In Chinese, the National Health Insurance (NHI) program is known as jianbao (健保) for short, a word consisting of the characters for “health” and “protection.” It is perhaps from this that the misconception sometimes arises that the system is a kind of social welfare, rather than a form of health insurance.
From its inception, the NHI has given people paying into it access to quality healthcare for little personal outlay, one’s own personal burden for the system being calculated according to one’s income.
This is why the system has come to be regarded as a form of social welfare and, as a consequence, why resources are being misused and why the system is incurring losses over the long term.
As a form of insurance, the premium calculation for the NHI should be based not only on income, but also on risk and usage frequency. The more people use it, the higher the premium and individual burden ought to be.
This would be no different from car insurance. If you have applied for a payout in the past, you lose your no-claims bonus. It means you are an increased risk, and up goes your premium.
The NHI was not always like this. In the past, people would have to pay more the more they used it. This system has since been abandoned. The government should resurrect it and put the onus of payment back onto the user. There are also certain kinds of behavior that put one’s own, or others’, health at risk, and thereby increase the burden on the medical care system. This type of behavior warrants higher premiums.
For one, there should be a health tax levied on smoking, making smokers assume some responsibility for the additional risks they create as a result of their habit. Betel nut chewers should be asked to do likewise, for the same reason. There are other kinds of social behavior, too, such as drunk driving, speeding, a tendency to violence or producing tainted or dubious foods, that should mean higher payments, depending on the case.
Reasonable health insurance premiums can be calculated according to the risk plus the potential for payout, so that people buying insurance can have reasonable guarantees, while the insurance companies can be assured of a sustainable business. In the current system, the premium is calculated according to an individual’s income, and not to the risk they entail. This is making the NHI like a social welfare system, which it is not designed to be: no wonder it continues to run at a loss.
To save on costs, the National Health Insurance Administration has kept on reducing the amount it pays for healthcare and medicines, forcing many patients to pay for these items out of their own pockets, and thereby seriously curtailing the reason the NHI system was set up in the first place.
As the health insurance payments the hospitals receive are so limited, health professionals’ hands are often tied, and the biggest losers are the patients themselves, leading to a vicious cycle.
In the interests of sustainability, the NHI should revert to requiring that users pay depending on how much they use it, and those with dubious behaviors, and who therefore present a greater risk, should be required to pay extra.
Otherwise, the burden for the losses will have to be spread over all users. This would not only be unfair and unjust, it would also do little to address the fundamental problems in the system.
Yang Der-yuan is a professor in the money and banking department at National Kaohsiung First University of Science and Technology.
Translated by Paul Cooper
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