Only 3 states had enacted laws mandating health insurers to reimburse for chlamydia screening in at-risk populations before the passage of the ACA.¹⁴ However, because the ACA requires private insurers issuing or renewing plans on or after September 23, 2010, to provide, without cost sharing, certain recommended preventive services (i.e., USPSTF [grades A and B], the Advisory Council on Immunization Practices [ACIP], and those supported by the Health Resources and Services Administration [HRSA]¹²), the grade A USPSTF recommendation for chlamydia screening for women 24 years and younger¹⁵ provides an explicit pathway to increased coverage of this service (see Table 1 for glossary.) The ACA also extends this requirement to most private and group health plans, including those offered to individuals and small businesses through either the state-run Marketplaces or the federally facilitated Marketplace (hereafter Marketplace[s]),^16–18 ensuring coverage of preventive services without cost sharing to people who will receive coverage through the Marketplace beginning as early as January 1, 2014 (2015 enrollment estimated at 13 million).¹³

The requirement to cover preventive services without cost sharing does not apply to “grandfathered” health plans (i.e., plans existing before passage of the ACA [03/23/2010] or those that have not substantially changed [i.e., reduced benefits and/or increased costs] since passage of the ACA).^19–21 Likewise, grandfathered plans do not have to offer the “essential health benefits” (EHB) package of services, or the minimum categories of services to be offered by private plans sold in the Marketplaces that most individual and small group plans must offer beginning in 2014.^16,22 (Recent guidance from the President changed grandfathering in certain states.)²³ The number of plans meeting the definition of grandfathered is decreasing over time; in 2013, 36% of workers receiving coverage through their employer were enrolled in a grandfathered plan versus 56% in 2011.²⁴ High-end estimates indicate that up to 80% of small employer plans and 64% of large employer plans may relinquish grandfathered status by the end of 2013.²⁰ Many grandfathered plans cover chlamydia screening but may require young women to pay a portion of the cost. Once grandfathered status is relinquished, “new” plans will be required to cover preventive services without cost sharing.

Under the standard Medicaid program (i.e., as it existed pre-ACA), which currently provides coverage for more than 62 million individuals, states are required to offer Medicaid enrollment to certain categorically eligible groups, including low-income children, pregnant women, and parents with dependent children with income below specified minimum thresholds. Although prevention is a major focus of health reform, the provisions under the ACA that seek to increase coverage of preventive services available under standard Medicaid and Children’s Health Insurance Program (CHIP) programs (which are separate and distinct from “Medicaid expansion”),^25,26 are limited. Unlike coverage under private plans, Medicaid beneficiaries do not have universal coverage of preventive services, including chlamydia screening.²⁵ Nevertheless, the ACA attempts to move in the direction of universal coverage of preventive services in Medicaid by providing an incentive to encourage state Medicaid programs to cover preventive services with no cost sharing.

Nonelderly, nonpregnant, nondisabled adults without dependent children have not previously been eligible for Medicaid. Some states have set more generous eligibility standards for childless adult populations, but most low-income adults are ineligible for Medicaid coverage and remain uninsured.⁴⁰ To increase coverage for low-income uninsured populations, one goal of the ACA was to expand Medicaid eligibility to all adults aged 65 years and younger at 133% or less (138% with income disregard)⁴¹ of the federal poverty level (FPL; i.e., Medicaid expansion).⁴² Original estimates projected that full implementation of Medicaid expansion would enroll 16 million uninsured individuals by 2019.⁴³ However, a June 2012 Supreme Court decision on the constitutionality of the ACA effectively altered Medicaid expansion from a mandatory provision to a state option.⁴⁴ As of January 2014, 26 states and the District of Columbia have determined that they will participate in Medicaid expansion, with several states undecided.⁴⁵ Accordingly, fewer people will be covered by the Medicaid program moving forward than originally planned.⁴⁶ Some will obtain coverage through the Marketplaces, but many are expected to remain uninsured.^46–48

Individuals eligible under Medicaid expansion are entitled to coverage, without cost sharing, of the preventive services included in the EHB package available to those enrolled in private plans through the Marketplaces (note that these benefits differ significantly from preventive benefits under standard Medicaid, as described above).⁴⁹ This extends this benefit to sexually active young women who are part of the Medicaid-expansion population, including young women who are not pregnant or parenting. Had Medicaid expansion moved forward as outlined in the ACA, it is likely that chlamydia screening without copay would have been extended to a number of eligible young women who may now remain uncovered. The impact would have been most noticeable in those states where income eligibility requirements for Medicaid are set at a low percentage of the FPL.⁵⁰

Safety net providers provide health care to individuals at reduced or no cost and so often serve uninsured and Medicaid populations.⁵¹ In addition, barriers to accessing chlamydia screening might lead some young women with insurance coverage to seek screening through safety net agencies which provide care underwritten by public dollars, including state or local health departments, federally qualified health centers (FQHCs), or Title X clinics, as these entities often provide confidential services for no cost or on a private pay, sliding-fee scale. Anticipating increased uptake of health care services as a result of coverage expansions, the ACA authorized US$11B for community health center expansion to meet new demand.⁵² Likewise, the ACA requires all qualified health plans offered through state exchanges to include essential community providers (ECPs) within their network.⁵³ Proposed guidance offered by the Centers for Medicare & Medicaid Services indicates that eligible ECPs include FQHCs, Title X clinics, and STD clinics within health departments, although health plans are not required to contract with all of these entities within their covered area.⁵⁴

The ACA was intended to reduce health care costs, in part, by shrinking the pool of individuals in need of uncompensated care. As such, the use of state or federally supported services by insured individuals who choose not to use their insurance and instead receive uncompensated care from one of these entities could constitute a diversion of funds away from care of the uninsured. Although ACA provisions strengthen the capacity of these providers, public funding should remain a payer of last resort for women with other reimbursement options.

Increased public and private access to preventive screening under the ACA is a positive step in preventing, identifying, and treating chlamydia among sexually active young women; however, substantial challenges remain.

Chlamydia screening of sexually active young women is a core component of STD prevention and control, and the ACA provides a number of opportunities for extending the reach of this critical service: requiring coverage without cost sharing for certain public and non-grandfathered private group and individual plans, introducing health insurance Marketplaces to make more accessible and simplify coverage options, providing premium subsidies to purchase insurance to individuals between 100% and 400% FPL, expanding Medicaid in participating states, and offering increased financial incentives to states with Medicaid plans which include coverage of preventive services without cost sharing. However, many challenges remain. Coverage requirements are not uniformly mandated across all private and public insurance plans. Women in non-grandfathered private plans enjoy chlamydia screening without cost sharing, whereas women accessing care via standard Medicaid may have inconsistent coverage of this service. Meanwhile, because many states have not indicated that they will expand Medicaid, a number of young women might not be able to acquire coverage if they fall outside Medicaid eligibility categories and premium subsidy income requirements. Thus, local context may affect the potential impact of ACA requirements which facilitate chlamydia screening. For example, a young woman living in a state with a low threshold for Medicaid eligibility (e.g., ≤99% FPL) that does not adopt Medicaid expansion will likely see less benefit than a young woman who lives either in a state adopting Medicaid expansion or who qualifies for premium insurance subsidies.

Sufficient data are not yet available to estimate the effect of ACA-driven changes described here on chlamydia screening rates in the post-ACA era. Many of the law’s provisions did not go into effect until 2014, and others have not been in place long enough to achieve mature implementation. Moving forward, however, the HEDIS measure of chlamydia screening among sexually active young women will provide insight into the impact of these changes at both the national and state levels and for women with private or public insurance.

Although many existing barriers to screening (e.g., confidentiality concerns and inadvertent disclosure of sensitive information) may need to be ameliorated through legal remedies at the state or federal level and thus may be beyond the reach of an individual public health professional,⁷⁴ an understanding of these issues can allow for local innovation to counteract their effects. Beyond this, public health professionals can play an important role in community-level prevention and control of chlamydia in the post-ACA health care landscape. Foci might involve working with health plans or state and local health departments to identify a network of safety net providers, providers accepting new Medicaid patients, or providers offering walk-in clinic hours or who see individuals on a walk-in basis for STD services. Likewise, provider education efforts may help improve performance on the HEDIS measure of chlamydia screening among sexually active young women by improving sexual history taking, focusing screening efforts on the appropriate target population, or suggesting small, often structural, changes within a practice, which have been shown to increase screening rates.⁷⁸ Overall, successful efforts by public health professionals to close the gap between the potential for increasing coverage and access to chlamydia screening offered by the ACA and complications and misunderstandings present in on-the-ground implementation could amplify the impact of the legislation.