Health insurance coverage and healthcare utilization among infants of mothers in the national methadone maintenance treatment program in Taiwan
Introduction
Substance use during pregnancy is an important health and social problem. To date, it is estimated that less than 1% of pregnant women aged 15–44 in the United States and nearly 6% in South Australia used illegal drugs during pregnancy, with heroin being one of the most commonly reported drugs (Kennare et al., 2005, Substance Abuse and Mental Health Services Administration, 2012). Adverse effects of opioid use and abuse during pregnancy can be manifested in pregnancy process (e.g., placental abruption and miscarriage; Hulse et al., 1998a, Kennare et al., 2005), or in trans-generational unfavorable perinatal outcomes on offspring (e.g., preterm birth, low birth weight, and neonatal death; Burns et al., 2006, Hulse et al., 1998b, Kennare et al., 2005). In many countries, methadone maintenance treatment (MMT) is the first line of management to help pregnant women with heroin addiction ameliorating intoxication and withdrawal. Cumulative evidence suggests that methadone is beneficial to heroin-dependent pregnant women in terms of pregnancy outcomes; however, there is still a great concern about the adverse effects of methadone on neonates’ health outcomes (Hulse et al., 1998a, Hulse et al., 1998b, Kennare et al., 2005, Webster et al., 1996). Some clinical observational studies have found that certain unfavorable neonatal outcomes, such as growth retardation, low birth weight, preterm delivery, and neonatal abstinence syndrome [NAS], were very common (e.g., NAS: 40–75%) among the offspring of women enrolled in the opioid substitute therapy (Burns et al., 2010, Chen et al., 2015, Cleary et al., 2012, Dryden et al., 2009, Hulse et al., 1997, Hulse et al., 1998b, Kakko et al., 2008). Relative to infants of non-drug using mothers, the needs in healthcare for children born to women on an opioid substitute therapy are expected to be higher (Johnson et al., 2003, Jones et al., 2010, Kakko et al., 2008), and as such their access to quality and regular well child services is especially important.
Health insurance coverage and healthcare utilization have been conceptualized as two important dimensions when evaluating children's access to health care. Insurance coverage is often identified as the most crucial determinant for health care utilization, especially in countries without universal coverage (Abdus and Selden, 2013, Cummings et al., 2009, Dietz et al., 2012, Holl et al., 1995, Kogan et al., 2010). Evidence from the United States consistently indicates that none- or discontinuously insured children, as compared with fully insured ones, were more likely to experience delays in receiving needed health services and to have difficulties in accessing a usual source of care, including preventive healthcare (Cummings et al., 2009, Holl et al., 1995, Olson et al., 2005). Given the importance of health insurance coverage, some strategies have been implemented at national, state, or local levels to reduce the access barriers (e.g., universal health care, social insurance, and special program), yet the related benefits can still be underutilized. For example, studies on children eligible for the public health insurance program in the US have shown that over one in ten children were still uninsured (DeVoe et al., 2008, DeVoe et al., 2011). Factors influencing children's insurance status and health service use included parents’ insurance status, employment, educational attainment, copayment, rural residence, among others (DeVoe et al., 2008, DeVoe et al., 2011, Quimbo et al., 2008).
The first year of life is the period with the greatest need for healthcare. Evidence indicates that having up-to-date pediatric preventive care (e.g., well-child visits) was associated with reduced avoidable hospitalization among poor and near-poor children (Hakim and Bye, 2001), and that having better access to primary health care may lower children's visits to emergency department (Piehl et al., 2000). Therefore, to monitor growth/development and to provide timely treatment, pediatric preventive and primary health care visits are crucial (Magnani et al., 1996), and this is especially true for those infants in poor health and disadvantaged families. Prior studies have shed light on health care utilization in the first year of life in a variety of subpopulations, such as children of low income families and children with special needs (Dietz et al., 2012, Dietz et al., 2013, Farr et al., 2013, Holl et al., 2012). However, information is generally scant on offspring of heroin-addicted or methadone-treated mothers even though this group of children often experienced more health and developmental problems due to in utero heroin or substitute medication exposure, maternal unfavorable lifestyle, and disadvantaged socioeconomic condition.
In Taiwan, the National Health Insurance Program (NHIP) has been implemented since 1995 and has provided comprehensive and universal health insurance coverage for more than 23 million enrollees. Although the NHIP is compulsory, the coverage rate of NHIP has not reached 100% due to job loss or change or incarceration for more than two months. Since children under 18 are generally covered as dependents under their employed parents, parental unemployment and financial disadvantage may affect their insurance status and healthcare utilization. To address the abovementioned research gaps, we conducted a retrospective longitudinal study using several national datasets in Taiwan to investigate the accessibility and utilization of healthcare among children born to heroin-addicted women. Specifically, we examined (i) whether maternal methadone treatment is an important factor when assessing children's insurance coverage in the first year of life under the universal health insurance program, and (ii) whether the utilization of preventive, outpatient, and emergency care in the first year of life is affected by maternal methadone treatment status.
Section snippets
Multiple sources of datasets
The administrative data used in this study came from (i) the 2004–2008 Birth Notification System in the Bureau of Health Promotion, (ii) the 2004–2008 Birth Registry in the Ministry of the Interior, (iii) the 2006–2009 MMT program in the Center for Disease Control and Prevention, (iv) the 2001–2009 Death Registry in the Ministry of Health and Welfare, and (v) the 2001–2009 National Health Insurance Database in the National Health Insurance Administration. The dataset was linked with each other
Results
The characteristics of the BM (born before the MMT enrollment)-, AM (born after the MMT enrollment)-, and ND (non-drug exposed)-infants are summarized in Table 1. As compared to the ND-group, a relatively higher proportion of infants in the BM-group were born to mothers who had lowest or highest levels of educational attainment (i.e., elementary school: 12.02% vs 3.74%; college or above: 61.26% vs 48.98%, P < 0.001), unmarried status (60.21% vs 19.92%, P < 0.001), mental disorders in postnatal
Discussion
Based upon a population-based matched retrospective cohort study, we found that approximately one third of the infants born to mothers in the two MMT groups had incomplete insurance coverage during the first year of life, and such risk was 29–56% higher than the non-drug exposed matched infants. As compared with the non-drug exposed matched infants, infants born before maternal methadone treatment had 15% fewer preventive visits; infants born after maternal enrollment in methadone treatment had
Conclusions
This study, to our knowledge, is one of the first few to document the health care accessibility and utilization among infants of heroin-addicted mothers in the methadone maintenance treatment. Our findings indicated that even with universal health insurance, infants born to mothers in the MMT program were at a greater risk for having discontinuous or even no insurance coverage during their first year of life. Infants born before maternal methadone treatment (when the mothers were likely still
Role of funding source
Nothing declared.
Author's contribution
S.Y. Fang performed the data analysis and wrote the first draft of article. S.Y. Huang assisted in the writing of the article and interpretation of the findings. T. Lin and I.K. Ho assisted with the data linkage and reviewed the draft of the article. C.Y. Chen conceptualized the study, framed the analyses, and supervised all stages of study. All the authors have read and approved the final version of manuscript.
Conflict of interest
None.
Acknowledgements
We thank those in Taiwan's Center for Disease Control who collected and managed the methadone registration dataset and the Collaboration Center of Health Information Application (CCHIA), Ministry of Health and Welfare. This work was supported by a grant from the National Health Research Institutes (MDPP04-014 and NHRI-102A1-PDCO-1312141). Dr. Chen was supported by a grant from the Ministry of Education, Aim for the Top University Plan. The grant funders had no role in the design or conduct of
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