By focusing on policy-level interventions, states and territories can address rising congenital syphilis rates through increasing access to care, optimizing Medicaid, and promoting cross-agency collaboration.

The prevalence of congenital syphilis (CS)—which is spread to the infant during pregnancy or birth—continues to climb at an alarming rate in the United States. Although preventable, rates more than tripled between 2017 and 2021, with more than 2,800 cases reported in 2021 alone. ASTHO has identified a select group of related interventions that, taken together, help achieve and sustain improvements related to risk factors or health outcomes. It is important to note that Medicaid-Public Health partnership is the crux of implementing evidence-based policy and strategies to address CS. These policy-level interventions that states and territories can pursue starting in pregnancy are outlined in ASTHO’S “Effective Public Health Approaches to Reducing Congenital Syphilis” summary, published in the January 2024 issue of the Journal of Public Health Management and Practice.

Increase Universal Screenings for Pregnant Persons

Testing pregnant people for syphilis at three points of pregnancy—during the first and third trimesters and at delivery—is proven to reduce CS. Screening recommendations differ by jurisdiction and often require either assessing an individual’s risk or providers’ familiarity with local syphilis epidemiology. By modifying laws to require screening three times during pregnancy, jurisdictions remove some of the risk of provider bias and uncertainty that may lead to missed screening and diagnosis of prenatal syphilis.

How Public Health Can Partner with Medicaid to Reduce CS Rates

Medicaid provides coverage for low-income adults nationwide and covers more than 40% of all births. Syphilis rates are nearly six times higher among women insured through Medicaid compared to women insured through commercial insurance.

Expanding eligibility for Medicaid Family Planning Programs allows states to provide family planning benefits and STI services to people who would not otherwise qualify. Additionally, implementing State Plan Amendments (SPA) to expand Medicaid postpartum coverage can allow coverage of postpartum treatment for syphilis. As of November 22, 40 states have implemented a postpartum coverage SPA. States can work with Medicaid agency partners to ensure Medicaid services comprehensively cover STI testing, treatment, and counseling with minimal cost-sharing.

States can leverage alternative provider types, such as community health workers (CHWs), doulas, and perinatal case managers to facilitate access to services, encourage first and third trimester STI screenings, and provide support services. These alternative providers, as well as alternative care sites such as safe syringe programs, can help with care coordination, coaching, providing social support, and health education.

S/THAs can work with their Medicaid agency partners to submit an SPA or 1115 waiver to cover services performed by CHWs, doulas, or perinatal case managers. Additionally, states can incorporate requirements for Managed Care Organizations (MCOs) to integrate these provider types into quality improvement initiatives and case management programs into Medicaid RFPs and contracts with MCOs.

Incentivize Providers to Comply with Universal Syphilis Screening Requirements

S/THAs can work with Medicaid agency partners to adopt and incentivize the Prenatal and Postpartum Care CMS Core Measure (National Committee for Quality Assurance Measure #1517) as part of the state’s quality strategy. Incentivizing the quality measure encourages providers to meet performance metrics through a financial incentive. Further, states can update practice guidelines to encourage providers to conduct universal STI screenings during prenatal care visits, including syphilis testing in the first and third trimester.

Establish an Implementation Plan for a Congenital Syphilis Quality Improvement Strategy

S/THAs offer support to their Medicaid agency partners by developing consumer education materials, including information on how to enroll in Medicaid, covered services, provider availability, and how to reduce the risk of CS and sharing these materials with public health service clients. Targeted enrollment outreach to pregnant persons in their first trimester is critical for early testing and treatment since being screened for syphilis is more likely if a person is enrolled in Medicaid earlier.

S/THAs can also support their Medicaid agency partners by building provider awareness of quality measure changes and educating them on how to leverage incentive payments through communication materials. For example, a S/THA could re-promote Medicaid provider bulletins and state quality strategies with S/THA Perinatal Quality Collaboratives and maternal and child health stakeholders like local chapters of ACOG, March of Dimes, and Primary Care Associations.

Establish Cross-Agency Collaboration and Governance Structures

A critical step in ensuring implementation of payment incentives and legislation is creating mechanisms for S/THAs and their state Medicaid agencies to better coordinate services and polices directed toward low-income individuals at risk for CS and other syndemic conditions. Collaborative strategies to consider:

• Establish a joint Medicaid/public health quality committee related to syndemics (e.g., CS and/or HIV).
• Create a standing policy body that has a designated position for OB/GYN physician leaders to advise and engage in practice change.
• Build relationships and engage with Medicaid quality committees to highlight public health data, policy, best practice, and support available to respond to the rise in cases.

Remove Barriers to Care by Addressing Stigma and Provider Bias

Removing barriers to screening and treatment and addressing stigma and implicit bias will help reduce CS rates. Structural racism and prejudice exacerbate disparities in maternal and neonatal morbidity and mortality, including CS rates. To address stigma, policymakers can consider strategies that address systematic prejudice and discrimination including developing systems that have several points of entry for care, provide culturally competent training for the providers and perinatal workforce, and fostering multi-sector referral relationships.

Additionally, leveraging the perinatal workforce, including doulas, can support pregnant and postpartum people in seeking and remaining in prenatal and postnatal care.

Conclusion

States and territories can address the rise in CS infections by focusing on policy-level interventions provided in “Effective Public Health Approaches to Reducing Congenital Syphilis.” These evidence-informed practices focus primarily on pregnancy and provide recommendations for enhancing screening, optimizing Medicaid eligibility and services, establishing and implementing a quality strategy, incentivizing and educating providers, educating consumers, establishing and implementing cross agency collaboration and governance, and increasing access to care.

Further resources from ASTHO

• Policy Considerations for Reducing Congenital Syphilis

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Julia Greenspan (she/her) is a Director on ASTHO’s Infectious Disease Infrastructure and Policy team. She oversees ASTHO’s STI portfolio and helps to support projects related to syndemics, HIV, and other infectious diseases. Julia has a BA from Clark University and an MPH from Emory University.

Sanaa Akbarali serves as Senior Director of Maternal and Infant Health with ASTHO and is a content expert in maternal and neonatal morbidity and mortality, breastfeeding, and perinatal behavioral health. Sanaa received her BA from the University of Oklahoma and MPH from the Milken Institute of Public Health at GW.

JoAnne McClure, MSW, is a Senior Analyst for State Health Policy at ASTHO. She provides public health leaders and agencies with policy-related technical assistance such as resources and training in policy development frameworks and communication strategies, as well as monitoring legislative landscapes related to infectious disease, overdose prevention, and immunization policies.

Caroline Brazeel (she/her), Senior Director, Population Health, oversees ASTHO’s access to care, Medicaid policy, and health systems partnership portfolio. Prior to joining ASTHO, she worked in the private and public sectors on health systems joint ventures, Medicaid value-based payment initiatives, managed care operations, and population health program development and implementation.

Kate Heyer is the Senior Director, Infectious Disease Infrastructure and Policy at ASTHO. Her experience includes oversight and management of programs addressing a range of infectious disease and epidemiology topic areas. Kate holds a BA in International Relations from Randolph-Macon College and an MPH from The George Washington University.