Health departments brace for loss of STD funds

Quandary over how to continue testing for diseases that cause infertility

0 | KDHE, Public Health

Bob Bumgardner, a microbiologist at the Kansas Department of Health and Environment, tests samples for chlamydia and gonnorhea. The sexually transmitted diseases are the leading causes of infertility in Kansas and the U.S. It is unclear if KDHE will continue testing for the diseases once the Affordable Care Act is implemented. Federal funding for the testing is expected to end once the Medicaid expansions planned under ACA become effective.

Bob Bumgardner, a microbiologist at the Kansas Department of Health and Environment, tests samples for chlamydia and gonnorhea. The sexually transmitted diseases are the leading causes of infertility in Kansas and the U.S. It is unclear if KDHE will continue testing for the diseases once the Affordable Care Act is implemented. Federal funding for the testing is expected to end once the Medicaid expansions planned under ACA become effective.

— State health officials are raising concerns about the future of a federally funded program that helps county health departments prevent infertility in women by testing for the sexually transmitted diseases of chlamydia and gonorrhea.

“There hasn’t been an official announcement, but it certainly appears that the funding will be going away after January of 2014,” said Jennifer VandeVelde, who runs the Kansas Infertility Prevention Project at the Kansas Department of Health and Environment. “The assumption is that with the Affordable Care Act everyone will have insurance so we won’t need the funding we have now.”

Combined, chlamydia and gonorrhea are the leading cause of infertility, according to the Centers for Disease Control and Prevention (CDC).

The mandatory coverage provisions in the federal health reform law are scheduled to take effect Jan. 1, 2014.

What’s unclear, VandeVelde said, is how county health departments would offset the costs of testing patients who, despite new law’s requirements, will remain uninsured.

“A lot of health departments today are dealing with people who won’t be eligible for health insurance under any circumstances – the undocumented folks, for example,” said Greg Stephenson, head of the clinical services division at the Wyandotte County Public Health Department.

Also, thousands of Kansas adults whose incomes fall below 133 percent of the federal poverty level and who are currently uninsured would remain uninsured if Gov. Sam Brownback decides to opt out of the Medicaid expansion provisions in the Affordable Care Act.

Brownback, an outspoken critic of the reform law, has said he will not announce his decision about the Medicaid expansion at least until after the November election. Republican presidential candidate Mitt Romney has pledged to repeal the law, if elected.

The leading cause of infertility

Last year, KDHE conducted more than 27,500 tests for chlamydia and gonorrhea. Of those, 19,200 involved women younger than 26 years old and 8,400 of the tests involved older women and men.

Almost 9 percent of the younger women, 4 percent of the older women and and 17 percent of the men tested positive for chlamydia.

Less than 1.5 percent of the women and less than 5 percent of the men tested positive for gonorrhea.

“Chlamydia and gonorrhea are the leading cause of infertility, both in Kansas and nationally,” VandeVelde said, noting that between 10 percent and 15 percent of women with untreated chlamydial infections develop infertility-related problems.

According to KDHE, the state’s health providers – a group that includes health departments as well as family physicians, OBGYNs, emergency rooms, student health centers and other walk-in health clinics - reported more than 10,600 confirmed cases of chlamydia and 2,200 cases of gonorrhea last year.

It’s not known how many tests were performed by private laboratories because providers aren’t required to report tests that do not come back positive.

“Chlamydia is so widespread that it hits every demographic you can think of,” VandeVelde said. “It’s very across-the-board, very non-discriminatory.”

Those who test positive, VandeVelde said, are treated and counseled about “behavior changes” to limit their exposure to sexually transmitted diseases. They’re also asked to identify their sexual partners so that the partners also can be treated.

“The idea is to treat (partners) preventatively so that they do not re-infect the person who tested positive and so that they don’t continue to pass it along to anybody else,” she said.

Finding a way to cover costs

Assuming though that the Affordable Care Act remains on the books and that the federal funds for testing for chlamydia and gonorrhea go away, county health departments would have to figure out a way to cover the costs of testing those who remain uninsured, Stephenson said.

“There may be two or three of the larger health departments that may have a little wiggle room left in their budgets, but there aren’t very many,” Stephenson said. “I don’t know what’s going to happen because, politically, trying get more money for (preventing or treating) sexually transmitted diseases isn’t all that appealing. It’s hard to get the money locally, which is why the feds have funded it all these years.”

Neither Stephenson nor VandeVelde could predict how much the health departments might need to spend testing uninsured patients.

“There are so many variables involved in that – it’s impossible to make an educated guess at this point,” VandeVelde said. “A lot of it’s going to depend on geography, on the patient, and whether the health department is in a position to bill for services.”

Currently, VandeVelde said, KDHE covers the staffing and overhead costs associated with the testing, which is about $7 per test.

Health departments and community health centers, she said, are asked to pay up to $15 for tests for women ages 26 years or older.

They’re also asked to pay $15 for tests that involve men of any age.

About $200,000 in federal grant funding channeled through KDHE covers the cost of testing women who are not yet 26 years old and who are not on Medicaid or covered by a private health plan.

In an effort to maximize participation, most of the county health departments do not charge their patients for the tests.

“From a public health standpoint, you want to cure the patient, but you’re even more interested in keeping control of the disease out in the community,” Stephenson said. “You don’t want to be turning people away because they don’t have the money.”

KDHE uses the $200,000 to pay for the chemicals and pipettes (glass tubes) used in the testing.

“In the grand scheme of things, $200,000 dollars isn’t a ton of money,” VandeVelde said. “But, overall, we get less than $1 million from the federal government for STDs (sexually transmitted diseases), and most of it goes to support investigations – things like partner investigations for syphilis, HIV, gonorrhea, and chlamydia. So within that context $200,000 is a lot of money.”

The test for chlamydia and gonorrhea is the same.

After the Affordable Care Act

Last month, KDHE officials informed health departments that the agency was exploring the possibility of a putting together a loose-knit, collective bargaining agreement aimed at helping them secure a volume discount from one or more private testing facilities.

“If enough providers agreed to be part of the agreement, they would, in theory, be paying for the testing themselves but at a lower cost,” VandeVelde said.

Currently, KDHE’s laboratory is not set up to process the thousands of private insurance claims the testing likely would likely generate. So after the Affordable Care Act’s launch, it is expected that local health departments would need to find a private lab to handle most of their testing.

For their uninsured patients, VandeVelde said, the health departments might be able to continue to use KDHE’s laboratory.

“It’s completely possible that our lab may be the best place for that to happen, but we’re still in the process of determining that,” she said. “If we can do it better, faster and cheaper for the citizens of Kansas we want to do that. If it’s better suited in a private lab, then by all means it we would want to do that as well. This is all about doing what’s best for the site and what’s best for the patient.”

Laura Hanen, government and public affairs chief at National Association of County and City Health Officials, praised KDHE for raising the issue.

“Because of the Affordable Care Act, health departments are going to have to get more sophisticated in order to continue to provide these services,” Hanen said. “We’ve already seen significant cuts in state and federal budgets and we’re to the point where the other shoe is about to fall. There’s already a cap on federal spending, public health spending. It’s not a matter of if, it’s a matter of how much.”



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