these clinics collaborate with community-based health clinics, including family planning clinics and school-based programs, university and hospital medical centers, and private sector health care professionals, to improve the scope and quality of care in dedicated public STD clinics.

As previously mentioned, the committee supports incorporating STD-related services into primary care. The committee believes that, in some communities and situations, dedicated public STD clinics should continue to be an important component of STD prevention because, in most areas, persons who use public STD clinics usually are uninsured. Data cited in Chapter 5 indicate that convenience, confidentiality, low cost, and perception of expert care at public STD clinics are important to clinic users. The populations at greatest risk for STDs-the young, disenfranchised groups, and certain ethnic and racial groups-tend to have the least access to health care. One of every four persons 15-29 years old is uninsured. Lack of private health insurance and dependence on Medicaid suggest why some ethnic groups and persons with lower incomes account for a disproportionately large share of public STD clinic visits in many urban areas. Therefore, without universal health care coverage in the United States or improved access to STD-related services in the public and private sector, effective STD prevention will continue to require public STD programs to ensure access to STD-related services for the uninsured.

The committee is particularly concerned regarding the potential adverse public health impact of the recently enacted welfare reform legislation, proposals to restrict social and health services to immigrants, and the proposed reductions in the rate of growth of Medicaid funds. It is likely that such legislation will increase the number of persons without health insurance coverage, and thus without financial access to health services. It is also possible that the above policies will indirectly promote certain behaviors that increase risk for STDs or inhibit prompt health-seeking behaviors. Adding to these public policies, the continuing decline in employer-provided health insurance also is likely to increase the number of uninsured. These developments raise grave concerns that even larger numbers of persons will be dependent on publicly financed STD clinics, increasing the importance of this safety net at the same time that such services are being curtailed in some places.

Therefore, the committee makes the following recommendations:

  • Based upon local conditions and health department determination, dedicated public STD clinics should continue to function as a ''safety net" provider of STD-related services for uninsured and disenfranchised persons and for those who prefer to obtain care from such clinics. Should universal health care coverage in the United States be achieved, or if proposed changes in the existing delivery system for STD-related clinical services, including incorporating STD-related clinical services into primary care and improved access to

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