Looking at Medicaid's Role in Treating, Preventing, and Reducing Sexually Transmitted Infections
Cases of chlamydia, gonorrhea, and syphilis have increased for the sixth consecutive year in the United States—reaching a historic high, according to the Centers for Disease Control and Prevention (CDC). Sexually transmitted infections (STI) clinics and other community-based organizations play a vital role in providing timely access to STI prevention services, particularly for medically underserved communities, such as racial and ethnic minorities, individuals with lower socioeconomic status, and LGBTQ individuals, all of whom are at higher risk for STIs. However, federal funding for these efforts has stagnated over the past two decades, resulting in a nearly 40% decline since 2003. Reductions in funding hamper stakeholders’ ability to adequately provide STI treatment and prevention services for the populations they serve and can result in safety net clinics offering fewer services or even closing.
In the midst of this reduced public health funding, Medicaid, the largest public funder of STI treatment in the U.S., becomes an even more critical partner for filling gaps in the provision of STI prevention and treatment services. However, many people who receive Medicaid benefits are not able to receive treatment for STIs, for a few key reasons. Here we review some of these barriers and offer considerations for Medicaid’s role in combatting STI transmission.
Barriers Medicaid Beneficiaries Face in Receiving STI Services
1. Variations in Medicaid Eligibility
Lack of health insurance or having less-generous coverage can affect if and how individuals seek health care services, including services for STIs. Conversely, research from the Kaiser Family Foundation has shown that individuals who received health care coverage as a result of expanded Medicaid eligibility showed improvements in the timeliness of accessing care, as well as general improvements in health outcomes for a variety of conditions.
There are large geographic disparities in the spread of bacterial STIs in the U.S., with southeastern U.S. states tending to have some of the highest rates. Much of this region includes states that have not expanded Medicaid eligibility under the Affordable Care Act. Of the 10 states (Alaska, Mississippi, Louisiana, South Carolina, New Mexico, North Carolina, Georgia, Alabama, New York, and Illinois) that CDC data show have the highest bacterial STI burden, about half have not expanded Medicaid eligibility in accordance with the Affordable Care Act.
2. Variations in Medicaid Coverage and Reimbursement
Variations in Medicaid reimbursement policy and administrative requirements mean that enrollees and health care providers experience barriers to receiving and providing STI testing and treatment services.
While federal law requires all state Medicaid programs to cover family planning services as a part of their general benefits package, not all states consider STI testing a family planning service. To further complicate matters, STI treatment is often defined as a “family planning-related” service and not specifically a family-planning service. Variations in how these services are defined can affect the level of reimbursement and coverage for the service and lead to additional cost-sharing for the enrollee.
Additionally, federal law permits Medicaid enrollees, including those enrolled in managed care, who seek family planning services to visit any Medicaid provider without a referral. However, enrollees could be left fully or partially responsible for covering the cost of these services, depending on how and when states define STI testing as a family planning service.
For Medicaid enrollees with a particularly high risk of contracting an STI, the CDC recommends extragenital testing at the sites of contact, which could include rectal and pharyngeal testing, in addition to urethral testing, when applicable. Extragenital testing is vital in combating STI transmission, as a recent study showed that 70-88% of rectal or pharyngeal chlamydia or gonorrhea infections did not have a concurrent urethral infection. Despite this, many payers, including Medicaid, may not fully reimburse or may outright reject claims for multisite STI testing for an enrollee on the same day. This could disincentivize providers from conducting and advocating for enrollees to receive additional tests.
Stigma around STIs creates barriers to testing and treatment. Specifically, research suggests that perceived stigma around STIs reduces the odds a person will seek out STI testing. To make meaningful progress in reducing STI transmission, Medicaid stakeholders must consider strategies to address STI-related stigma to bolster access to, and uptake of, the services.
Considerations for Expanding Access to STI Care
State Medicaid agencies and providers, researchers, federally qualified health centers, and other stakeholders could consider the following policy and programmatic options to address barriers and increase access to STI care.
Variations in how STI services are defined and which services are fully covered under traditional Medicaid benefits packages can lead to additional costs incurred for enrollees and could disincentivize them from seeking regular testing and treatment.
- Expanding Medicaid family planning eligibility. In states that have not expanded Medicaid, policymakers and other stakeholders could consider advocating for Medicaid family planning expansion, which provides expanded eligibility for individuals who might otherwise not qualify for specific family planning services. This could be done through a state Medicaid plan amendment.
- Enhancing and standardizing reimbursement policy for STI testing and treatment services. As highlighted above, variations in how STI services are defined and which services are fully covered under traditional Medicaid benefits packages can lead to additional costs incurred for enrollees and could disincentivize them from seeking regular testing and treatment. To address this, state Medicaid programs could move toward defining all STI testing and treatment services as family planning services, as well as ensuring the coverage for recommended multisite testing when applicable.
- Streamlining monitoring and surveillance efforts. Given that specific STI-related programs often fall under the purview of public health departments, allowing public health agencies to access Medicaid claims data could help experts analyze STI transmission trends and inform outreach and intervention efforts.
- Expanding the use of Pre-Exposure Prophylaxis (PrEP). PrEP is a daily oral medication that is up to 99% effective at preventing HIV infection. A vital component of the PrEP care regimen involves quarterly visits with a PrEP clinical provider for adherence counseling, a risk assessment, and lab work, which includes STI testing. Given this, expanded PrEP use could be a strategy to increase STI testing and ultimately reduce undiagnosed STI transmission.
- Using expedited partner therapy to facilitate enhanced partner management of STIs. Expedited partner therapy is “the clinical practice of treating the sex partners of patients diagnosed with chlamydia or gonorrhea by providing prescriptions or medications to the patient to take to his/her partner without the health care provider first examining the partner.”
Despite this therapy being legal in most states, the clinical practice is historically underused because of enrollee stigma in divulging STI results to former partners, providers’ limited awareness or resistance to using this therapy, and potential costs incurred to the enrollee for the treatment. Medicaid officials could consider conducting education efforts for both providers and enrollees around the therapy, including how and when it can be used, and advocating for the practice in all 50 U.S. states and territories.
- Addressing stigma and expanding access. One potential way to address stigma surrounding enrollees’ reluctance to receive STI services might be to expand STI services via telehealth. Such services provide at-home testing kits to patients, who can then send their self-collected samples to a lab for testing. If the patient tests positive, some mobile applications can also provide treatment.
Though many such services accept private insurance, most do not accept Medicaid, which serves as a barrier for Medicaid enrollees who would like to access treatment outside of an in-person clinic. Further, Medicaid stakeholders could consider including routine STI screenings as a part of enrollees’ primary care visits. Setting up testing to be both routine and opt-out (i.e., included as a component of normal lab work unless the patient opts out) and using normalizing language for certain high-risk populations have proven to be cost-effective strategies and can assist in reducing STI-related stigma.
Medicaid has a significant role to play in addressing rising numbers of STI cases in the U.S. Despite generally having a higher risk of STI infection, screening rates for high-risk Medicaid enrollees remain low, and a number of policy and programmatic barriers hinder access to care.
Screening rates for high-risk Medicaid enrollees remain low, and a number of policy and programmatic barriers hinder access to care.
While Medicaid is the largest public payer of STI-related care, more research is needed to determine the effects of expanded reimbursement for STI testing and treatment, Medicaid delivery system reforms (i.e., telehealth), strategic data partnerships (e.g., Medicaid and public health), and alternative communication campaigns on reducing STI-related stigma.
To make meaningful progress on reducing undiagnosed STI transmission among enrollees, Medicaid officials and stakeholders must consider a multifaceted approach moving forward.