adverse impact of these social problems on STDs, even if these dilemmas are not solved directly.

Poverty and Inadequate Access to Health Care

Health insurance coverage enables individuals to obtain professional assistance in order to prevent potential exposures to sexually transmitted infections and to seek care for suspected STDs. Uninsured persons delay seeking care for health problems longer than those who have private insurance or Medicaid coverage (Freeman et al., 1987; Donelan et al., 1996). Those with private health insurance who are living at or near poverty level have limited access to health care because of copayments and deductibles that are typically part of private insurance coverage (Freeman and Corey, 1993). Medicaid coverage is often less effective than private health insurance coverage since many physicians refuse to treat Medicaid beneficiaries, thereby restricting access to comprehensive health services (Schwartz et al., 1991).

Private health insurance generally provides the most comprehensive coverage with the greatest access to physicians and other health care professionals. However, not all plans offer adequate coverage for STD-related services. Little information is available on coverage for STD-related services in the private health care sector. A recent study of how women pay for reproductive health care suggests that many health plans either do not cover some important STD-related preventive reproductive health services or require copayments and deductibles for these services (WREI, 1994). STD-related diagnostic and treatment services are covered under general clinical care. However, the study found that only about half of all health plans cover preventive care such as routine gynecological examinations that may be important in detection of asymptomatic sexually transmitted infections.

Managed care organizations may provide better coverage for certain STD-related services than do many indemnity health plans, but they pose different challenges to the prevention of STDs, particularly for many Medicaid beneficiaries enrolled in managed care. Most managed care organizations require their enrollees to obtain all their health services from the plan's network of providers. This disrupts established patterns of STD care for many women on Medicaid by denying patients access to their preferred providers. A recent study found that neither the federal government nor the states had taken steps to ensure that Medicaid beneficiaries enrolled in managed care organizations could obtain services from family planning programs or public STD clinics (Rosenbaum et al., 1995). A number of family planning programs have taken the initiative to develop contracts with managed care organizations that serve Medicaid clients, thus both avoiding the problem of nonreimbursed out-of-plan use and retaining an important source of revenue for their program (Orbovich, 1995). This is an especially important policy issue as states increasingly encourage or require Medicaid

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