There are 2 ways the ACA is expected to expand access to health care. As drafted, the ACA expanded Medicaid by setting a program eligibility standard of 133% or less of the federal poverty level (FPL) for all adults, to be implemented by 2014.³ Also, the ACA provides incentives to individuals not covered under public programs to purchase private health insurance through legal requirements and subsidies for individuals between 100% and 400% FPL.^4,5 The combined effect was to expand health insurance coverage to nearly all individuals up to 400% FPL. Even so, the Congressional Budget Office (CBO) initially estimated that 21 million people would remain uninsured in 2016.⁶In addition to these general reforms, the ACA aims to increase access to services by requiring coverage without cost sharing for US Preventive Services Task Force (USPSTF) Grade A and B services (for non-grandfathered private insurance plans).⁷ USPSTF recommendations include screening of sexually active women younger than 25 years for chlamydia and screening of all sexually active women for gonorrhea if they are at increased risk for infection.⁸

Safety net STD providers offer confidential STD services free of charge or for reduced fees, often to individuals of limited means or who otherwise lack access to health care. Safety net STD providers can take a number of forms, depending on community demographics, STD burden, and decisions regarding public resources. Research has identified several sources of safety net services including public health and community clinics,^9,10 family planning clinics,^11–13 and STD clinics.¹⁴ Collectively, these providers serve vulnerable populations—predominantly low-income¹⁴ men¹⁵ and women,^12,13 high-risk youth,¹⁰ and minority groups at increased risk for STDs.¹⁴ In addition, national data have shown that vulnerable populations often report seeking STD services from safety net providers.¹² Specifically, among women aged 15 to 44 years who received STD services in 2006 to 2010, 18.3% received services from a community or public health clinic and 12.1% received services from a family planning clinic.¹² Approximately half of women seeking care at a community or public clinic (52.7%) or a family planning clinic (44.6%) had an income-to-poverty ratio of less than 134%.¹² In addition, men infected with gonorrhea are more likely to be symptomatic than women, and they are also more likely to attend an STD clinic.^14,16Furthermore, African American and Hispanic women were among the subpopulations most frequently reporting receiving services from community or public clinics (30.3% and 25.5%, respectively).¹²

Individuals seek STD services from safety net providers for reasons that include general health care access issues (not having a regular provider; financial considerations) and issues related to confidentiality, same-day services (for symptomatic persons), and quality of care.^14,15,17,18 Any access to health care can be challenging for some subpopulations. For example, one study of STD clinic attendees found that 68% of men did not have a regular doctor.¹⁵ Also, financial considerations are commonly cited as a barrier to health care and a reason for seeking STD services from safety net providers. In one study, 59% of survey respondents cited the low cost of care at STD clinics as an important factor.¹⁴ A similar client study found that “free” care distinguished STD clinics from general practitioners and family planning clinics.¹⁷ One public STD clinic evaluation showed that demand for STD services declined after imposing a US$15 fee for county residents (US$65 for nonresidents), although fees could be waived for symptomatic patients or partners of STD patients.¹⁸ Nine months after imposition of the fees, visits and diagnosed cases of chlamydia and gonorrhea fell by 30.5%, 28.1%, and 38.1%, respectively, versus the same period in the year before imposing the fees.¹⁸ The clinic later rescinded fees for county residents.

Even when individuals are insured, there may be demand for safety net STD services because some individuals prefer to seek STD services from safety net providers to maintain confidentiality (i.e., patients may not want their regular provider to know or may want to avoid billing-related notifications, e.g., explanation of benefit forms and being sent home). In Massachusetts, which in 2006 implemented reforms similar to those under the ACA, it was found that 24% of patients attending an STD clinic were uninsured and that 66% of insured STD clinic patients chose to not use their insurance because of confidentiality concerns, an inability to afford the copay, or their perception that the services would not be covered under their plan.¹⁹ Similarly, another Massachusetts study found that after a US$75 per visit fee was implemented for patients not using insurance for their visit, STD clinic visits decreased by 20% overall and 50% of patients paid the fee, despite 98.1% of state residents having insurance.²⁰ Other studies also cite confidentiality as a reason individuals seek STD services from safety net providers.^14,21,22 Similarly, individuals can seek STD care from safety net providers to avoid stigma, citing it as a reason for not receiving STD services from their primary care physician^7,14 or from clinics where they are likely to be seen by their peers.²³Also, it is possible that some primary care providers may be uncomfortable providing STD services.

Some safety net providers offer same-day services, and some are perceived as having a higher quality of care. In one study of STD clinic attendees in 8 areas, 68% of patients cited walk-in services or same-day appointments as the reason they chose an STD clinic.¹⁴ Furthermore, young men have expressed concern over having to see multiple providers for reproductive health services.²³ Same-day services, especially for symptomatic persons, are important because timely testing and treatment of high-risk individuals is a population-level priority to minimize the duration of infection, thereby decreasing the number of new infections.²⁴ Also, it has been suggested that STD services provided by health departments may be of higher quality compared with private clinics, particularly in terms of availability of STD services, education, counseling, and condom dissemination.²⁵ Furthermore, editorials in professional journals have stressed the continued importance of dedicated facilities for the diagnosis and treatment of STDs and tuberculosis, citing similar considerations: the complexity of these conditions, the increased competence of specialists, and the performance of public health activities such as partner notification, reporting, and testing for comorbidities.^26,27 Also, some STD clinics may serve as centers of expertise and training.²⁷ Therefore, there may be a continued need for safety net STD providers to ensure that the supply of affordable, timely, high-quality services is available to meet the new demand created by the ACA’s increases in access to care. Because chlamydia and gonorrhea are often asymptomatic, screening is an important component of STD control.^28,29

The Supreme Court’s 2012 decision regarding the ACA made Medicaid expansion optional to states.² In response to the decision, the CBO estimated that 31 million people (10%) would remain uninsured by 2016, an increase of 10 million over its prior estimate.³⁰ The CBO based this increase primarily on its expectation that not all states will expand their Medicaid programs.³¹ The effect of Medicaid expansion decisions could prove especially challenging for STD prevention efforts. It is not likely that all states will expand their Medicaid programs,³² and for nonpregnant adults with dependent children in many states, the maximum income level eligible for Medicaid is currently below 100% FPL (the cutoff for private insurance subsidies).³³ Some populations, such as childless adults, are not eligible for Medicaid at any income level in many states.³³ In a state that does not expand its Medicaid program, the need for providers of safety net STD services will likely continue because some populations will be ineligible for both Medicaid and private insurance subsidies.

Finally, despite services recommended by USPSTF being covered without cost sharing under the ACA, some private insurance plans and state Medicaid plans do not cover some STD screening and treatment services.^34–36 Therefore, increases in insurance coverage may not result in patients receiving care at lower costs than before the ACA.³⁷

Although the ACA is expected to increase access to STD services, many vulnerable populations are expected to remain uninsured.³⁸ Furthermore, in states that do not expand their Medicaid programs, certain populations may continue to rely on safety net providers for STD services. Accordingly, careful consideration of access to safety net services would be useful for STD prevention. In addition to financial considerations, safety net providers may serve an important role in the provision of confidential, high-quality, same-day STD services.