of sexual partners in the past year by gender and sexual behavior (anal, oral, and vaginal sex), condom use, and substance use. Using a separate questionnaire administered at intake, we also reviewed insurance information, including patients' insurance type, length of time with their current insurance plan, and whether they obtained insurance coverage as a result of the ACA (“Did you obtain insurance through the ACA [ie, Obamacare or HealthSource RI]?”). Patients were also asked whether they were willing to allow the STD clinic to use their insurance for services and to identify barriers to billing their insurance using nonmutually exclusive, categorical response options. Choices were based on reported barriers to using insurance identified in previous research.10–12 Review of demographic, behavioral, and insurance data was approved by The Miriam Hospital Institutional Review Board.
We calculated frequencies for each demographic and behavioral variable and tested the distribution of variables across groups using χ2 and Fisher exact tests. Bivariate and multivariable Poisson regressions with robust standard errors were used to calculate the relative risk of being uninsured and declining to use insurance if insured, adjusting for demographic characteristics. We selected the Poisson regression model to calculate relative risk, which is a more accurate measure of risk than the odds ratio for outcomes with greater than approximately 10% prevalence, at which point the odds ratio overestimates the relative risk.13 The robust standard error is used to adjust for the overestimated variance of binary data in a Poisson model.14 To test the hypothesis that certain demographic characteristics were associated with insurance status, we conducted bivariate and multivariable Poisson regression analyses with robust standard error using demographic variables selected a priori, based on previous studies of disparities in health insurance coverage and access.10,15 Significance was defined at 2-tailed α = 0.05. All statistical analyses were performed in Stata/SE 13.1 (StataCorp, College Station, Tex).
A total of 692 surveys were collected over the course of the 5-month study period, representing 53% of all clinic visits during that time. Of those surveyed (n = 692), 74% were men, 54% were 29 years or younger, 44% identified as nonwhite, and 20% identified as Hispanic or Latino/a (Table 1). Twenty-four percent of survey respondents identified as women who had sex with men only, 1% women who had sex with women only, 2% women who had sex with both women and men, 39% men who had sex with women only, 31% men who have sex with men (MSM) only, and 3% men who have sex with both men and women. The latter 2 groups together were considered MSM for the purposes of this analysis. Compared with nonrespondents, those who responded to the survey were more likely to be white (56% compared with 50% among nonrespondents; P = 0.028) and non-Hispanic (80% compared with 74% among nonrespondents; P = 0.007), and to have had an anonymous sexual partner in the past 12 months (43% compared with 36% among nonrespondents; P = 0.008).
Forty percent of patients reported being uninsured. Patients without health insurance were more likely than those with insurance to be nonwhite (50% compared with 40% among insured; P = 0.014) and Hispanic or Latino/a (25% compared with 16% among insured; P = 0.006), and less likely to be MSM (27% compared with 39% among insured; P = 0.001; Table 1). The most commonly endorsed barriers (nonmutually exclusive) to obtaining health insurance coverage among those without insurance were cost (36%), followed by being unemployed (29%), having no time to enroll (19%), and waiting for benefits from a new job to begin (17%; Figure 1).
Of insured patients, 24% reported receiving public insurance coverage (ie, through Medicaid, Medicare, or both). Twenty-six percent of insured respondents obtained coverage as a result of the ACA, and 56% of those were uninsured before enrolling in coverage through the ACA. Half of the insured respondents reported having copayments for medical visits, though 37% of those reporting a copay did not know the amount; 18% of those with insurance were unsure whether their plan required copayments. Of the 29% of insured patients who reported having a deductible for their plan, 53% were unaware of the deductible amount. Forty-percent of insured individuals were unsure whether their health insurance had a deductible.
Age was significantly associated with uninsured status in both unadjusted and adjusted models (Table 2). Survey respondents 20 to 29 years of age (adjusted incidence risk ratio [aIRR], 2.67; 95% confidence interval [CI], 1.27–5.60; P = 0.009), those 30 to 39 years of age (aIRR, 2.93; 95% CI, 1.38–6.22; P = 0.005), and those 40 years and older (aIRR, 2.74; 95% CI, 1.28–5.86; P = 0.009) all had close to 3 times the risk of being uninsured compared with those younger than 20 years when adjusting for other demographic characteristics. Race and ethnicity were significantly associated with insurance coverage in bivariate models, as nonwhite (incidence risk ratio [IRR], 1.26; 95% CI, 1.05–1.52; P = 0.014) and Hispanic or Latino/a patients had greater risk of being uninsured compared with white and non-Hispanic or Latino/a individuals (IRR, 1.35; 95% CI, 1.10–1.65; P = 0.004), respectively. However, these associations did not maintain significance in the adjusted multivariable model. MSM had lower risk of being uninsured compared with all other sexual risk behavior groups (aIRR, 0.70; 95% CI, 0.55–0.88; P = 0.016).
Compared with non-MSM, MSM patients were disproportionately older (56% were 30 years of age or older compared with 41% among non-MSM; P < 0.001), white (70% compared with 49%; P < 0.001), and non-Hispanic or Latino/a (85% compared with 78%; P = 0.021). To evaluate possible effects of age, race, and ethnicity on insurance status among MSM, we conducted a second set of Poisson regression analyses limited to MSM. However, none of the significant associations between demographic characteristics and insurance status remained when analyses were repeated among MSM patients only (Table 2).
Fifty percent of insured patients used their insurance to pay for STD laboratory services. Age distribution differed significantly between those who did and did not use insurance (Table 1). Other demographic characteristics did not differ significantly between those who did and did not use insurance. Concern about anonymity (46%) was a prominent barrier to insurance use for STD care, as was preventing parents (35%) or partners (10%) from receiving billing statements in the mail (Figure 2). Furthermore, a total of 31% of insured patients identified cost sharing, in the form of a copay, deductible, or both, as a barrier to insurance use for STD care.
In the Poisson regression analysis, older patients were more likely to use insurance, as those 20 to 29 years (aIRR, 0.76; 95% CI, 0.59–0.98; P = 0.034) and 30 to 39 years (aIRR, 0.47; 95% CI, 0.32–0.69; P < 0.001) of age had significantly lower risk of not using their insurance compared with those 20 years and younger. No other demographic factors were associated with not using insurance (Table 3).No demographic variables were significantly associated with using insurance among MSM clinic patients only.
The ACA has resulted in significantly improved insurance coverage throughout the United States, and specifically in states that expanded Medicaid. Our study presented two novel and important findings regarding STD services and the role of health insurance in a post-ACA setting. First, many surveyed individuals presenting to the Rhode Island STD Clinic were still uninsured, despite a low proportion of uninsured individuals statewide. Second, even with the high prevalence of insurance coverage in Rhode Island, significant barriers, such as cost sharing and the desire for anonymity, may prevent some patients from seeking STD testing and treatment elsewhere, suggesting that public STD clinics will continue to play an important role in providing accessible safety-net services to these populations.16,17
In our study, a greater proportion of individuals presenting to the Rhode Island STD Clinic were uninsured (40%) compared with the overall state population (4.5%).9 This disparity likely reflects the nature of safety-net STD services, which have historically served marginalized populations, such as those without access to health insurance, including, as demonstrated in our clinic, racial and ethnic minority groups. Patients without insurance were more likely to be nonwhite and Hispanic or Latino/a, further supporting previous findings of disparities in insurance coverage and health care access across racial and ethnic groups.4,9 MSM were more likely to be insured than other sexual behavior groups, which also reflects findings in previous research.10 Importantly, MSM in this sample were disproportionately white and non-Hispanic compared with other groups. Because race and ethnicity were significantly associated with insurance status, these differences may account for some of the difference in insurance status between MSM and non-MSM.
Even among those who were insured, 57% indicated that they were unwilling to use their insurance for STD care. This aligns with findings from other urban STD clinic settings, where 35% to 66% of patients were unwilling to provide insurance information for their care.6,18–20 Among insured patients, the stigmatized nature of sexual health and STD care and the desire of patients to remain anonymous present significant, nonfinancial barriers to testing. Destigmatizing STDs and working with insurance carriers to ensure that STD testing remains confidential should be a priority in the movement toward payment-based STD services. Privacy and anonymity were significant concerns in preventing the use of insurance for STD care among patients in our sample.
Explanation of benefits (EOB) statements are one source of concern among patients. The EOB statements are generated by insurance companies to describe use of services, and may compromise the confidentiality of individuals who share insurance coverage with others (eg, a parent or partner) who may receive these statements in the mail.21 In our study, participants younger than 20 years had significantly lower risk of being uninsured but significantly higher risk of not using insurance compared with older patients. It is likely that the majority of clinic patients younger than 20 years were covered by their parents' or guardians' insurance and that privacy was a major concern.20 Similar findings have been reported elsewhere, as in another STD clinic study where 47% of patients with private insurance, including 67% of privately insured adolescents, expressed concern over having EOB statements mailed to their homes.6 In the absence of detailed EOB statements, insurance reporting may still include total costs incurred by testing, which may compromise confidentiality even if the reason for those costs is not cited.
Another major barrier to insurance utilization to pay for STD care in our study was cost sharing (ie, copays and deductibles). Thirty-one percent of those with insurance identified cost sharing as a barrier to using their insurance for STD care. Many patients did not know the amount of their copays or deductibles. This finding echoes data from previous studies indicating that cost sharing, coupled with lack of knowledge about health insurance plans (eg, the belief that STD care services are not covered by insurance), poses a significant obstacle to insurance use for STD testing.5,7 Payment structures for STD clinics vary across the United States. In previous studies, utilization of STD services has decreased dramatically when public STD clinics implemented fees for STD care for those who did not have or chose not to use their insurance.8,12 Addressing the financial burden of STD services among patients is critical to reducing barriers for testing and treatment. Partnerships and commitments across the public and private sector, including departments of health, public and private payers, and clinical institutions, are needed to effectively address this issue.
The present study was subject to several limitations. Incomplete patient data precluded analysis of some patients who received STD services at the clinic. Patients who participated in the survey were more likely to be white and less likely to be Hispanic/Latino compared with those who did not participate. Given previous studies reporting similar findings,11,22 a higher proportion of nonwhite and Hispanic/Latino individuals in the study sample would likely have amplified disparities and barriers already observed in the study. Additional socioeconomic indicators that may contribute to access to insurance were not assessed. The study also relied on patient self-report for all measures. Self-report is subject to recall and social desirability biases, and data collected through self-report are limited by respondents' knowledge. In particular, low health insurance literacy may have led patients to report inaccurate information regarding their own insurance coverage. For instance, it is possible that some participants receiving Medicaid selected the carriers administering those programs, which also carry private plans, as their insurance provider, resulting in an underestimate of those receiving public health insurance. The results of this study may not be generalizable to other safety-net clinics or Medicaid-expansion states with different demographics. Nonetheless, this study produced novel insight into the health insurance landscape subsequent to ACA implementation with Medicaid expansion in the context of safety-net STD care in Rhode Island.
Implementation of the ACA has led to significant improvements in health care access, particularly in states that have adopted Medicaid expansion.4 This study is among the first to evaluate provision of safety-net STD services in a Medicaid expansion state after implementation of the ACA. These findings demonstrate persistent barriers to obtaining insurance coverage and to using insurance to pay for STD services, despite the high statewide prevalence of insurance coverage. These findings support the need for public STD clinics and can inform ongoing efforts to implement sustainable methods of billing system in these settings. Priorities should include identifying means of ensuring patient confidentiality and addressing cost sharing by alleviating out-of-pocket costs for patients for STD testing. Further study and evaluation of effective payment models are needed to help guide the implementation of effective billing practices. Provision of STD services should rely on partnerships between public health organizations and public and private third-party payers to address these barriers and optimize payment structures for STD services.
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