Insurance Coverage and Utilization at a Sexually Transmitted Disease Clinic in a Medicaid Expansion State

Abstract

Background In Rhode Island, the Patient Protection and Affordable Care Act (ACA) has led to over 95% of the state’s population being insured. We evaluated insurance coverage and barriers to insurance use among patients presenting for services at the Rhode Island STD Clinic. Methods We analyzed factors associated with insurance coverage and utilization among patients presenting for STD services between July and December 2015. Results A total of 692 patients had insurance information available; of those, 40% were uninsured. Patients without insurance were more likely than those with insurance to be non-white (50% among uninsured, compared to 40% among insured; p = 0.014) and Hispanic or Latino/a (25%, compared to 16%; p = 0.006), and less likely to be MSM (27%, compared to 39%; p = 0.001). Of those with health insurance, 26% obtained coverage as a result of the ACA, and 56% of those were previously uninsured. Among uninsured individuals, barriers to obtaining health insurance included cost and unemployment. Among those with insurance, 43% reported willingness to use insurance for STD services. Barriers to insurance use included concerns about anonymity and out-of-pocket costs. Conclusions Despite expanded insurance access, many individuals presenting to the Rhode Island STD Clinic were uninsured. Among those who were insured, significant barriers still existed to using insurance. STD clinics continue to play an important role in providing safety-net STD services in states with low uninsured rates. Both public and private insurers are needed to address financial barriers and optimize payment structures for services.

The Affordability of Providing Sexually Transmitted Disease Services at a Safety-net Clinic

“…Yet, a previous analysis over 6 months at the same Rhode Island STD Clinic found that 30% of the total sample used insurance. 27 This is in line with the current analysis at the same clinic over a full year, which found that 28% of visits used insurance, which is well below the 73% that would be needed to break even if all visits were based on Medicaid. The previous study also showed that 22% of the total sample used private or other insurance 27 which is below the 38% of visits needed to break even at the private insurance rates, but exceeds the 11% of visits needed to break even at the list insurance rates.…”

“…27 This is in line with the current analysis at the same clinic over a full year, which found that 28% of visits used insurance, which is well below the 73% that would be needed to break even if all visits were based on Medicaid. The previous study also showed that 22% of the total sample used private or other insurance 27 which is below the 38% of visits needed to break even at the private insurance rates, but exceeds the 11% of visits needed to break even at the list insurance rates. This makes the authors optimistic that a sufficient volume of visits would be reimbursed at an insurance rate that is higher than Medicaid and that would allow a clinic to be financially solvent.…”

“…In a previous study, fewer than half of patients were willing to use insurance. 27 Nearly two thirds of patients cite privacy as the biggest barrier to using insurance for services 15,27 and the risk of exposure of receipt of STD services on an insurance bill 28 or explanation of benefits may be a deterrent to seeking care, especially for youth covered by a parent’s plan or partner covered by a spouse’s plan. One of the primary reasons patients cite for obtaining testing at an STD clinic rather than a primary care clinic is because of preferences for anonymity and the option to not have their testing disclosed to a provider or on an electronic medical record.…”

The Role of the Medicaid Expansion in the Use of Preventive Health Care Services in California Men

“…The impact of expanded public health insurance programs is limited. Even with expansion of Medicaid funding to 95% of the adult population in Rhode Island, among patients seeking sexually transmitted infections testing and treatment, concerns about out-of-pocket expenses were still a barrier, especially for those who were unemployed (Montgomery et al, 2017). Individuals who had recently become insured in this study were more likely to be non-White minorities and of Hispanic/Latino(a) ethnicity and 26% of them obtained coverage under the Affordable Care Act.…”

Increasing Sexually Transmitted Infections in the U.S.: A Call for Action for Research, Clinical, and Public Health Practice

“…Multiple individual, interpersonal, community, and societal factors may impact access to health care, including appropriate STI screening, diagnoses, and treatment. The most common barriers to STI testing include lack of access to clinical services, out-of-pocket costs for both uninsured and underinsured, confidentiality concerns, and stigma associated with testing (Montgomery et al, 2017). These barriers may be more pronounced in racial and ethnic minorities with rates of chlamydia and gonorrhea highest in Black/African Americans in 2018.…”