Like similar systems in other countries, Taiwan's National Health Insurance (NHI, 全民健保) program wastes a great deal of resources. But in terms of overall consumption of social resources, the program ranks at a medium-to-low level. Taiwan's health insurance problem is therefore definitely different from, for example, that of the US, which has already affected that country's overall economy and international competitiveness.
Next, the financial problems facing the NHI program are not the result of problems with government finances. Although some government agencies would have us believe otherwise, the program is not damaging the government's finances. On the contrary, the government has channeled private resources into the public health system by means of the insurance premium, thereby shirking its responsibility by stealth. Ironically, the placing of the financial burden onto the insurance program itself is one of the sources of the problem.
Another is the absence of a fair mechanism for sharing the cost of the program. As a result, none of the parties financially responsible for the program (employers and patients, who pay for it, and the medical profession and NHI management, which are responsible for minimizing costs) have a platform for rational negotiations. As a result, every re-allocation of financial responsibility has resulted in meaningless conflict.
To solve this problem, a tailor-made negotiation mechanism removed from political influences is necessary. That mechanism must first be capable of calculating the costs of the program objectively and within the ranges of quality of medical provision and levels of payment at the point of treatment that are acceptable to the public. Then it must be capable of producing specific guidelines for all the parties involved to share the financial burden, with hospitals and NHI management pledging specific cost-savings and quality of service. To avoid departmentalism, the negotiation mechanism should be cross-ministerial in nature.
The third source of the problem is mismanagement on the part of the NHI management. It has failed to show, with detailed, accurate and objective statistics, that everyone and every agency concerned has made their due contribution. The fact is that, ever since the program was launched about seven years ago, the excessive profits of the hospitals have been greatly reduced through intensive, long-term control by the NHI management. On the one hand, however, it is not easy to translate such savings into concrete figures. On the other hand, the NHI authorities have neither the patience nor the ability to engage in dialogue with the public. As a result, the people have come to believe that they are the only "victims" of the premium hikes.
To begin with, adjusting premium rates is part and parcel of the financial responsibility system defined by the National Health Insurance Law (全民健保法). The NHI authorities have failed to plug the drug pricing "black hole" either by exercising their powers or by creative use of market mechanisms. They are also unable to collect the huge debts owed by the local governments -- debts resulting from political wrangling. This is all highly unsatisfactory.
As it demands better health care, however, the public cannot just sit back and watch as the program's financial plight worsens. Today, the social function of the NHI program is beyond doubt. As a social insurance system, however, NHI is very much like the black tuna, a sea fish considered public property. Everyone wants a bite of the black tuna, but people have no immediate incentive to protect the fish. As a result, tragedy is inevitable.
Michael Chen is an associate professor at the department of social welfare, National Chung Cheng University.
TRANSLATED BY EDDY CHANG
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