Author: Paige Allen

What are Sexually Transmitted Diseases (STDs)?

Also known as sexually transmitted infections (STIs), sexually transmitted diseases (STDs) are “infections that are passed from one person to another through sexual contact”. While there are more than 20 types, the eight most common in 2018 included chlamydia, genital herpes, HIV, HPV, syphilis, trichomoniasis, and hepatitis B. STDs can be symptomatic or asymptomatic, and STDs caused by bacteria or parasites are easier to treat because antibiotics are effective remedies. Viruses, on the other hand, cannot be treated and medications can only be used to mitigate the spread and severity of symptoms. Preventative measures include latex condoms (although condom usage remains low), regular screenings, and vaccines for HPV (the most common type of STD) and hepatitis B. 

Rates of STD transmission remain high throughout the United States, and disproportionately affect gay and bisexual men as well as Black and Hispanic populations. In 2018, 20% of Americans were infected with an STD, totaling out to 68 million infections by the end of the year. Those within the 15-24 year-old age group comprised 46% of those cases. STD cases are increasing; as are the healthcare costs associated with treating STD patients. In direct costs alone, spending amounted to $16 billion in 2021. It is crucial to treat STDs early because untreated diseases such as chlamydia, gonorrhea, and syphilis can lead to ectopic pregnancies and fertility issues for women and a higher risk of contracting HIV. 

Current Financial Coverage for STD Resources and Healthcare

Medicaid is the largest financial contributor to reproductive healthcare coverage. Medicaid is also the largest public funder of HIV treatment and care. In 2014 and 2015, data from the National Ambulatory Medical Care survey indicated that compared to other payment sources, Medicaid disproportionately covers services for individuals that are most likely to need STD care, which is usually those who are younger, female, minorities, part of the LGBTQ+ community, people with disabilities, and those of lower socioeconomic status. In 2020, 37 states and the District of Columbia made STI screenings and counseling, preventative vaccinations, and PrEP eligible for coverage under Medicaid. 

Medicare provides healthcare financing to those who are 65+ and/or have long-term disabilities. Part B covers “STI screenings for chlamydia, gonorrhea, syphilis, and/or hepatitis B once every 12 months for individuals at increased risk for an STI or at certain times during pregnancy for pregnant individuals”. It also covers one HIV screening per year, and Part D covers all approved antiretrovirals (with potential for cost sharing). Under the Affordable Care Act, private health insurance plans are mandated to cover recommended preventative services (HIV, other STI screenings, and prescriptive contraceptives for women) with no cost sharing. Uninsured individuals can receive care from health clinics and departments that are federally funded by agencies like HRSA, the CDC, and the Office of Population Affairs (OPA). 

Title X

Title X, created in 1970, is a program for low-income individuals to obtain affordable birth control and reproductive healthcare. Wellness exams, birth control, contraception education, and testing/treatment for STDs and HIV are all provided. Participating clinics like Planned Parenthood, federally qualified health centers (FHQs), and state and county health departments receive federal funding for services of this nature. In 2019, the Trump administration passed the Title X gag rule. This effectively banned physicians associated with the program from providing patients with information about abortion. Other services were also affected by this decision–Title X’s network patient capacity was reduced by half, Planned Parenthood could no longer serve 40% of the program’s four million patients, and six states lost Title X providers entirely. The original provisions of the Title X program were reinstated by the Biden administration in 2021. 

Arguments in Favor of the Right to Contraception Act & Financial Coverage of Contraceptives

The Right to Contraception Act was introduced in summer 2022 with the objective of protecting “a person’s ability to access contraceptives and to engage in contraception, and to protect a health care provider’s ability to provide contraceptives, contraception, and information related to contraception”. This bill also argues that access to contraception is a fundamental human right, that it is essential to one’s ability to participate equally in economic and social life (especially for marginalized populations), and that it is vital to sexual and reproductive health. Furthermore, it acknowledges that some states have attempted to associate contraceptives with the definition of abortion.

The bill would grant individuals the statutory right to obtain and engage in contraception, for healthcare professionals to provide “contraceptives, contraception, and information related to contraception” (codifying the right to contraception nationwide), and for the Justice Department to take contraception restrictions to court. Following the overturning of Roe v. Wade, legislators have begun to explore codifying other policies, like access to contraception, which were not viewed as necessary before. 

Arguments Against the Right to Contraception Act & Financial Coverage of Contraceptives

Some in opposition argue that the legislation violates states’ rights to regulate their own healthcare policy and violates the Religious Freedom Restoration Act, which “establishes balancing test courts can use when deciding religious-liberty cases involving federal laws and regulations”. There is also concern because the bill does not list any age restrictions, making protections for minors more difficult. 

There is also concern that the bill is a “Trojan horse for more abortions”. It would grant a federal right to use the abortion drug Mifepristone (which has both contraceptive and non-contraceptive uses). The legislation would also prohibit states and the federal government from cutting off taxpayer subsidies to Planned Parenthood, and abortion services are offered by Planned Parenthood subject to state regulation. 

In September 2022, the state of Texas was taken to court by a group of residents and employees over the Affordable Care Act. They argued that mandating the coverage of preventative care violated their religious freedoms and that health plans covering screenings for STDs and HIV prevention drugs should not be required because it will “facilitate and encourage homosexual behavior, prostitution, sexual promiscuity, and intravenous drug use”. Judge Reed O’Connor’s final ruling was that “compulsory coverage for [these] services violates [employers’] religious beliefs by making them complicit in facilitating homosexual behavior and [illegal] drug use”. Therefore, Texas insurers no longer have to cover PrEP (prevents transmission of the HIV virus), contraception, HPV vaccines, and screenings/behavioral counseling for illicit drugs and STDs. 

What Happened to the Right to Contraception Act?

The Right to Contraception Act ultimately passed the House of Representatives with a 228-195 vote. In July 2022, Senators Patty Murray and Edward Markey sought unanimous consent to get the Right to Contraception Act passed, but it was blocked by Senator Joni Ernst. As a result, the bill died because “Legislation not passed by the end of a Congress (in this case, from January 3rd, 2021 to January 3rd, 2023 in the 117th Congress) is cleared from the books”. Today, this question remains: should contraceptives continue to be publicly and privately funded, or should access be regulated on a state level?

Overview

The year before the coronavirus (COVID-19) pandemic hit, the Global Health Security Index ranked the United States first in pandemic preparedness. However, 1.01 million American deaths later, it is crucial to reflect upon the actions of other countries in considering what could have gone differently in the United States. This brief will compare how the United States implemented medical leave policies, addressed hospital capacity issues, and dealt with medical supply/device shortages during the course of the pandemic, with the approaches of other countries. 

Medical Supply and Device Shortage

When an outbreak of a novel pathogen occurs, the United States federal government utilizes two tools to ensure states have the needed medical supplies and equipment: 

• The Strategic National Stockpile, which keeps medical supplies, equipment, medicines, and devices on hand to distribute amongst states during public health emergencies
• Invoke the Defense Production Act, which encourages and obliges private companies to mass produce any products that are in high demand. 

During the first two months of the pandemic, the Trump administration did not use these resources immediately, and opted to pass responsibility for medical supplies on to states. Competition for medical supplies in global markets became intense, and the Federal Emergency Management Agency (FEMA) started confiscating the personal protective equipment (PPE) that states had ordered. The prices of N95 and surgical masks soared because of global export restrictions. Furthermore, the Strategic National Stockpile was not fully equipped after being depleted by the 2009 H1N1 influenza pandemic. By March, the Defense Production Act was put into effect, two months after the first case of COVID-19 was discovered in the United States. 

The Coronavirus Aid, Relief, and Economic Security Act (CARES Act), passed in March 2020, took several steps in an attempt to address the issues with the Strategic National Stockpile and supply/device shortages, including: 

• Amending the Public Health Service Act so the stockpile was required to include PPE, ancillary medical supplies, and supplies needed for drug administration, vaccines, other biological products, medical devices, and diagnostic tests
• Raising reporting requirements for manufacturers to prevent drug shortages 
• Having the Secretary of Health and Human Services develop a publicly available and updated list of medical devices in shortage
• Having the Secretary of Health and Human Services and the National Academies of Sciences, Engineering, and Medicine work jointly to analyze the impacts of increasing domestic production and the levels of international dependence within the United States’s medical supply product chain

In December 2020, an additional $3 billion dollars was allocated to improving the Strategic National Stockpile by The Coronavirus Response and Relief Supplemental Appropriations Act. 

The Biden administration passed the American Rescue Plan, which invested $30 billion into the Disaster Relief Fund to purchase medical supplies/PPE and provided reimbursement to states, local governments, and Tribes for critical emergency response resources (such as the deployment of the National Guard). Another $10 billion was set aside for the expansion of domestic manufacturing of pandemic supplies. 

France reacted similarly in delegating the storage of PPE to individual healthcare facilities and self-employed physicians, and this strategy also caused chaos, but for different reasons. Overall, France faced difficulty when passing responsibility down from the national Ministry of Health to Regional Health Agencies (ARS) and local healthcare institutions. Due to mixed messaging from the government regarding mask necessity, masks were not readily available to the general population until July 2020. Contrary to the United States, France prioritized reducing mask stocks after the H1N1 pandemic hit, as they were criticized for their abundance of mask supply because it was seen as an overreaction to the severity of the outbreak. By early 2020, approximately 600 million masks were supposed to be destroyed and replaced per the French Public Health Agency and the Ministry of Health’s recommendation, as many of the stocks were found to be expired (but not ALL of them were expired). This inadvertently affected healthcare workers outside of hospitals the most, and it was weeks before they had an adequate supply of masks. 

Hospital Capacity

The United States did not have enough ICU and acute care beds to meet the demands of the pandemic. Even after the cancellation of elective procedures, in January 2021,  ⅕ of hospitals were still at 95% capacity in the Intensive Care Unit (ICU). Makeshift acute care units were set up in other hospital wards and spaces including lobbies and parking lots. Healthcare professionals were in high demand, and affluent hospitals retained more employees because they had the resources to pay them more, leaving rural and under-resourced hospitals short-handed. In response to such issues, the CARES act secured a portion of $150 billion for increased hospital capacity, and expanded telehealth services. The Coronavirus Response and Relief Supplemental Appropriations Act allocated funds to increase support for healthcare providers. 

Canada’s federal government compiled a list of suggested actions for regional and local healthcare authorities. Recommendations included training medical personnel in other departments to work in ICUs so that all ventilators and beds could be adequately monitored, and advance planning for transporting patients to other facilities in the event of hospitals reaching their maximum capacity. They too rescheduled non-urgent surgeries, relied on telehealth services, and decreased emergency visits by half through establishing off-site screening facilities. The early implementation of this plan contributed to Canada’s lower hospitalization and death rates than in the United States or the European Union during the first wave of the pandemic from January to April 2020. 

Medical Leave

The Families First Coronavirus Response Act (FFCRA) was passed by Congress in March 2020 and stayed in effect until December 2020. It guaranteed that:

• Full-time employees would receive up to two weeks of paid medical leave at their full salary rate if they were unable to work due to being quarantined and/or were symptomatic and getting tested for coronavirus 
• Full-time employees would receive up to two weeks of paid medical leave at ⅔ of their full salary rate if they had to care for someone quarantining or a child under the age of 18 that could not attend school or daycare due to closures attributed to COVID-19
  • Applicable to public employers and private employers with fewer than 500 employees
  • Excluded federal employees from the expanded family and medical leave provisions but left the paid sick leave provision covered under Title II of the Family and Medical Leave Act
  • Part-time employees would be covered for the average number of hours they work over a two-week period
  • Under the same provisions listed for childcare, employees could receive up to an additional ten weeks of paid leave at the same rate so long as they have been employed for 30 calendar days
    • Employers with less than 50 employees could qualify for exemption from these provisions if compliance would put their business at stake

The American Rescue Plan extended some of the benefits of the FFCRA until September 2021. This bill:

• Renewed the paid medical leave requirements and removed the exemptions for private employers with more than 500 employees and less than 50 employees
  • Made 106 million more workers eligible for paid medical leave
• Allowed employees to receive up to an additional twelve weeks of paid leave versus 10 weeks, under the same provisions listed for childcare, employees could 
• Gave all federal employees the same benefits as other full-time employees
• Guaranteed that eligible workers earning up to $73,000 annually would receive a maximum paid-leave benefit of $1,400 per week
• Provided employers with less than 500 employees the right to use refundable tax credit in order to be reimbursed for covering medical leave
• Paid medical leave reimbursement costs for state and local governments 

Germany used paid medical leave to incentivize its population to get vaccinated (a higher percentage of Germans are vaccinated than Americans). The most recent policies for paid medical leave are as follows:

• In order to qualify for up to six weeks of paid medical leave (employers are reimbursed for these costs by state governments), you must be:
  • Fully vaccinated and boosted
  • Symptomatic 
• If you meet the above criteria and need more than six weeks of paid medical leave, once the seventh week commences, you will receive a sickness benefit that is less than your salary from your health insurer instead (as long as you can provide a sick note from your doctor)
• One could apply for up to 30 days of child sickness benefits through their health insurance that would amount to 90% of their net income (with more days allotted to single parents and families with several children) if they:
  • Can provide documentation to their health insurer that confirms their child’s school or daycare facility is closed
  • Have public health insurance or are civil servants