beneficiaries to enroll in managed care organizations. The role of managed care organizations and other health plans in STD prevention is further discussed in Chapter 5.

Health insurance coverage influences where people obtain STD services. A recent study found that uninsured women and those covered by Medicaid were far more likely to obtain reproductive health services from a public or community-based clinic rather than a private physician's office, compared to women who were covered by either a managed care organization or other private health insurance (Sonenstein et al., 1995). Even those with adequate insurance coverage may be reluctant to obtain care for potential STDs from their regular health care providers because of the social stigma associated with these infections. A significant number of persons with private insurance are reluctant to bring STD exposures to the attention of their family doctor or health plan and prefer the anonymity of a public STD clinic or other public clinic (Celum et al., 1995).

In 1993, 40.9 million Americans, or 18.1 percent of the nonelderly population, were not covered by any public or private health insurance coverage, up from 39.8 million or 17.8 percent of the nonelderly population in 1992 (EBRI, 1995b). Further analysis of these data revealed that of the 1.1 million increase in uninsured persons from 1992 to 1993, 900,000 or 81.8 percent of the newly uninsured population were children and youth under 18 years of age (EBRI, 1995a).

The age and ethnic groups with the highest rates of STDs are also the groups with the poorest access to health services. One-third of persons in high-risk age groups are uninsured or covered by Medicaid (UCLA Center for Health Policy Research, unpublished data, 1996). Among persons 15-29 years of age, 25 percent are completely uninsured (Figure 3-1), including one in every five persons 15-20 years old and at least one in every four persons 21-29 years old. One in every nine persons 15-29 years old depends on Medicaid or other publicly sponsored insurance for health care access. In addition, Hispanic and African Americans are most likely to lack insurance coverage.

Poverty and other socioeconomic factors also contribute to STD risk in other ways. Even if a person in poverty perceives himself or herself to be at risk for an STD, he or she may not practice preventive behaviors if there are other risks that appear more imminent or more threatening or both (Mays and Cochran, 1988; Ramos et al., 1995). Mays and Cochran (1988:951) point out that poor women of certain ethnic groups face continual danger and have few resources to deal with them: "Competition for these women's attention includes more immediate survival needs, such as obtaining shelter for the night, securing personal safety or safety of their children, or interfacing with the governmental system in order to obtain financial resources." Traditional cultural values associated with passivity and subordination also diminish the ability of many women to adequately protect themselves (Amaro, 1988; Stuntzner-Gibson, 1991).

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