Taiwan’s National Health Insurance (NHI), a universal health insurance program implemented in 1995, covers comprehensive healthcare services. The NHI is a government-run, single-payer national health insurance scheme, financed through a mix of premiums and taxes, which compensates a mixed public and private delivery system predominantly on case-payment and fee-for-service bases. Insured individuals, employers and government each pay a share of premiums.
Recently, the Department of Health (DOH) has been planning to introduce a new premium scheme because soaring healthcare expenditure has aggravated the financial pressure on the NHI. The DOH has proposed that an individual whose marital status is single (including divorced, widow, widower, gay and lesbian) should bear two to four times the current premium.
For example, a single individual whose monthly income is NT$50,000 would have to pay NT$1,600 for the NHI premium per month under the new premium scheme, which is twice the amount he or she has to pay now. On the other hand, an individual who whose monthly income is NT$50,000 but has three children would also pay NT$1,600 per month for the NHI premium under the new scheme.
To convince the Legislature to pass the bill, Minister of Health Yaung Chih-liang (楊志良) told lawmakers that singles should pay higher premiums under the new premium scheme because this population is more likely to suffer from mental illness. He cited Google search results using keywords “marriage” and “health” as indicating that many international studies have shown a statistically significant correlation between marriage and health.
Yaung’s arguments have drawn a lot of criticism and do not make sense to many people. Why? First of all, statistical correlation does not necessarily indicate causality. Does marriage make people mentally healthier, or do mentally ill people have a lower likelihood of getting married? The answer could be either of the two, or both. Anyway, regardless of what causes what, marital status should never be used to determine NHI premium rates because the NHI is a social insurance scheme. Wide pooling of risks is one of the special characteristics of social insurance, and in this respect it is quite different from traditional private insurance. Besides, marital status is not the most important determinant of health, or of healthcare utilization.
Second, patients who have psychiatric illnesses are still stigmatized in Taiwan. If Yaung thinks mentally ill people should have to bear higher premiums just because they are mentally ill, it would worsen discrimination against mentally ill people and retard the development of a better mental healthcare system, as well as frustrate the endeavors of many mental health professionals in Taiwan.
Third, although Taiwanese society has become more diverse than it used to be, same-sex marriage is still not legally recognized in Taiwan. Asking gays and lesbians to pay higher premiums is tantamount to inflicting a punishment on them. Nor should the rights of divorced people, widows and widowers be sacrificed by the DOH’s new policy, because their medical and living expenses could be even higher than those of married people.
Finally, the new policy also would be unfair to infertile couples. In Taiwan, assisted reproductive technology (ART) is not covered by the NHI, so infertile patients have to pay for costly ART treatment themselves. Under the new NHI premium scheme, however, infertile couples would need to pay more than couples with a similar household income who do have children.
Yaung further insists that this new policy can stimulate Taiwan’s fertility rate, which has been declining. He is telling people: If you don’t want to pay higher premiums, why don’t you get married and have children? In reality, there are various reasons for Taiwan’s rapidly declining fertility, such as economic recession, lower wages, postponement of marriage and later childbearing age. Singles should not be punished for Taiwan’s declining fertility and the increasing costs of bearing children by being charged higher premiums.
Again, being single is not the true reason for either the NHI’s financial burden or Taiwan’s low fertility. The potential effects of financial incentives on people’s fertility decisions remain ambiguous and controversial. While pronatalist policies may stimulate fertility rates, they also lower the cost of preventing births for eugenic or whatever reasons. NHI reform policies and those aimed at stimulating fertility rates should be discussed separately.
Michelle Ma is an assistant professor in the Graduate Institute of Healthcare Administration at Kaohsiung Medical University.
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