Talking about STDs with Health Professionals: Women’s Experiences

Glamour/Kaiser Family Foundation National Survey

Methodology

Talking about STDS with Health Professionals: Women’s Experiences was conducted for the Kaiser Family Foundation and Glamour by Market Facts, Inc. The results are based on telephone interviews conducted between May 27 through June 1, 1997 with a sample of 482 women ages 18-44 who had been to a new doctor within the last year for gynecological or obstetrical care. These women were selected using Market Facts’ Consumer Mail Panel, a nationally balanced sample of households. All interviews were conducted by female interviewers. The margin of sampling error for results based on the total sample is plus or minus 5 percentage points at the 95 percent level of confidence.

Final Topline Data

Hello, may I please speak to (Ask for panel member)? This is ______ calling on behalf of Marie Brighton of the Consumer Mail Panel. Today I’d like to speak with the female aged (Insert age from sample) in your household. Would that be you?

Yes (Continue with remainder of Introduction) No (Ask to speak with that person, reintroduce and continue with remainder of Introduction — If not available, arrange callback) No one that age (Ask: Are you, or any other female in your household between the ages of 18 and 44? If Yes — Ask to speak with a female 18-44 and continue with remainder of Introduction; If No, terminate) Today I have a few questions regarding doctors and screening for sexually transmitted diseases. I’d like to remind you that your responses will be kept strictly confidential and that your responses here will be combined with that of approximately 700 other women we are interviewing and shown only as percentages.

1. My first question is… in general, how would you describe your own health? Is it excellent, good, only fair, or poor? (Single response)

Excellent 47 Good 48 Only Fair 3 Poor 1 Don’t know 0 Refused 0 2. Do you have a doctor or other health care professional who you see regularly for gynecological care that is, for annual exams, birth control, or other reproductive health care? (Interviewer Note: If respondent has a regular place to go for care, but no regular provider at that place, record as “no.”) (Single response)

Yes 93 No 7 Don’t know 0 Refused 0 3. When was the last time you visited a doctor or clinic for gynecological or pregnancy-related care? Would you say your last visit was within (read list)? (Single response)

The past month 24 1-3 months ago 30 4-6 months ago 23 7 months to 1 year ago, or 23 More than 1 year ago Terminate) Never Been (Don’t read) (Terminate) 4. And was this most recent visit for prenatal care or gynecological care? (Single response)

Prenatal/Pregnancy-related care 18 Gynecological 82 Don’t know * Refused 0 4b. Was this most recent visit at a private doctor’s office, a family planning clinic, or some other type of clinic? (Single response)

Private doctor’s office 75 Family planning clinic 10 Some other type of clinic 15 Don’t know 0 Refused 0 5. Was this most recent visit your first appointment with this (doctor’s office [If private “doctor’s office” or “DK/REF” at Qu. 4b] / clinic [If “family planning” or “other type of clinic” at Qu. 4b]) or had you been there before? (Single response)

First visit 46 Been there before 54 Don’t know 0 Refused 0 5b. How long ago was your first appointment with this (doctor’s office [If private “doctor’s office” or “DK/REF” at Qu. 4b] / clinic [If “family planning” or “other type of clinic” at Qu. 4b])? (Read list) (Single response)

Based on those whose most recent appointment was not their first appointment. (n=261)

The past month 2 1-3 months ago 15 4-6 months ago 21 7 months to 1 year ago, or 62 More than 1 year ago (Terminate) Never Been (Don’t read) (Terminate) [If “been before” at Qu. 5 say:] For the remainder of this survey, we are going to ask about your first visit to this (doctor’s office [If private “doctor’s office” or “DK/REF” AT Qu. 4b] / clinic [If “family planning” or “other type of clinic” at Qu. 4b])

6. What type of doctor or health professional did you see at (this visit [If first at Qu. 5] / your first visit [If been before at Qu. 5])? Was it an ob/gyn, a general practitioner, some other type of doctor, or health professional? (Single response)

Ob-gyn/Gynecologist/Obstetrician 70 General Practitioner/Family Practice Doctor/Internist 18 Other type of doctor, such as a specialist or a surgeon 3 Other, such as a nurse practitioner, a nurse midwife, or physician’s assistant 9 Don’t know * Refused 0 7. Was the health professional a man or woman? (Single response)

Male 49 Female 51 Don’t know 0 Refused 0 8. Why did you go to a new health professional? (Do not read list) (Multiple response)

I changed health insurance coverage/health plans 20 I moved 17 Because of current problem or question 11 Referred to this doctor by another health professional or clinic 10 I got pregnant 8 Previous doctor closed/moved 8 Didn’t like previous doctor 6 I got health insurance coverage 6 For a pelvic exam or pap smear 5 To get established with a doctor in case of need 4 My first gynecological visit 3 Just wanted change/Other general change mentions 3 Wanted doctor closer/More convenient 3 Regular doctor not available 2 Wanted female doctor 2 Friend/relative/co-worker recommended 2 Less expensive 1 I lost health insurance coverage 1 Previous doctor too expensive * I am planning to get pregnant * I don’t have a regular doctor * Refused * 9. Thinking about this first visit, were you asked to fill out a form with questions about your medical history? (Single response)

Yes 92 No 7 Don’t know * Refused 0 10. Did this form have specific questions on it about current or past sexual activity, such as number of sexual partners, contraceptive use, or sexually transmitted diseases? (Single response)

Based on those asked to fill out a form. (n=445)

Yes 54 No 40 Don’t know 7 Refused 0 11. Were you worried about whether your answers to the questions on this form would be keptconfidential? Would you say you were (read list)? (Single response)

Based on those who filled out a form with sexual history questions on it. (n=239)

Very worried 1 Somewhat worried 2 Not too worried, or 16 Not at all worried 81 Don’t know 0 Refused 0 Now I am going to ask you some questions about what you and your health professional discussed at this first visit. Your answers to these questions will be kept completely confidential, and your responses will be shown only in combination with the many other women we survey.

12. Did someone in your (doctor’s office [If private “doctor’s office” or “DK/REF” at Qu. 4b] / clinic [If “family planning” or “other type of clinic” at Qu. 4b]) discuss pap smears with you at this visit? (Single response)

(If respondent says the doctor did a pap smear, probe with: Did he or she just perform the pap smear, or did they have a discussion with you about pap smears?)

Yes 74 No 26 Don’t know * Refused 0 13. Who initiated this conversation, you or someone in your (doctor’s office [If private “doctor’s office” or “DK/REF” at Qu. 4b] / clinic [If “family planning” or “other type of clinic” at Qu. 4b])? (Do not read list) (Single response)

Based on those who discussed pap smears. (n=357)

You 16 Someone in your doctor’s office/clinic 81 Don’t know 3 Refused 0 14. Did someone in your (doctor’s office [If private “doctor’s office” or “DK/REF” at Qu. 4b] / clinic [If “family planning” or “other type of clinic” at Qu. 4b]) discuss breast self-exams with you? (Single response)

(If respondent says the doctor did a breast exam, probe with: Did he or she just perform the breast exam, or did they have a discussion with you about breast self-exams?)

Yes 74 No 26 Don’t know * Refused 0 15. Who initiated this conversation, you or someone in your (doctor’s office [If private “doctor’s office” or “DK/REF” at Qu. 4b] / clinic [If “family planning” or “other type of clinic” at Qu. 4b])? (Do not read list) (Single response)

Based on those who discussed breast self-exams. (n=357)

You 6 Someone in your doctor’s office/clinic 94 Don’t know 1 Refused 0 16. Did someone in your (doctor’s office [If private “doctor’s office” or “DK/REF” at Qu. 4b] / clinic [If “family planning” or “other type of clinic” at Qu. 4b]) discuss mammograms with you? (Single response)

(If respondent says the doctor did a mammogram, probe with: Did he or she just perform the mammogram, or did they have a discussion with you about mammograms?)

Yes 41 No 58 Don’t know 1 Refused 0 17. Who initiated this conversation, you or someone in your (doctor’s office [If private “doctor’s office” or “DK/REF” at Qu. 4b] / clinic [If “family planning” or “other type of clinic” at Qu. 4b])? (Do not read list) (Single response)

Based on those who discussed mammograms. (n=197)

You 16 Someone in your doctor’s office/clinic 83 Don’t know 1 Refused 0 18. Have you ever had a mammogram yourself? (Single response)

Yes 34 No 66 Don’t know 0 Refused 0 19. Did someone in your (doctor’s office [If private “doctor’s office” or “DK/REF” at Qu. 4b] / clinic [If “family planning” or “other type of clinic” at Qu. 4b]) discuss birth control with you? (Single response)

Yes 54 No 46 Don’t know 0 Refused 0 20. Who initiated this conversation, you or someone in your (doctor’s office [If private “doctor’s office” or “DK/REF” at Qu. 4b] / clinic [If “family planning” or “other type of clinic” at Qu. 4b])? (Do not read list) (Single response)

Based on those who discussed birth control. (n=259)

You 37 Someone in your doctor’s office/clinic 62 Don’t know 1 Refused 0 21. Did someone in your (doctor’s office [If private “doctor’s office” or “DK/REF” at Qu. 4b] / clinic [If “family planning” or “other type of clinic” at Qu. 4b]) discuss alcohol use with you? (Single response)

Yes 25 No 73 Don’t know 2 Refused 0 22. Who initiated this conversation, you or someone in your (doctor’s office [If private “doctor’s office” or “DK/REF” at Qu. 4b] / clinic [If “family planning” or “other type of clinic” at Qu. 4b])? (Do not read list) (Single response)

Based on those who discussed alcohol use. (n=121)

You 5 Someone in your doctor’s office/clinic 95 Don’t know 0 Refused 0 23. Did someone in your (doctor’s office [If private “doctor’s office” or “DK/REF” at Qu. 4b] / clinic [If “family planning” or “other type of clinic” at Qu. 4b]) discuss AIDS or HIV with you? (Single response)

Yes 21 No 78 Don’t know 1 Refused 0 24. Who initiated this conversation, you or someone in your (doctor’s office [If private “doctor’s office” or “DK/REF” at Qu. 4b] / clinic [If “family planning” or “other type of clinic” at Qu. 4b])? (Do not read list) (Single response)

Based on those who discussed AIDS or HIV. (n=101)

You 10 Someone in your doctor’s office/clinic 89 Don’t know 1 Refused 0 25. Did someone in your (doctor’s office [If private “doctor’s office” or “DK/REF” at Qu. 4b] / clinic [If “family planning” or “other type of clinic” at Qu. 4b]) ask you about your sexual history and current sexual activity? (Single response) (Do not read list)

Yes 38 No 59 Asked about sexual history, but not current sexual activity * Asked about current sexual activity, but not sexual history 1 Don’t know 2 Refused 0 26. Who initiated this conversation, you or someone in your (doctor’s office [If private “doctor’s office” or “DK/REF” at Qu. 4b] / clinic [If “family planning” or “other type of clinic” at Qu. 4b])? (Do not read list) (Single response)

Based on those who discussed sexual history or sexual activity. (n=188)

You 7 Someone in your doctor’s office/clinic 92 Don’t know 1 Refused 0 27a. Where did the discussion take place? (Do not read list) (Multiple response) (If respondent says “examining room” probe with: Was that while you were dressed or undressed?)

Based on those who discussed sexual history or sexual activity. (n=188)

In doctor’s personal office 42 In examining room while you were dressed 41 In examining room while you were undressed 14 In counseling room 3 In waiting room 2 All other 2 Don’t know 1 Refused 0 27b. Where would you have preferred this conversation took place? Would you say (read list)? (Single response)

Based on those who discussed sexual history or sexual activity. (n=188)

In doctor’s personal office 45 In examining room while you were dressed 43 Doesn’t matter 4 In examining room while you were undressed 3 Don’t know 5 Refused 1

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Talking About STDs With Health Professionals: Women’s Experiences:Press Release Report Survey Part One Part Two Part Three

Contraception 911

If a condom breaks, a diaphragm slips, or you realize after having sex that you forgot to take the pill for three days in a row, it can be enough to make the calmest person very upset! Fortunately, there is something you can do. If you act within 72 hours after unprotected intercourse, two doses of a special combination of birth control pills, available by prescription, can prevent or delay ovulation and reduce the chance of pregnancy by about 75 percent. The method is called emergency contraception (the morning-after pill).

You can get the pills from a doctor or a family planning clinic. If there is any chance you might already be pregnant you’ll need a pregnancy test. (If you are pregnant, the treatment won’t work.) The medication isn’t without side effects, though; nausea, especially, is very common for a day or so. And it’s not foolproof – it only reduces your chance of pregnancy by 75%. And even if it does work, the pregnancy protection doesn’t last so you’ll need to go back to another birth control method right away. Generally, emergency contraception costs $55 to $245 for the whole shebang (examination, pregnancy test, and pills); costs are less – or even free – at family planning clinics and health centers. To find a provider near you, you can call the Emergency Contraception Hotline at 1-888-NOT2LATE.

What Doesn’t Work

If you’re considering any of these folklorist contraceptive methods, fuhgeddaboudit!!! Here’s why:

• Douching: Rather than rinsing sperm out of the vagina, douching could actually send them swimming upstream towards an egg. (It can also increase the risk of infection.) All in all, a bad idea!
• Peeing after intercourse: An old folks’ tale! Urinating after sex does nothing to protect against pregnancy because the urinary opening is near to, but not inside, the vagina. So sperm won’t be touched by the liquid rush.
• Having intercourse during your period: First of all, just because you’re bleeding doesn’t mean you’re having your “true” period; some women bleed during ovulation. And it’s often hard to predict when you’ll ovulate. So you’d better use protection whenever you have intercourse, all month long.

How to Negotiate with Your Partner

Think you might be ready to have sex with a special someone? Before deciding, make sure you’ve considered all the issues and discussed them with your partner. After all, the decision is – always! – up to both partners. Here are three tricky sexual scenarios and solutions for how to handle them:

Scenario #1: You’re thinking about having sex but you’re just not comfortable talking about it with your partner.

Solution: First things first: If you can’t talk about it, how are you going to feel comfortable doing it? Maybe one of you thinks that talking about sex kills the mood or that it should just happen naturally when the moment is right. Wrong, wrong, wrong. Talking about sex can actually help you trust each other more and feel closer to each other because it shows you care. But most importantly, it helps you make wiser decisions, and if you decide to begin a sexual relationship, to plan ahead to protect yourselves against pregnancy and STDs. In fact, you should hash out what you’re willing to do and what you’re not and agree to use condoms for your mutual protection before things get too intimate.

Scenario #2: Your partner does not want to use a condom.

Solution: Some people will use a zillion lame excuses to weasel out of using condoms so you’d better be armed with a snappy comeback. If she says, “It takes away the romance,” you could say, “So could getting an STD.” If he says, “I can’t feel anything with a condom,” tell him “You’ll feel even less if you don’t use one because we won’t be having sex.” If she swears she won’t give you any diseases, tell her it’s nothing personal but you want to make sure both of you stay healthy. The bottom line: Don’t feel bad about saying “No condom, no sex.”

Scenario #3: You’ve already had intercourse together but now you realize that it’s just too soon for you – and you don’t want it to happen again.

Solution: It’s not too late to slam on the brakes. One thing to keep in mind is that just because you’ve done it once or twice doesn’t mean you have to do it again and again. It’s okay to say “no” to any part of sex at any time, regardless of what you’ve done in the past. The key is to be firm and clear – hopefully, before you get to the undressing stage – about how you’re feeling and what you want for the future. If your partner tries to push the issue, stand your ground, and remind him or her how strongly you feel about slowing things down. Anyone worth your time and affection should respect that.

Sexually Transmitted Diseases

You’ve heard about all these scary things that can happen to you if you don’t practice safer sex, and you may even know people who have caught sexually transmitted diseases (STDs). Which isn’t surprising, considering that at least one in four people will contract an STD at some point in his or her life. What is there to worry about? Plenty. Here’s what you need to know about the risks of unprotected sex.

Each year more than 12 million Americans, including 3 million teenagers, are infected with STDs, and many of them probably thought they didn’t need to worry about protection. While a few STDs are just annoying, many others can have lasting effects on your health and sex life. We all know that HIV is an incredibly deadly STD. In fact, half of all new HIV infections occur in people under 25, and AIDS has become the leading cause of death among Americans between the ages of 25 and 44. And if you think the new AIDS drugs you have been hearing about are a magic cure, forget it. They are hard to take, often have strong side effects, and do not always work. Other STDs can cause nasty recurrent symptoms, such as painful or itchy sores, and a select few can cause death or increase the risk of cancer for both women and men. What’s more, several STDs can cause infertility, meaning you could never have children.

And get this: Almost any STD increases your chances of contracting HIV. In fact, people who already have an STD, like herpes, gonorrhea or chlamydia, are three to five times more likely to become infected with HIV than someone who does not have an STD if they have unsafe sex with an HIV-positive partner.

It’s a myth that you can tell if someone has an STD by the way he or she looks or acts. That wholesome-looking guy or woman may look safe and seem safe but appearances can be deceiving. After all, you’re not just having sex with that person but with everyone they’ve ever had sex with . . . and everyone THEY’VE ever had sex with… and… well, you get the point. Because lots of STDs have no symptoms (or only subtle ones), your partner may not even know he or she has one. That’s why if you have had sex in your life, you should get tested for STDs like chlamydia, and for HIV, even if you have no symptoms and are feeling just fine.

To be blunt about it: The only way to be sure you’re having safer sex is to keep your partner’s blood, semen, or vaginal fluids out of your body. Abstinence is the safest course. But, if you’re going to have sex, always use a condom.

How can you tell if you’re infected with an STD?What should you do if you are?

If you’ve been experiencing burning urination; heavy, smelly discharge from the vagina, penis or anus; bumps, sores or itching in the genital area; pain or tenderness in the pelvic area; or other funky symptoms, you may have a sexually transmitted disease. In that case, you need a medical visit right away so you can get tested.

Why is it important to get tested early? Because if you have an STD and don’t know it – and so don’t get treatment – you could pass it on to your partner and you could risk your health and your ability to have kids in the future. Not all STDs are curable, but even for ones that aren’t, treatments are available that can help. If you have HIV, for example, finding out early means you can take advantage of new medications that are more effective if you take them before you start to get sick.

If you are a woman and you’ve been experiencing cramping or persistent pain in the abdomen or back; abdominal tenderness with movement or going to the bathroom; abnormal vaginal discharge; pain during intercourse; or any of these symptoms with a fever over 100.5 degrees Fahrenheit – these may be signs of pelvic inflammatory disease (PID). If you have these symptoms, see a doctor or go to a clinic or a hospital emergency room immediately; PID can lead to infertility in a woman if it’s left untreated. PID can also be silent – an infection that spreads to your tubes from chlamydia or gonorrhea with no severe signs that could alert you that something is wrong.

Now, to get the inside scoop on the most common STDs, consult this table:

STD Chart

STD: Chlamydia What it is: A bacterial infection of the genital area. How many get it: About 4 million Americans each year; the highest rates are among women aged 15 to 19 – in fact, in some communities studies have found that up to 30 percent of sexually active teenage women and 10 percent of sexually active teenage men are infected. Signs: There are no symptoms in most women and many men who have it. Others may experience abnormal vaginal bleeding (not your period), unusual discharge or pain within one to three weeks of having sex with an infected partner. How it’s spread: Through vaginal or anal intercourse. Treatment: Oral antibiotics cure the infection; both partners must be treated at the same time to prevent passing the infection back and forth – and need to abstain from intercourse until the infection is gone. Possible consequences: Pelvic inflammatory disease (PID) in women, tubal (ectopic) pregnancy, infertility, and increased risk of HIV infection.

STD: Trichomoniasis (“Trich”) What it is: A parasitic infection of the genital area. How many get it: As many as 3 million Americans each year. Signs: Often there are no symptoms, especially in men. Some women note a frothy, smelly, yellowish – green vaginal discharge, and/or genital area discomfort, usually within 3 to 28 days after exposure to the parasite. How it’s spread: Through vaginal intercourse. Treatment: Antibiotics can cure the infection. Both partners need to be treated at the same time to prevent passing the infection back and forth – and need to abstain from intercourse until the infection is gone. Possible consequences: Increased risk of HIV infection; can cause complications during pregnancy. Also, it’s common for this infection to happen again and again.

STD: Gonorrhea What it is: A bacterial infection of the genital area. How many get it: Approximately 800,000 Americans a year; the highest rates are among women aged 15 to 19. Signs: Most women and many men who get it have no symptoms. For those who do get symptoms, it can cause a burning sensation while urinating, green or yellowish vaginal or penile discharge, and for women, abnormal vaginal bleeding, pelvic pain, and/or fever within 10 days of getting infected. It takes 1 to 14 days for symptoms – such as discharge or pain – to appear. How it’s spread: Through vaginal, oral, or anal intercourse. Treatment: Oral antibiotics. Both partners need to be treated at the same time to prevent passing the infection back and forth – and need to abstain from intercourse until the infection is gone. Possible consequences: PID, tubal (ectopic) pregnancy, sterility, increased risk of HIV infection. The infection can spread into the uterus and fallopian tubes. It can also cause complications during pregnancy (including stillbirth) or infant blindness or meningitis (from an infected mom during delivery).

STD: Human Papilloma Virus (HPV) What it is: A viral infection with 60 different types, primarily affecting the genital area, both the outer and inner surfaces. How many get it: An estimated 500,000 to 1 million Americans per year; about 40 million people already have it. Signs: Soft, itchy warts in and around the vagina, penis, and anus, may appear two weeks to three months after exposure. Many people, however, have no symptoms but may still be contagious. How it’s spread: Through vaginal or anal intercourse, or by touching or rubbing an infected area. Treatment: There is no cure. Warts can be removed through medication or surgery. Even with such treatments, the virus stays in the body and can cause future outbreaks. Possible consequences: Increased risk of genital cancer for men and women. Some virus types cause the most common form of cervical cancer in women.

STD: Genital Herpes What it is: A viral infection of the genital area (and sometimes around the mouth). How many get it: Between 200,000 and 500,000 Americans each year; an estimated 40 million Americans already have genital herpes. Signs: There are two kinds of herpes. Herpes 1 causes cold sores and fever blisters on the mouth but can be spread to the genitals; Herpes 2 is usually on the genitals. Nearly two – thirds of people who are infected with herpes don’t even realize it. An outbreak can cause red bumps that turn into painful blisters or sores on the vagina, penis, buttocks, thighs, or elsewhere. During the first attack, it can also lead to fever, headaches, and a burning sensation when you urinate. Symptoms usually appear within 2 to 20 days of infection but can take longer in some cases. The first outbreak is usually more severe than later recurrences. How it’s spread: By touching an infected area or having vaginal, oral, or anal intercourse. Warning: some people may be contagious even when they don’t have symptoms. Treatment: There is no cure. An antiviral drug can help the pain and itching and also reduce the frequency of recurrent outbreaks. Possible consequences: Recurrent sores (the virus lives in the nerve roots and keeps coming back), as well as increased risk of HIV infection. May cause complications during pregnancy, possibly causing severe illness, disabilities, or (in rare cases) death for an infant if there is active infection during childbirth. (A cesarean section delivery can reduce this risk.)

STD: Syphilis What it is: An infection caused by small organisms, which can spread throughout the body. How many get it: About 120,000 Americans a year. Signs: In the first phase, sores may appear on the genitals or mouth about three weeks to three months after exposure, lasting for three to six weeks. Often, however, there are no noticeable symptoms. In the second stage, about three to six weeks after sores appear, a variety of symptoms can appear, including a rash (often on the palms of the hands and soles of the feet). How it’s spread: Through vaginal, oral, or anal sex – and through kissing. Treatment: Antibiotic treatment can cure the disease if it’s caught early, but medication can’t undo damage the disease has already done. Both partners must be treated at the same time. Possible consequences: Increased risk of HIV infection. If syphilis is untreated, about a third of people who reach the disease’s late phase may experience brain damage, heart disease, nerve damage, and other incapacitating health problems. If untreated, it can seriously harm or even kill a developing fetus during pregnancy.

STD: Hepatitis B Virus (HBV) What it is: A viral infection primarily affecting the liver. How many get it: About 200,000 Americans a year; more than 1.5 million people in the U.S. now have HBV. Signs: Many people don’t have any symptoms. Others may experience severe fatigue, achiness, nausea and vomiting, loss of appetite, darkening of urine, or abdominal tenderness, usually within one to two months of exposure. Yellowing of the skin and whites of the eyes (called jaundice), and darkening of the urine can occur later. How it’s spread: Through vaginal, oral, and anal sex – and through kissing. Also by sharing contaminated needles. Treatment: Most cases clear up within one to two months without treatment, during which complete abstinence from alcohol is recommended until liver function returns to normal. Some people are contagious for the rest of their lives. A vaccine is now available to prevent this STD. Possible consequences: Chronic, persistent inflammation of the liver and later cirrhosis or cancer of the liver; plus, 90 percent of babies born to women with HBV will carry the virus unless they are vaccinated within an hour of birth.

STD: HIV What it is: The human immunodeficiency virus (HIV), the cause of AIDS. How many get it: An estimated 40,000 to 80,000 Americans are infected each year. AIDS is the leading cause of death among Americans between the ages of 25 and 44. Signs: Many people who have HIV don’t even know it because symptoms may not appear for 10 years or longer. Others experience unexplained weight loss, flu-like symptoms, diarrhea, fatigue, persistent fevers, night sweats, headaches, mental disorders, or severe or recurring vaginal yeast infections. How it’s spread: Through body fluids such as blood, semen, vaginal fluids and breast milk – in other words, during vaginal, oral or anal intercourse; by sharing contaminated needles; via pregnancy or breast – feeding. During vaginal intercourse, the risks of catching the virus are higher for women than for men. Treatment: There is no cure – and AIDS is considered fatal. Several new antiviral medications can slow progression of the infection and delay the onset of AIDS symptoms. Early treatment can make a big difference. Possible consequences: It is the deadliest STD of all and can weaken the body’s ability to fight disease, making someone with HIV vulnerable to certain cancers and infections such as pneumonia. Fifteen to thirty percent of babies born to HIV – positive mothers can get the disease if the mother is not receiving treatment, but treatment can reduce that rate significantly.

Possible STD Symptoms

Do you or your partner have any of these symptoms? If so, you can review the information in the corresponding sections, and consult your doctor.

• Abdominal pain or tenderness (especially with a fever):See Hepatitis B Virus (HBV)
• Bleeding from the vagina (other than your period):See Chlamydia and Gonorrhea
• Blisters on your genital area:See Genital Herpes
• Discharge from the vagina or penis:See Chlamydia, Trichomoniasis, Gonorrhea
• Irritation in the genital areaSee Trichomoniasis
• Itching in the genital areaSee Human Papilloma Virus (HPV)
• Pain or burning while urinatingSee Gonorrhea, Genital Herpes
• Painful intercourseSee Pelvic Inflammatory Disease (PID)
• Pelvic painSee Gonorrhea
• Sores on the vagina, penis, buttocks or thighsSee Genital Herpes
• Very dark urineSee Hepatitis B Virus (HBV)
• Vaginal yeast infectionsSee HIV
• Warts or bumps on the genitalsSee Human Papilloma Virus (HPV)
• Yellowing of the skin or whites of the eyesSee Hepatitis B Virus (HBV)

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It’s Your (Sex) Life; Your Guide to Safe & Responsible SexReport Two Part One Part Three

• Report: Why Some Men Don’t Use Condoms: Male Attitudes About Condoms and Other Contraceptives

• Fact Sheet:

• Report:

• Fact Sheet: What Are HIV Prevention Needs of Adults Over 50?

Small Employers and Health Insurance

Nearly half of all uninsured workers are either self-employed or work for firms with fewer than 25 employees; another 14% are in firms with 25-99 workers (EBRI, 1996). Differences in health coverage depending on the size and type of businesses have existed for years. Today, only half of small businesses sponsor health benefits.

Health insurance among small employers has changed dramatically during the first half of the 1990s, however. More are offering coverage and there has also been a major shift in the nature of health coverage. Now two-thirds of small firms offering insurance provide coverage through a managed care plan. This contrasts sharply with a few years ago when small employer offerings of health maintenance organizations (HMOs), preferred provider organizations (PPOs), and point-of-service plans (POSs) were relatively rare.

Who Offers Coverage?

Fifty-three percent of businesses with less than 50 employees offered health insurance in 1995. Firms with more employees, those that are incorporated, and firms that are older are much more likely to sponsor insurance.

Within nearly all sizes of small firms, health coverage declined between 1989 and 1991, due largely to the economic recession. The improving economy and to a small extent, state reforms in the small group market, are responsible for the increase in coverage since then (Figure 1).

The Changing Nature of Coverage Provided

Between 1993 and 1995 many small businesses began offering managed care plans for the first time. By 1995 managed care became the dominant form of health coverage in the small group market, covering 70% of all workers insured through small firms, from only 27% just two years earlier (Figure 2).

Small firms have shifted to managed care plans for a combination of reasons: the limited nature of their previous conventional coverage, the rising price of such plans relative to managed care premiums, and the expansion of managed care plans into the small group market.

It is still the case however, that most small businesses that offer insurance offer only one plan. Today that plan is much more likely to be a managed care plan rather than conventional insurance (i.e., indemnity or fee-for-service). Only 10% of insured workers in small firms are offered a choice of plans, whereas in firms with 200 or more workers, 84% can choose from a menu of plans.

Why More Small Firms Don’t Sponsor Insurance

Small firms choose not to provide health benefits for many different reasons. Most small businesses (83%) say it is because premiums are too high (Figure 3). Additional reasons include: the firm’s profits are too uncertain to commit to it, health insurance is not a high priority among its workers, or the administrative burden would be too great. The problem is not a lack of opportunity to buy coverage. Most uninsured firms report they are inundated with solicitations to purchase a plan.

Studies of insurance demand suggest that small firms are extremely price sensitive, e.g., a 5% decrease in price would result in a 10-15% increase in the likelihood of purchasing a plan. On the other hand, recent evaluations of several state subsidy programs for small businesses have found that these programs did not spur much new coverage.

The findings from these demonstration projects however, may have resulted from a lack of knowledge about the programs, the short-term nature of the subsidies, and in some instances, the fact that no premium subsidy was provided for insuring the business-owner and his or her family, rather, only employees’ premiums were eligible for a subsidy.

Policies Available in the Small Group Market

Access:

Health insurance has become more accessible to small firms in recent years. Fewer firms in 1995 said that an inability to qualify for group coverage was a major barrier to their offering a plan (46% vs. 54% in 1993). Fewer also reported that particular workers or their dependents were being excluded from the company plan due to poor health. One reason for these changes is that many states enacted “guaranteed issue” legislation in the early 1990s. Another reason is that more HMOs have expanded into the small group market and since most HMOs are federally qualified, they must guarantee the issue and renewal of their policies to all within the market.

Cost-sharing:

Overall, the gap between the cost-sharing provisions in small and large firms plans is narrower than it was just a few years ago. Average deductibles for conventional insurance have actually fallen for small businesses. This is partly a result of the shift to managed care because many of the conventional plans that small firms dropped had higher-than-average deductibles. While small firms’ deductibles are still higher than those in large firms, the gap has narrowed since 1993. At the same time, copayments in HMOs offered by small firms have increased significantly. Copayments of $10 to $20 per visit are now the norm, instead of $3 to $9 per visit, as in 1993. Small firms’ copays are still higher than those of large firms, but the differences are not that large.

Premium-sharing:

Small businesses have also made changes in their premium-sharing arrangements since 1993. Significantly fewer workers are being asked to contribute toward premiums, however the average percent contribution among those required to contribute has risen (Figure 4.)

Figure 4Premium-Sharing in Small Firms (<50 Employees), 1993 and 1995 Single Coverage: 1993 1995 Percent of workers required to contribute to single coverage premium 49% 30% Avg. contribution as a percent of single premium (among those required to contribute) 39% 44% Family Coverage: 1993 1995 Percent of workers required to contribute towards family coverage premium 59% 46% Avg. contribution as a percent of family premium (among those required to contribute) 47% 54% Source: 1993 and 1995 Wayne State University Survey of Employer Sponsored Health Benefits in Small Firms Issues

• The provision of health insurance has increased among small firms in the first half of the 1990s. While encouraging, it is still the case that close to half of small firms do not sponsor coverage, and for them, price is paramount to offering coverage.
• So many small firms switched to managed care between 1993 and 1995, it became the dominant form of small business health coverage.
• Unlike large firms, the vast majority of small firms offer only a single health plan– most often, a managed care product. Thus, workers in small firms lack a choice of health plans and are limited also on their choice of providers. In other respects, however, the differences between small and large firm coverage are narrowing.
• Fewer workers in small firms have to contribute toward premiums, but workers’ average contributing share (among those asked to pay) has risen.
• Access to health insurance plans has improved. Between 1993 and 1995, fewer small firms said they were being denied coverage, or that particular workers or their dependents were excluded from the company plan due to poor health.

Funding for the sources of information on this fact sheet and the 1995 Survey of Small Businesses was provided by the Henry J. Kaiser Family Foundation:

• GA Jensen, MA Morrisey, S Gafney, and DK Liston, “The New Dominance of Managed Care: Insurance Trends in the 1990s,” Health Affairs, January/February 1997, 16 (1), pp. 125-136.
• MA Morrisey and GA Jensen, “Switching to Managed Care in the Small Employer Market,” Inquiry, Fall 1997, 34 (3), forthcoming.
• GA Jensen and MA Morrisey, “Managed Care and the Small Group Market,” in MA Morrisey (ed.), Managed Care and Changing Health Care Markets. Washington, DC: AEI Press, forthcoming 1998.

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Small Employers: Health Insurance Coverage and the Impact of State Reforms:Fact Sheet Fact Sheet 2

Fact sheets on health insurance among small employers and state reforms of small group health insurance.

• Fact Sheet: Small Employers and Health Insurance
• Fact Sheet: Small Employers and Health Insurance
• Fact Sheet: State Reforms of Small Group Health Insurance
• Fact Sheet: State Reforms of Small Group Health Insurance

Retiree Health Trends and Implications of Possible Medicare Reforms

Prepared by: Hewitt Associates LLC

Prepared for: Kaiser Medicare Policy Project

September 1997

Preparation of this report was supported by The Henry J. Kaiser Family Foundation Grant Number 96-1710B. The study consists of a review and analysis of recent trends in the provision of employer-sponsored health benefits to retirees, as well as an assessment of potential changes to employer-sponsored retiree health plans in the future, including the effects of certain proposed changes to Medicare. The views expressed in this paper are solely the responsibility of the authors and do not necessarily represent those of The Henry J. Kaiser Family Foundation.

Acknowledgments

This report was prepared by Frank B. McArdle, Ph.D., and Dale H. Yamamoto, F.S.A., of Hewitt Associates, a global management consulting firm specializing in human resource solutions. Saline Leckman prepared the tables allowing for a comparison of trends between 1991 and 1996. Libby Terry and Nancy Newman collaborated on many aspects of this report.

For Further Information Contact:

Frank B. McArdle, Ph.D.Hewitt Associates LLC2401 Pennsylvania Avenue, N.W.Suite 450Washington, DC 20037(202) 331-1155

Contents

• Contents
• Executive Summary
• Background
• Part I: Key Trends, 1991-1996
• Part II: Implications of Potential Medicare Reforms
• Conclusion
• Appendix A: Retiree Health Plan Design: 1996
• Appendix B: Retiree Health Plan Design and Trends: 1991-1996
• Appendix C: Current Medicare Eligibility Age and Proposed Change
• Appendix D: Methods and Assumptions

Executive Summary

Retiree Health Benefits Play an Important Role

Employer-sponsored retiree health benefits are a source of valuable coverage to individuals, both through the provision of coverage to early retirees before they become eligible for Medicare and as a supplement to Medicare for retirees age 65 and over. More than a third (approximately 12 million) of Medicare aged and disabled beneficiaries have employer-sponsored coverage.

In 1996, most large employers (1,000 or more employees) provided some form of retiree health benefits, of which the vast majority provided coverage both before and after age 65. However, because of rising health care costs and changes in accounting rules, and after years of expanding coverage and benefits, the prevalence of employers offering such coverage has been declining since the early 1990s; eligibility has been tightened; and more of the costs have been shared with retirees.

In addition, because Medicare pays a large portion of the costs for post-65 retirees, certain proposed changes to Medicare could potentially accelerate the decline in retiree health coverage by shifting financial liability to employers and to retirees.

The purpose of this study is twofold:

• Document trends in retiree health benefits using an extensive database that annually tracks benefit provisions of major employers, and
• Analyze the potential impact on retiree health plans of major Medicare reform proposals, such as increasing the age of eligibility.

Key Trends

Part I of this report analyzes key trends in retiree health plans for a constant sample¹ of large companies in the Hewitt database, finding that between 1991 and 1996, the vast majority of large employers continued to provide retiree health benefits, but there were significant changes in coverage, eligibility rules, and beneficiary contribution requirements. (Figure 1 summarizes selected key findings with respect to coverage of retirees.)

Availability of coverage declined for retirees ages 65 and over

• For retirees age 65 and over, the share of large employers offering retiree benefits declined from 92 percent in 1991 to 87 percent in 1996.²

More retirees charged premiums

• The share of large employers requiring pre-65 retirees to pay premiums increased from 85 percent in 1991 to 95 percent in 1996, and increased for post-65 retirees from 72 percent in 1991 to 88 percent in 1996.

Eligibility for postretirement medical coverage tightened through higher age and service requirements

• The percentage of large employers setting minimum eligibility requirements for benefits at age 55 and 10-15 years of service (versus age 50 and shorter years of service) increased from 31 percent in 1991 to 35 percent in 1996.

Financial caps placed on future retiree health obligations

• Virtually no large employers had financial caps on their future benefit obligations in 1991. By 1996, 39 percent of large employers have some form of dollar cap on the employer’s contribution for post-65 retiree coverage, and 36 percent had caps on pre-65 coverage.

More employers encourage use of managed care for retirees

• The number of large employers offering Medicare risk HMOs has grown sharply from 7 percent in 1993 to 38 percent in 1996, according to other survey data.³

Implications of Medicare Reforms

Changing our focus from existing trends to possible future changes in retiree health plans, Part II of this report considers another potential wave of changes that might result from three significant Medicare reform proposals.

Option #1: Proposed increase in the Medicare age of eligibility

During the recent Medicare reform debate in connection with the Balanced Budget Act of 1997, the Senate included a provision that would have gradually raised the Medicare age of eligibility from 65 to 67, in tandem with the already scheduled increase in the Social Security eligibility age. Although dropped from the final bill, this issue will likely be revisited, and if enacted, could have a significant impact on retiree health plans. A few examples of the impact of raising the eligibility age include:

• Raising the Medicare eligibility age to 67 would mean that plan costs for a 65-year-old retiree could be two to four times higher (depending on plan design) for each year of coverage without Medicare.
• For a typical large company with a predominately younger workforce, the employer’s actuarial cost for lifetime retiree health benefits would rise about 16 percent (18 percent for a large employer with an older workforce).
• Employer response to the eligibility age increase will vary, but the increased costs could encourage them to reduce (or eliminate) their retiree health financial commitment to active employees, while preserving coverage for current retirees, along with plan design changes.
  • For example, eliminating Medicare eligibility may increase the retiree health plan costs for a 66-year old from $1,000 per person per year to $4,000. To keep the cost effect neutral, the employer could require the retiree to pay the extra $3,000 for coverage, or redesign the plan to offset the increased cost. A cost-neutral plan redesign might include, for example, a $10,000 deductible, 50 percent coinsurance, with a $50,000 out-of-pocket limit on the retiree’s obligations.

Option #2: Changes in Medicare payments to Medicare HMOs

With employers increasingly moving toward Medicare managed care to keep costs down and provide comprehensive coverage to retirees, the favorable financial impact of that strategy could be significantly affected by changes in the way Medicare pays health plans in the future.

The Balanced Budget Act of 1997 makes significant changes in payments to Medicare managed care plans, in part to increase payment rates in rural areas but also to reduce future Medicare spending increases. Employers will soon begin the process of assessing what the specific financial impact of these changes may be. The revised payment formulas may significantly alter the geography of Medicare managed care plan offerings to retirees, as well.

Smaller payment increases in certain areas of the country as a result of the 1997 legislation could potentially make managed care plans less attractive to employers and to retirees in those areas if HMO benefits are reduced or premiums rise. Alternatively, payment and other policies that support the expansion of Medicare managed care may help to stabilize retiree health benefit coverage by helping to manage employer costs over the long term.

Option #3: Proposed shift to a defined contribution program

Another option for reforming Medicare, supported by some experts in the health care community, is to shift away from having Medicare pay the cost of each beneficiary’s care, e.g., a defined benefit approach, toward a defined contribution approach in which Medicare would pay a fixed sum for each beneficiary, who would then use that sum, e.g., through a voucher-like mechanism, to select coverage from competing health plans. In fact, the Balanced Budget Act of 1997 creates a private fee-for-service option under Medicare+Choice. The conferees note that this private fee-for-service option “represents the first defined contribution plan in which beneficiaries may enroll in the history of the [Medicare] program.”⁴

Broad-based use of a defined contribution approach, while empowering retirees to choose their own health plan, also shifts financial risk to employers sponsoring retiree health plans and to retirees. In addition, that cost shift could grow over time if the defined contribution rate increases yet fails to keep pace with medical inflation. This is particularly worrisome to employers because Medicare coverage is already less generous than what large employers typically offer active employees. Comparing the plan value of Medicare benefits to those of 250 large employers participating in the 1996 Hewitt Health Value Initiative^TM database, 82 percent of the indemnity plans offered to active employees provide higher benefit levels than Medicare.

A broad-based defined contribution scheme for Medicare could also create administrative complexities for employers, in terms of the difficulty of coordinating the retiree plan with the specific Medicare health plans retirees choose, and determining an appropriate price for them.

The combination of financial and administrative impacts could thus lead employers to reassess the manner and the extent of coverage they offer to future retirees.

Summary

Retiree health benefits remain important to employees and retirees, even though the prevalence of such coverage has declined, eligibility has tightened, and more cost sharing is required of retirees. Potentially the biggest source of profound changes to employer-sponsored retiree health programs in the future would come from proposals to restructure the Medicare program. Depending on their specific nature, such changes could either create a safety net beneath employer-sponsored coverage for retirees or create additional incentives for employers to cut back. Policymakers focusing on potential reforms of Medicare would be well advised to take a more integrated look at the interactions between Medicare coverage and the employer-sponsored retiree health coverage on which millions of retirees still depend.

About the Hewitt Associates Database

Hewitt Associates has been tracking the salaried employee benefit provisions of major employers since 1972 through annual updates to its database of companies. The 1996 Hewitt database contains plan design information on 1,050 major employers, including 62 percent of Fortune 500 companies. Analyses of trends based on large employers (e.g., those with usually at least 1,000 employees) provides a reliable indication of the main sponsors of employer-provided coverage for retirees, because smaller firms are far less likely to provide such coverage. Ninety percent of the Hewitt database consists of companies employing 1,000 or more employees; 57 percent of the database consists of companies with 5,000 or more employees, representing roughly 25 percent of all public and private companies in the United States of that size.

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Retiree Health Trends And Implications Of Possible Medicare Reforms:Press Release Fact SheetReport Part One Part Two Part Three Part Four Part Five Part Six Part Seven Part Eight

Retiree Health Trends And Implications Of Possible Medicare Reforms

September 1997

Approximately 12 million of Medicare’s 39 million beneficiaries receive employer-sponsored retiree health benefits as a supplement to their Medicare coverage. In addition, millions of retired workers under age 65 rely on retiree health benefits as their primary source of health insurance coverage. While employer-sponsored health insurance is an important source of coverage for current retirees, health benefits for future retirees are uncertain.

Retiree Health Benefits Decline, 1991-1996

A declining share of large employers offered health benefits to retirees in 1996 compared to 1991, and an increasing share implemented reforms to limit their financial liability for retiree coverage (Figure 1), based on an analysis of a constant sample of about 600 large employers (with 1,000+ employees) conducted by Hewitt Associates LLC.

Availability of retiree coverage has declined:

Based on a constant sample of large employers, the share of employers offering retiree benefits to retirees age 65 and over declined from 92 percent in 1991 to 87 percent in 1996. Coverage for pre-65 retirees remained relatively stable. By comparison, the proportion of all large firms offering retiree coverage declined from 80% in 1991 to 71% in 1996, based on the Hewitt database.

Required payment of premiums has increased:

The share of large employers requiring post-65 retirees to pay premiums increased from 72 percent in 1991 to 88 percent in 1996; for pre-65 retirees, the share increased from 85 percent to 95 percent.

Use of financial caps has grown:

Dollar caps on future employer obligations for retiree health costs has emerged as a new feature of retiree benefits. In 1991, virtually no large employers had such caps; by 1996, 39 percent had caps on post-65 retiree coverage and 36 percent had caps on pre-65 coverage.

Other reforms have been implemented:

Between 1991 and 1996, a growing share of large employers tightened eligibility requirements, increased deductibles, raised contributions for dependent coverage, and increased enrollment of retirees in managed care plans.

The trend toward declining retiree benefits in the 1990s is due to a number of factors including: the pressure to control increasing health care costs; new accounting rules (FAS 106) which require companies to report accrued future retiree health benefit liabilities on their current financial statements; and employer concerns about the future financial impact of an aging population.

Medicare Reforms Affect Employer-Sponsored Retiree Coverage

Because retiree health benefits generally supplement Medicare for retirees age 65 and older, changes in the Medicare program are likely to affect health care costs incurred by both employers and retirees. For example, raising Medicare’s eligibility age gradually from 65 to 67 (linking the Medicare and Social Security eligibility age) would increase the actuarial costs for lifetime retiree benefits by 12 percent for large employers with a younger workforce and by 8 percent for employers with an older workforce (Figure 2). When fully implemented at age 67 (no phase-in), this change would increase costs by 16 percent for employers with a younger workforce and by 18 percent for employers with an older workforce. This is because the average per person cost of health coverage for a retiree before Medicare eligibility is about three times the cost of a retiree with Medicare coverage ($4,000 vs. $1,350, respectively) (Figure 3).

Changes in Medicare HMO payments could also impact retiree health costs. Higher Medicare HMO payments in rural areas, as enacted under the Balanced Budget Act of 1997, could encourage the migration of plans to rural areas and allow employers in these areas to move additional retirees into managed care plans. However, reductions in future Medicare payments to HMOs in other areas could make managed care a less attractive option for employers and retirees if HMOs respond to payment changes by offering fewer benefits or charging higher premiums.

More comprehensive Medicare reforms under discussion, such as a shift to a defined contribution program, could also impact employer-sponsored retiree coverage. Under a defined contribution approach, Medicare would pay a fixed sum on behalf of each beneficiary and beneficiaries could apply the amount to the cost of coverage from a variety of Medicare-approved private health plans. If Medicare’s defined contribution rate does not keep pace with medical inflation, additional costs are likely to be shifted to employers, retiree with employer-sponsored coverage, and other beneficiaries.

Issues

Employer-sponsored retiree health plans play an important role in covering retirees both before and after Medicare eligibility. Retirees are generally at an age when health problems tend to increase, annual incomes decline, and coverage for medical expenses becomes more critical. Since 1991, there have been declines in the availability and generosity of retiree health benefits offered by employers. Employers and retirees face significant financial risks from potential changes to the Medicare program because of the strong interaction between employer-sponsored retiree health benefits and the Medicare program.

This fact sheet is based on Retiree Health Trends and Implications of Possible Medicare Reforms, prepared by Hewitt Associates LLC with support from the Kaiser Family Foundation, September 1997. This study analyzed key trends in retiree health plans from 1991 through 1996 using a constant sample of large companies (generally those with at least 1,000 employees) in the Hewitt Associates database. The 1996 Hewitt database contains plan design information for 1,050 major employers. The study also analyzed the potential impact of Medicare reform options on retiree health plans.

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Retiree Health Trends And Implications Of Possible Medicare Reforms:Press Release Fact Sheet Report