Barriers to accessing and using health insurance cards among methadone maintenance treatment patients in northern Vietnam

Injection drug use is considered to be a primary cause of HIV transmission in most countries worldwide [1]. Methadone maintenance treatment (MMT) is regarded as a highly effective medication to treat opioid dependence [2] and is viewed as an important component of HIV/AIDS prevention strategies [3]. Methadone reduces the frequency of illicit drug use, improves treatment outcomes among HIV-positive and negative individuals, and eventually, helps to alleviate the economic burden caused by substance abuse [4].

Addiction to opiates has been well documented to constitute a chronic medical illness [5], and as such, individuals who are dependent on opiates need access to long-term medical care. People who inject drugs are at increased risk of acquiring many diseases in addition to HIV/AIDS, which require medical care and may lead to catastrophic healthcare expenditures and impoverishment [6]. This vulnerable population needs financial support to help them pay for their health coverage, the primary source of which is health insurance. Appropriate and consistent access to health insurance (HI) helps patients pay for and utilize necessary treatments such as methadone maintenance therapy (MMT) or other health care services if needed. Studies conducted in other countries have highlighted the importance of health insurance in improving opiate-addicted patients’ access to methadone treatment. One study conducted by Peterson, et al., in the United States found that opiate-addicted patients often remain out-of-treatment due to a lack of health insurance or money to be able to pay for care [7]. Importantly, MMT has been shown to lead to improved long-term outcomes for opiate-addicted patients in comparison to other treatment options [8].

Vietnam is currently pursuing the 90-90-90 HIV/AIDS target for 2020 [9] and MMT programs represent an important way for Vietnam to achieve this goal. In Vietnam between the years of 2008 and 2013, MMT treatment was provided free of charge by international donors [4]. However, in more recent years, the country has experienced reduced financial support from these sources [6, 10]. As a result, patients on MMT are now required to pay co-pays for their care as an essential resource mobilization method of the Vietnam Government [11]. However, along with the potential financial burden of methadone treatment, MMT patients in Vietnam are particularly wary of the high costs of both outpatient medical treatment and hospitalizations. Thus, health insurance has a central role in ensuring the accessibility of health service for the opiate drug users. Health insurance for MMT patients has been linked with better clinical outcomes such as lower probability of AIDS and sustained viral suppression if patients are HIV-positive, as well as overall reduced premature death [12]. Moreover, previous studies have found that drug-addicted individuals are more likely to engage in treatment if they have health insurance to help them alleviate some of the costs [7].

For the past several decades, Vietnam has been moving toward universal health insurance coverage [13, 14]. Indeed, the government has greatly expanded health insurance coverage and increased subsidies to poor and ethnic minorities across the country [15]. However, there are many barriers to achieve this goal in the country, including limited affordability, low-quality and fragmented insurance options, and no comprehensive legal system for health insurance [16]. Indeed, while health insurance in Vietnam has been shown to increase inpatient services among poor citizens, it has not been shown to greatly increase outpatient or preventive services [17]. Therefore, in the coming years, expanding health insurance coverage to vulnerable populations such as MMT patients is a priority in the Master Health Plan of the Vietnamese Government.

Previous researchers have found that level of enrollment in health insurance was associated with cost of insurance premiums, knowledge of insurance benefits, and overall affordability [18]. Other scholars have cited the importance of the country’s national and provincial governments maintaining control over health insurance funding and trying to find creative ways to increase enrollment at the provincial level [13]. In Vietnam, insured patients can access MMT freely because HI covers this service; however, patients have to own the HI card when using service. Despite national efforts to increase health insurance enrollment among the Vietnamese population, there is a dearth of studies looking at barriers to and facilitators of health insurance access among MMT patients in Vietnam. Thus, this study was conducted to better understand factors related to health insurance enrollment and utilization among MMT patients, and to propose solutions to achieve universal coverage among this patient population.

Table 1 displays the socio-demographic characteristics of the participants in our study. There was a total of 1016 respondents, most of whom were male (98.7%). The majority of patients (67.7%) lived with a spouse or partner, and 53% of whom were self-employed. The majority of the patients in our sample were 30 years and older and had at least a secondary school education. Participants used a mixture of central, provincial, district, and occasionally private healthcare services. Full payment was the most prevalent way that patients payed for both inpatient and outpatient services.

Health-related behaviors, health service utilization, and overall health status of respondents in urban and rural are presented in Table 2. Nearly 70% of the patients in our study had been receiving MMT therapy for greater than one year. The average number of times that participants had been to drug rehabilitation centers was 4.8 times. Participants from rural parts of northern Vietnam were statistically significantly more likely to endorse having difficulties with mobility and problems engaging in usual daily activities, as well as reported higher rates of overall pain/discomfort and anxiety/depression, than their urban counterparts. They were less likely to report ever injecting drugs or current injection drug use than participants from urban areas. Participants from rural regions were also less likely to have been to drug rehabilitation programs, and on the whole displayed shorter MMT therapy duration compared to participants from urban clinics.

Table 3 highlights current HI coverage status and barriers faced in trying to access HI among the respondents in our study. Nearly 80% of the patients in our study were uninsured. Participants from rural regions were significantly more likely than urban participants to report difficulty using HI (Chi-squared = 16.79, df = 2, p < 0.01). Overall, 37% of participants endorsed a lack of information about HI, nearly 22% of participants reported difficulty accessing HI, 22% reported difficulty using HI, and more than 20% stated they had trouble paying for HI. Information was also collected about the categories of HI utilized by participants’ family members. Voluntary HI was the most common type of HI used among participants’ family members, with nearly 45% of patients stating that their loved ones used voluntary HI and 29% stating that their loved ones used compulsory HI. Families from rural regions were more likely than families from urban regions to report utilizing poor HI (chi-square = 13.57, df = 1, p < 0.01). The majority of participants’ family members (nearly 63%) paid for HI on a quarterly basis.

Factors associated with use of and barriers to social health insurance among respondents are featured in Table 4. Older patients were less likely than younger patients to report a lack of information about HI. In addition, participants who had attended vocational school were less likely than illiterate participants to report a lack of information about HI. White collar workers and farmers were more likely than unemployed participants to have HI. Rich participants were more likely than their poor counterparts to both have HI and to have less difficulty accessing HI. Participants who reported difficulty using HI or who said they had an overall lack of information about HI were less likely to have HI. Patients who had been to drug rehabilitation centers in the past were more likely to obtain HI than their counterparts who had not been to rehabilitation, but they were also more likely to experience information insufficiency and have trouble accessing HI. Individuals who were HIV positive were more likely than their HIV negative counterparts to have sufficient information about HI options.

The study explored the barriers to accessing and utilizing HI among MMT patients in Vietnam. The vast majority of MMT patients in our study were uninsured, highlighting the high prevalence of poor insurance coverage among drug-addicted individuals in northern parts of the country. We also uncovered many of the barriers they face in finding HI information, understanding how to use it, and being able to pay for it. Not surprisingly, we found that participants who were impoverished and/or unemployed were among the least likely to obtain and utilize HI. Although individuals who had recently been to drug rehabilitation centers were more likely to obtain HI, they were also at higher risk of limited access to and information about HI, which paints a murky picture of the insurance environment for these patients. Importantly, the length of time that a patient had been enrolled in MMT was found to be positively correlated to amount of information about HI.

As mentioned, our results show a high rate of uninsured MMT patients in northern Vietnam. One potential reason for this high rate of uninsured patients lies in the economic vulnerability of Vietnamese individuals enrolled in MMT. Prior research has revealed that drug users, including those enrolled in treatment, suffer from significant financial constraints that may hamper HI subscription [21]. Indeed, MMT patients are likely to spend more money on drug and health care use, and to suffer from catastrophic health expenditures [11], which then makes it more difficult for them to pay for HI. Yet at the same time, without HI, they are much less equipped to be able to pay for such health expenditures. Since uninsured people incur considerable barriers to accessing substance abuse services [22], increasing access to HI for this population should continue to be a major priority among the Vietnamese government.

In summary, in this present study, we explored rates of HI and barriers to enrollment in HI among MMT patients in urban and rural parts of northern Vietnam. We found that the majority of patients were not enrolled in HI, largely due to financial constraints. Proposed solutions to increase enrollment include enrolling patients in HI when they begin MMT therapy and increasing employment opportunities for MMT patients. Because drug-addicted individuals face unique financial and health-related hardships, it is incredibly important to increase access to HI for these individuals.