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The Change in Insurance Status Among Patients Seeking Care at Chicago Sexually Transmitted Disease Clinics After Affordable Care Act Implementation

Mikati, Tarek MD, MPH; Maloney, Patrick MPH; Tabidze, Irina MD, MPH; Mehta, Supriya D. PhD, MHS

Sexually Transmitted Diseases: April 2016 - Volume 43 - Issue 4 - p 260–263
doi: 10.1097/OLQ.0000000000000425
The Real World of STD Prevention
Free

There was a 13% increase in the number of insured patients in Chicago sexually transmitted disease clinics 1 year after Affordable Care Act implementation. Major disparities in being insured persisted among those at higher risk for sexually transmitted diseases.

There was a 13% increase in the number of insured patients in Chicago sexually transmitted disease clinics 1 year after Affordable Care Act implementation. Insured patients were more likely to report having access to preventive (65% vs. 36%, P < 0.01) and sick care (72% vs. 44%, P < 0.01). Major disparities in being insured persisted among men, those aged 26 to 45 years, and racial minorities.

From the *Division of HIV/STI, Chicago Department of Public Health, Chicago, IL; and †Division of Epidemiology & Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, IL

Funding sources: None.

Conflict of interest disclosures: The authors do not have any potential conflict of interest to disclose.

Correspondence: Tarek Mikati, MD, MPH, 30-49 Crescent St, Apt H4C2, Long Island City, NY 11102. E-mail: tmikati@health.nyc.gov.

Received for publication August 28, 2015, and accepted December 28, 2015.

Sexually transmitted diseases (STDs) remain a major public health problem in the United States.1 Public STD clinics have an important role in STD and HIV prevention.2,3 They serve a high volume of diverse patients who are often uninsured and without routine access to health care services. The Centers for Disease Control and Prevention conducted a survey in 2013 among 4500 patients attending 21 public STD US clinics revealing that nearly 50% of the patients were uninsured and 40% were without routine access to preventive care.4

The number of Americans who carry health insurance has increased by nearly 19 million after the first year of Affordable Care Act (ACA) implementation. This was secondary to both Medicaid expansion that started in January 2014 and new Health Insurance Market Places first enrollment between October 2013 and March 2014 period.5,6

Before ACA, there were an estimated 1.8 million uninsured nonelderly adults in Illinois.7 Chicago, the largest city in Illinois, is located in Cook County, which has nationally the second highest number of reported cases of chlamydia, gonorrhea, and syphilis.1 The Chicago Department of Public Health (CDPH) operates 5 STD clinics that provided free care on walk-in basis to approximately 20,000 patients annually.

Most STD programs in the United States have experienced budget cuts after the 2008 economic recession.8 Given the contraction of free public STD services coupled with increased access to other health care services, it is unclear whether the need for free public STD clinics will persist after ACA implementation. The primary objectives of this study were to assess temporal changes in reported insurance status related to the first year of ACA implementation and examine access to care among patients attending CDPH STD clinics and to identify patient factors associated with insurance status to understand what population will more likely remain uninsured after ACA implementation.

We provided a self-administered English or Spanish questionnaire developed by the Centers for Disease Control and Prevention to patients attending all CDPH STD clinics between August and October 2013 and 2014.4 The 2013 survey was completed just before 2013 health insurance market places opened in Illinois and before the state Medicaid expansion, whereas the 2014 survey was conducted 9 months after Medicaid expansion and before the 2014 health insurance market places enrollment period opened. The anonymous and voluntary survey was conducted using convenience-based sampling. Because the survey was anonymous, to exclude observations with a high probability of being the same individual, observations that matched on 8 sociodemographic variables were excluded from the analysis. Sample size goals for each clinic were initially proportionately representative of the patient volume. However, given the similar demography of 3 of the clinics (>95% African American), we oversampled from 2 clinics to increase the representation of white and Hispanic participants to approximately 20% of the overall sample for sufficient power to make comparisons by race. All clinics met the target sample size within the allotted survey period. The institutional review board of CDPH approved this study.

We compared 2013 and 2014 survey responses using the χ2 test. Poisson regression with robust standard error estimate was used to identify explanatory variables associated with insurance status. Using backward elimination, product terms were eliminated if the likelihood ratio test had a P value greater than 0.10. A 2-sided P value of 0.05 or less was considered statistically significant. Analyses were conducted using STATA/SE version 13 (STATA Corp, College Station, TX).

The final analysis included 1718 surveys. Survey respondents in both years had similar demographics (Table 1). The proportion of insured respondents was 13 percentage points higher among 2014 than 2013 respondents (47% vs. 34%, P < 0.01; Table 1). In multivariable analysis, several variables were statistically significantly associated with insurance status (Table 2). Among 538 (86%) insured participants who responded, 57% in 2013 and 63% in 2014 were unwilling to use health insurance. The most frequent reasons for unwillingness to use health insurance were similar in both years: cost of copays and deductibles (28%) and privacy from parent/partner (25%) or health insurer (23%).

TABLE 1

TABLE 1

TABLE 2

TABLE 2

In 2013, 52% of respondents reported access to sick care, and that had increased to 57% in 2014 (P = 0.04; Table 1). An increase in access to preventive care was reported between 2013 and 2014 (45% vs. 50%) that was marginally statistically significant (P = 0.07). Insured patients were more likely to report having access to preventive care (65% vs. 36%, P < 0.01) and sick care (72% vs. 44%, P < 0.01). The most frequently cited reasons for choosing CDPH STD clinics for care were availability of walk-in/same-day services (60%) and the free services (25%; Table 1)

The main objective of the ACA is to increase proportions of individuals carrying health insurance to improve routine access to health care.9 The main finding of this study is that the proportion of insured patients surveyed at CDPH STD clinics increased significantly by 13% from 2013 to 2014 and patients with routine access to sick or preventative care were more likely to be insured. The increase in the insured patients in the STD clinics in 2014 is likely secondary to ACA implementation After the first year of ACA implementation in Illinois, the proportion of the uninsured decreased by 29% after the Illinois health exchange markets opened in October 2013, and Illinois adopted Medicaid expansion in January 2014.6,10 The increase in proportion of insured patients at STD clinics after ACA implementation was also soon seen in a recent sexual health clinic survey in Colorado, another Medicaid expansion state.11

Another explanation that the ACA is likely behind the increase in the proportion of insured STD clinics patients is that during the years of 2013 and 2014, there were no new billing policy changes in the STD clinics and CDPH continued to provide free STD care. Changes in insurance billing policies and implementing fees for STD care by other health departments in the past have affected volume, demographics, and insurance status of patients frequenting STD clinics12,13 In addition, there were no new STD clinical services in Chicago that might cause a change in the patient volumes of STD clinics during the survey implementation.

It is likely that the need for safety net services provided by STD clinics will persist after ACA implementation. At CDPH STD clinics, the proportion of uninsured patients remained much higher than the overall population in Illinois after ACA implementation (53% vs. 12%).14 Our analysis, like other national health survey analysis, revealed that disparities in insurance status still persist after ACA implementation, and certain populations are more likely to remain uninsured: men, racial and ethnic minorities, and those aged 26 to 45 years.15 In Chicago and the United States, racial and ethnic minorities and men who have sex with men are disproportionally affected by reportable STDs and HIV.1,16–18 As these populations remain more likely to be uninsured after ACA implementation, the role of STD clinics as a safety net provider remains crucial.19,20 A likely explanation that the age group 26 to 45 years is the least likely to be insured is that ACA has allowed children up to age 26 years to remain on their parents' insurance.9

In both years, more than 60% of respondents stated walk-in services and same-day appointments as the main reason they chose CDPH STD clinics for care. This is consistent with other STD clinic surveys.2,4 Sexually transmitted disease clinics have an essential role in timely treatment through availability of walk-in services. With ACA implementation, it is projected that primary care clinics will have an expanded role in STD treatment and prevention.21 However, the appointment-only system is likely to lead to delay in STD treatment in the absence of walk-in services dedicated to STD and competing priorities with other urgent medical conditions.22

Before ACA implementation, many studies have revealed that insured patients are not willing to use their insurance, especially those privately insured.4,23 Our study revealed that the unwillingness to use insurance persisted after ACA implementation. Currently, not all health insurance plans provide access to affordable confidential STD care. Almost two-thirds of 2014 respondents were not willing to use their insurance for STD care, primarily due to cost and privacy. As more young adults remain on their parents' insurance, health policy makers and insurers need to address the privacy concerns regarding explanation of benefits provided by health insurances. In addition, health insurance plans with high copays and/or deductibles among insured patients can remain an obstacle to those with limited income to seek timely STD care.

There are major limitations to this study. The increase in insurance status in this study after ACA implementation may not apply in other STD clinics, especially in non-Medicaid expansion states. In addition, survey research is limited by recall bias that could lead to misclassification of insurance status. Another limitation is that we used convenience sampling and did not assess information regarding patient' insurance status who did not participate in the survey. However, the sex, age, and racial/ethnic distribution of respondents were similar to the clinic censuses. Although different survey respondents were likely to participate in each year, both 2013 and 2014 surveys had strikingly similar demographic and socioeconomic background, and thus, it is unlikely to have selection bias.

The need for walk in sexual health services provided by the STD clinics in Chicago will continue after ACA implementation as disparities to health insurance access and unwillingness to use health insurance for STD care are likely to persist. As ACA continues to be implemented, it is important that other health departments evaluate the need services provided by STD clinics before introducing any changes.

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