Healthcare Infrastructure Crisis Compounds America's STI Epidemic

The Centers for Disease Control and Prevention's (CDC) September 2025 release of provisional 2024 STI surveillance data offers proof that public health interventions work: more than 2.2 million cases of chlamydia, gonorrhea, and syphilis represent a 9% decline from 2023, the third consecutive year of decreases. Primary and secondary syphilis dropped 22%, chlamydia fell 8%, and gonorrhea declined 10%. "The overall U.S. STI burden remains substantial, but signs of progress continue," noted Dr. Bradley Stoner, Director of CDC's Division of STI Prevention.

Yet congenital syphilis increased 2% to nearly 4,000 cases in 2024, continuing a 700% climb since 2012 that resulted in 279 stillbirths and infant deaths in 2023 alone. CDC analysis shows 88% of these cases were preventable with timely testing and treatment. This divergence—overall rates declining while the most vulnerable populations remain unreached—reveals a deeper crisis: we are systematically dismantling the healthcare infrastructure necessary to sustain these gains precisely when evidence demonstrates what works.

The Systematic Dismantling

The erosion of STI prevention capacity unfolded across three stages. It started with CDC's Division of STI Prevention losing 40% of its purchasing power since 2003 through chronic underfunding, while local health departments shed 20% of workforce capacity from 2008 to 2019. A Harvard study documented that nearly 50% of state and local public health employees left their jobs between 2017 and 2021. Decades of flat or declining budgets hollowed out the workforce that conducts contact tracing, provides testing and treatment, and links patients to care.

In June 2023, the Fiscal Responsibility Act eliminated $1.3 billion in CDC funding specifically intended to expand Disease Intervention Specialist capacity, with states like Nevada losing over 75% of their STI prevention budgets. These cuts targeted the 2,200 people nationwide who conduct partner services and contact tracing that prevent transmission chains. The 2024 data showing declining rates was collected during this period, demonstrating what the system could achieve even as Congress pulled resources.

Then in March 2025, the Trump Administration terminated $11.4 billion in pandemic-era grants. Under HHS Secretary Robert F. Kennedy Jr., the department eliminated 31% of its workforce. The President's proposed FY 2026 budget cuts CDC funding by 53% compared to FY 2024. A George Washington University analysis projects 42,000 eliminated jobs nationwide, with states losing hundreds of millions in funding. The Administration also withheld Title X grants from 23 states, threatening 200 Planned Parenthood clinics serving 2.8 million people annually. Utah's sole Title X recipient lost $2.8 million, forcing closure of clinics that served 26,000 patients.

The consequences are materializing. Penobscot County, Maine, faces the largest HIV outbreak in state history—28 new cases over two years, seven times typical rates, nearly all among people who use drugs and are homeless. The outbreak emerged after supply shortages forced closure of the region's largest syringe services program, then accelerated following February 2025 clearing of the city's largest homeless encampment. Broome County, New York, reported in September 2025 that new HIV diagnoses among people with injection drug use history exceed the previous four years combined. The 2015 Scott County, Indiana HIV outbreak that infected over 200 people occurred after public health funding cuts eliminated syringe access. We know what happens when we strip prevention infrastructure. We are choosing to repeat it.

Interconnected System Failures

The public health workforce collapse intersects with physical infrastructure deterioration to compound access barriers. American hospitals carry $390 billion in deferred maintenance, with 50% of health systems managing buildings over 50 years old. Deteriorating facilities cannot maintain proper medication storage, provide adequate clinic space for confidential counseling, or support infection prevention protocols that 80% of hospitals lack sufficient staff to implement.

Infrastructure failures drive facility closures that eliminate access entirely. Over 100 rural hospitals closed from 2013 to 2020, forcing residents to travel 20 miles farther for common services and 40 miles farther for specialized care. Deferred maintenance becomes a death spiral: aging infrastructure drives up operating costs, reducing resources for patient care, making facilities financially unsustainable. The closures concentrate in rural areas and communities serving predominantly low-income populations and people of color - the same populations bearing the highest STI burdens. Meanwhile, as we reported in our article titled, “CBO Data Proves Hospital Systems Exploit 340B Drug Program for Billions,” when hospitals do invest in facilities, they target affluent white neighborhoods.

A Center for Economic and Policy Research analysis documents that hospitals serving communities of color receive systematically less infrastructure investment. Hospital occupancy rates are 11 percentage points higher than pre-pandemic, driven by a 16% reduction in staffed beds. Overcrowded, understaffed, aging facilities cannot deliver consistent prenatal screening to prevent congenital syphilis.

Medication access compounds these failures. Pfizer's April 2023 Bicillin L-A shortage, ongoing through 2025 with July 2025 recalls further limiting supply, eliminates the only CDC-recommended treatment for syphilis in pregnancy. A November 2023 survey found 68% of health departments stated the shortage would directly increase syphilis rates. Among 2022 congenital syphilis cases, 37.9% of birth parents received no prenatal care whatsoever.

Who Bears the Cost

Geographic and economic barriers determine who suffers these system failures. Thirty-five percent of U.S. counties are maternity care deserts with no birthing facility or obstetric clinician, affecting 2.3 million people of reproductive age. Patients in these areas face twice the uninsured rates, 13% increased preterm birth risk, and average drive times of 38 minutes versus 16 minutes nationally. These are the predictable results of decades of policy choices that prioritized cost containment over access.

Racial disparities reveal who we are willing to sacrifice. Black populations account for 32.4% of all chlamydia, gonorrhea, and primary/secondary syphilis cases despite comprising 12.6% of the population, experiencing gonorrhea at 7.7 times the rate of White populations. American Indian and Alaska Native infants face congenital syphilis rates 75 times higher than Asian families, with maternal syphilis among American Indian and Alaska Native mothers increasing 783% from 2016 to 2022. Mississippi data shows African American infants account for 71.1% of congenital syphilis cases while representing 43.3% of the general population, with 92.6% of cases among Medicaid recipients.

CDC acknowledges explicitly: "Differences by race and/or Hispanic ethnicity cannot be understood without consideration of long-standing structural contributors that are not adequately captured in case notification data such as systemic racism, challenges with healthcare access, and disparities in social determinants of health." Eight percent of Americans—27.1 million people—lack insurance coverage, with 1.5 million in the Medicaid coverage gap in ten non-expansion states, over 60% people of color.

The 2% increase in congenital syphilis amid overall STI declines tells us exactly who cannot access care: pregnant people, disproportionately Black and brown, in maternity care deserts, served by overwhelmed safety-net systems, facing medication shortages, unable to reach closing clinics. This is the distribution of harm we accept when we defund infrastructure.

The Choice Before Us

The 2024 data was collected before March 2025 grant terminations fully materialized, before spring clinic closures accelerated, before proposed 53% CDC budget cuts take effect. The encouraging trends reflect a system already deteriorating through chronic underfunding and workforce elimination. They do not reflect what comes next if current trajectories continue.

We have evidence. Disease Intervention Specialists, syringe services programs, prenatal screening, Bicillin access, Title X clinics—these interventions work. The 22% drop in primary and secondary syphilis demonstrates it. The HIV outbreak in Maine after syringe program closure demonstrates the cost of abandonment. The congenital syphilis crisis demonstrates who pays when we moralize instead of invest.

This is not a resource constraint. It is a priority choice. We can reverse the 2025 funding cuts and restore public health workforce capacity. We can address the $390 billion hospital infrastructure deficit with focus on facilities serving communities of color. We can secure medication supply chains through domestic manufacturing and emergency stockpiles. We can eliminate maternity care deserts and expand Medicaid in ten remaining states. We can fund what works.

The 2024 data proves progress is possible. The 2025 policy choices determine whether it endures or whether we return to climbing rates, preventable infant deaths, and widening disparities. Tough budget choices may be required. But the health and survival of pregnant people and their babies should not be on the chopping block. We know what works. The question is whether we value those lives enough to fund it.

340B Drug Discount Program: Here’s What Patient Advocates Need to Know

The 340B Drug Discount Program for years has had little attention, aside from a few Congressional Hearings. As we cited last month in a blog, 340B program purchases has more than quadrupled in the last decade, now exceeding Medicaid’s outpatient drug sales. This growth has disturbed the bargain made between manufacturers, providers, and lawmakers in 1992, often leaving patients out of the benefit meant to be gained by the program.

Because 340B is an exceedingly nuanced payment system design, lawmakers have been reluctant to touch the issue – fearing a need to “crack” into the legislation, lacking agreement on how to proceed, and having to balance interests that are often in conflict – preferring to leave the management of issues arising around 340B to the Health Services Resources Administration (HRSA), which then has the unfortunate duty to remind lawmakers, the agency’s statutory authority is limited, and their budget is not large enough for more meaningful oversight. As administrations change, so do the perspectives on how to ensure the intent of 340B, making sure poorer patients can afford and access outpatient medications and the care required to acquire those medications, is captured in how the programs actually operates. Leaving us with the current situation of competing interpretations and interests heading to the court system to find answers and settle disputes.

Part of this program growth is driven by hospitals as a type of “covered entity”; a 2015 analysis showed the program having grown from about 600 participating in 2005 to more than 2,100 hospitals in 2014. In fact, a 2018 Government Accountability Office report found “charity care” and uncompensated care provided by hospitals receiving 340B revenue had steadily been decreasing over the years. The Affordable Care Act has something to do with that – in extending Medicaid eligibility, the Medicaid qualified population grew and as enrollment grew, so did the amount if “disproportionate share” of Medicaid patients certain hospitals served. Ultimately, this meant more hospitals qualified for the 340B Drug Pricing Program than had prior to the ACA.

Another reason for program growth is an expansion of definition of “covered entities” to include contract pharmacies – which have grown as an industry – used by federal grantees like federally qualified health centers (FQHCs) and hemophiliac clinics. Tim Horn, director of the Health Care Access team at the National Alliance of State and Territorial AIDS Directors, described why it was necessary for this expansion, in particular to Ryan White clinics, serving communities affected by and vulnerable to HIV as opposed to limiting program qualification to those pharmacies run and owned by clinics themselves, “340B contract pharmacies are vital to Ryan White and other safety net providers for a couple of important reasons: they help ensure equitable access to affordable medications by uninsured clients, including patients who might live too far from a program's in-house pharmacy, and they help programs maximize their ability to generate essential revenue on prescription fills for insured clients.”

Regardless of entity type, most patients access care through a “payer” (health care insurance provider, be they public – like Medicaid managed care organizations – or private), who play a central role in the 340B payment system design. In turn, this means “pharmacy benefit managers” (PBMs - who sometimes also own the contract pharmacies in question) also play a central role, by designating schemes for how providers are reimbursed for care they’ve provided or medications that have already been dispensed. Jeffrey Lewis, a board member of Community Access National Network and President & CEO of Legacy Health Endowment, described how some PBMs engage in discriminatory practices by paying for 340B drugs at lower rates than non-340B drugs, reducing the benefit Congress intended to give 340B hospitals and clinics:

“340B providers receive less revenue than if 340B drugs are reimbursed at normal non-340B rates. That loss of revenue results in 340B providers having less money to underwrite the cost of providing uncompensated care, including serving uninsured or underinsured patients or providing services that insurers do not reimburse. PBMs, on the other hand, retain the difference between the 340B and non-340B payment rates for themselves. This program "benefit", which was intended to go to non-profit safety net providers, ends up going to for-profit PBMs instead. In this manner, PBMs' payment policies prioritize PBMs’ for-profit interests over 340B providers' non-profit missions to support public health.”

The center of one of the most pressing actions to date is “who’s job is it to make sure the rules are being followed?” with manufacturers being the first to move – by way of seeking the ability to require entities wishing to participate in 340B to provide additional claims data. Lewis points out that in a unanimous Supreme Court decision in 2011, courts had previously interpreted covered entities as lacking authority to seek enforcement against manufacturers, so the same must be true in reverse, requiring all parties to use a dispute resolution process dictated by HRSA. Indeed, the ruling even goes so far to cite the ACA’s directive for HRSA to issue a formal “alternative dispute resolution” process. However, HRSA failed to formalize this process in a final rule until December 2020. That rule is now part of a patch work of suits from manufacturers looking to the courts for clarity, with manufacturers arguing that statutory enforcement can’t be one-sided – if manufacturers must provide these discounts, someone should be ensuring the entities receiving these discounts are actually using them for patients and HRSA, by their own admission, doesn’t have the capacity to do so. Of note, Justice Ginsburg, who pinned the 2011 ruling in Astra USA, Inc., noted HRSA’s failure to bilaterally enforce the rules did not necessarily provide for a right of action by 340B actors.

Nonetheless, 340B remains a critical source of revenue for Ryan White clinics and other federal grantees already meeting the legislative intent of the program, at least generally better than other payer and provider actors in this scheme. As a result of sustainable federal funding and legislators prioritizing public health funding, federal grantees are scrambling – and manufacturers should consider how best to not harm the “good guys” in what ever actions taken next. Indeed, NASTAD’s Tim Horn stated:

“340B program revenue will always be an important – and dynamic – supplemental funding source for our HIV care programs, particularly where Medicaid has not been expanded and where federal and state funding is both limited and inflexible. A number of factors that have real or potential impacts on 340B…are now requiring serious discussions regarding the sustainability of program revenue generation. Simply put, we're not going to end HIV as an epidemic without significant and nimble funding required to support the myriad medical and support services associated with the best possible health outcomes. 340B revenue is a substantial part of this and, absent alternative funding streams to ensure that these programs remain whole, will remain the lifeblood of HIV service delivery in the United States.” 

Legacy Health Endowment’s Jeffrey Lewis agreed:

“The value and importance of the 340B program are well known. However, where there is ambiguity, it impacts both covered entities and patients. With the positive growth of covered entities to serve more people in need, Congress must take a thorough look at why 340B was created, its absolute value and tackle the tough questions where ambiguity may exist. Clarity is needed now more than ever to stop pharmaceutical companies from indiscriminately deciding whether and how to participate and prevent jeopardizing patients' lives. Similarly, Congress has an obligation to evaluate the role of PBMs and Third-Party Administrators (TPAs) operating in the 340B space and set a specific rule regarding revenue sharing. The 340B program was created to aid covered entities in serving more people in need. Unfortunately, every dollar taken by PBMs or TPAs reduces the ability of covered entities to care for more and more patients.

Clear legislative intent and rules are critical to ensuring program stability and, ultimately, safety net provider stability. Ryan White Centers, Hemophilia Centers, FQHCs, and rural hospitals as particularly vulnerable to Congressional, HRSA, and OPA ambiguity. The current and future failure to clarify the uncertainty of the 340B program jeopardizes patients and the financial stability of covered entities.”

While the finger-pointing on “who’s at fault” for an unsustainable program growth rages on and works its way through both the courts and the minds of lawmakers or who is responsible for drawing the lines in which manufacturers, providers, and payers can color inside of, the only thing clear is the population this program is meant to serve is not receiving as much benefit from the program as it should. We could say “patients” here, but that word apparently needs to be defined with regard to 340B. In the end, all stakeholders, outside of lawyered language, know exactly who has been harmed by bad actors in the 340B landscape. Everyone with power in this minefield would do well to remember that.

We invite you to download the 340B Final Report, issued by the Community Access National Network’s 340B Commission.