Taiwanese singer Huang An (黃安) recently returned to Taiwan for medical treatment. Prior to his return, Huang drew a public outcry when he criticized Taiwanese K-pop star Chou Tzu-yu (周子瑜) for waving a Republic of China (ROC) flag on South Korean television. His return to the nation to receive medical treatment under the National Health Insurance (NHI) program has therefore sparked a heated debate over healthcare reform.
As someone who has long researched social insurance and been involved in the field of law dealing with the NHI, I can understand the emotional response triggered by Huang’s actions, but the NHI system should not be viewed solely through one’s own political or moral stance.
The NHI is a form of social insurance. Therefore, it was founded on principles originally developed for insurance, and later revised for social purposes.
It is neither a type of social assistance nor of social welfare. On the premise of a pre-existing insurance relationship, a relationship of rights and obligations must therefore be established between the parties based on the principle of equality between performance and counter-performance.
This is why, when considering the Huang case, it is important to first ask whether Huang has the rights and obligations that follow insurance under the NHI program. If the answer is yes, then the next question would be whether his rights and obligations under the insurance are equal in proportion.
In terms of whether Huang has the rights and obligations pertaining to the NHI, current law states that any Republic of China (ROC) citizen with a registered address in Taiwan — even those who do not consider Taiwan a nation — can enrol in the NHI program — see Article 8 of the National Health Insurance Act (健保法); and the government cannot reject any such enrolment.
The nationality requirement is complemented by a residency requirement, which considers the situations of residents without ROC citizenship. Under the latter principle, anyone who has been a registered resident of Taiwan for more than six months is eligible for enrolment in the NHI program as per Article 9 of the National Health Insurance Act.
Chinese citizens studying in Taiwan also belong to this category, and should likewise be discussed in the same context. The purpose of these two requirements is to make sure that the NHI program adheres to the spirit of the law, which is to attend to the needs of society and encourage reciprocal help.
Overall, the NHI program should adhere to universal values and provide equal help to residents without discrimination or privileged treatment.
For this reason, when amending the National Health Insurance Act, it is important to follow through on the spirit of equality and justice which the mutually complementary nationality and residency requirements are designed to realize.
More specifically, citizens who spend most of their time abroad should not have the same rights or obligations under the NHI — with the exception of those studying or working abroad. Those studying abroad should remain as insured as they were when they left Taiwan.
Those working abroad should provide evidence of employment and their salaries, by which their eligibility and the applicable terms and conditions can be determined.
This would prevent the problem of having high-income workers pay low premiums. As for those who spend most of their time abroad for reasons other than school or work, they should still be eligible for enrolment in the system, although the rights and obligations should be set out differently.
In Huang’s case, while he spends most of his time abroad — less than 183 days per year in Taiwan — see Article 35 of the National Pension Act (國民年金法) — he is apparently neither studying nor working, which suggests that he belongs to the leisure class, and should be considered as having the equivalent of the highest salary basis, and be charged at a much higher premium rate, to make things fair.
On the other hand, the government might consider amending the law on citizens living abroad who are neither studying nor working, by raising the share and maximum amount of medical expenses they need to pay. Presently, each insured patient pays no more than NT$36,000 in out-of-pocket expenses for one medical condition, and no more than NT$59,000 in total per year, according to Article 47 of the National Health Insurance Act.
By raising the share and the maximum amount of medical expenses the insured party must pay, the NHI system would avoid further controversies over “freeloaders” and “global coverage.”
Mawin Tsai is a professor of law at National Taiwan University.
Translated by Yu-an Tu
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