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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