People in metropolitan areas have easy access to hospitals thanks to their health insurance cards. For those who live in more remote places such as mountainous areas or the outlying islands, however, getting to a hospital for treatment can present a problem. We thus find ourselves in a situation where some people who pay the full health insurance fee have easy access to hospitals, while others who pay the same amount have limited or no access at all to medical care. How is this fair?
In view of this, the Bureau of National Health Insurance (BNHI) in 1999 implemented a system called the Integrated Delivery System (IDS). This tweaks the way health insurance fees are paid and encourages hospitals and medical institutions to provide comprehensive medical services in remote areas.
IDS was implemented in the hope that such support could mitigate the shortage of doctors, make it easier for people to get access to medical treatment and generally improve the quality of the care provided.
IDS has now been in place for 10 years, and so we can look at what it has achieved. There has yet to be a systematic analysis of the situation, but BNHI figures published in 2008 show that in 48 remote townships, accounting for about 400,000 people, each individual sought medical treatment an average of 15 times, higher than the national average of 14. This shows that people in more remote areas are statistically more likely to seek medical treatment than the national average.
The implications of this require further investigation, but they do show that the IDS system has increased the accessibility to medical services for such people. In addition, many of the hospitals signed up to IDS go above and beyond the narrow definition of medical treatment and are actively engaged in preventative treatment and health education work deep in local communities, catering to the specific local medical requirements.
The problem is that the populations of these areas are faced with their own catch 22: Whereas before they had insurance but no access to treatment, they now have improved access but no insurance.
In some mountainous areas in the east of Taiwan between Hualien and Taitung, more than 20 percent of the population have found themselves excluded from health insurance because they have been unable to afford the fees.
In the past they didn’t have access to doctors, but now doctors are available in their areas, they cannot go to the clinics, because they forfeited their health insurance cards after defaulting on the fee payments.
Many people in these remote areas are classified as being residents of “regional areas,” and have to pay about NT$600 per month each. That means that, in a four-person household, under the individual payment system, the family is liable for NT$2,400 a month. This is a significant amount of money for poor families living in these areas, and one that might be well beyond their means.
Fees for Aborigines under the age of 20 and over the age of 55 are paid for them, but other inhabitants of these areas do not qualify for exemptions.
That some people find it difficult to afford the health insurance payments is the result of shortcomings in the current system, which categorizes people according to their occupation when calculating their premium and what percentage of it they are personally expected to pay.
For example, a young Aborigine working as a laborer in the city might be liable for monthly payments of NT$300. Should he then lose his job and return to his local district, his monthly fee would actually increase to NT$600. In what way does that make sense?
The financial revisions in the second-generation of health insurance are designed to address this problem. They are to do away with the occupational categorization. Gone, too, will be the idea of calculating the fee per person, replaced with a system of calculating the premium based on total household income. This will reduce the burden on low-income families.
The new system will hopefully make the present scenario, in which people living in remote areas are denied health insurance because they cannot afford the premiums, a thing of the past.
It is, however, worth noting that the second-generation health insurance system in the incarnation currently being entertained by the government does not actually abolish individually calculated fees for all households.
The new system incorporates lower and upper limits: Those whose household income falls above or below these limits still have to pay insurance premiums based on their individual circumstances.
In fact, many of the households in remote areas that cannot afford the fees could well fall below the lower limit, and several members of those families will consequently still be liable to pay individual fees.
For the poor, this method of calculating the fees actually makes the second-generation system even more unfair than the previous one. The fact that this could mean poor families are still left out in the cold really needs looking into.
Lin Kuo-ming is an associate professor of sociology at National Taiwan University.
TRANSLATED BY PAUL COOPER
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