The nation’s healthcare system is ridden with problems, and medical provision in outlying areas is on the verge of collapse. What lies at the root of all these difficulties?
Possible solutions promoted by the government include setting up international medical zones and establishing a diagnosis-related group (DRG) system. Will these things turn out to be poisons or remedies? What is the real solution for our collapsing healthcare system?
The first step toward finding an answer to these questions must be a review of the nation’s healthcare history.
Many public health experts took part in designing the healthcare system, and they made it clear from the start that the National Health Insurance (NHI) system would be a kind of social insurance. The Bureau of National Health Insurance, which has now become the National Health Insurance Administration, would have to be financially self-supporting, and it would have to raise insurance premiums if its revenue was not enough to cover its expenditure.
However, politicians, including both government officials and elected representatives, have often gone against this principle because of their own political interests. They often treat the NHI as a kind of social welfare, giving the public the mistaken idea that it is an “all-you-can-eat” service.
Government spending accounts for an ever-smaller share of healthcare spending. Government-run hospitals in outlying areas keep closing and the public healthcare budget is being neglected.
When it is talking to the public, the government says that the NHI is a form of social welfare, so it is OK to take as much as you need. However, when it is talking to healthcare providers, it says that the NHI is a form of social insurance that has to be financially autonomous and implement global budgets.
On the one hand, the government has the power to allocate resources, but on the other hand, it does not fulfill the responsibilities that a government should have in a public health system. The authorities have sat by and watched as healthcare provision becomes highly marketized. Only big corporate-owned hospitals can survive in the market, because they are able to cut their costs.
As local healthcare provision crumbles, patients crowd into larger hospitals, no matter whether they are suffering from major or minor illnesses, and this overcrowding has pushed emergency rooms to the verge of collapse.
The second historical factor to consider is that the NHI was hastily launched a dozen or so years ago to win votes, and without sufficient preparation. This resulted in the NHI adopting the same kind of contribution standards that have given rise to problems with other government programs such as labor insurance.
More than a decade has passed, but there have been only limited reforms. One result is that in many cases, different people doing the same amount of work are paid differently, while those doing different amounts of work are paid the same. How irrational are payment standards?
Let us look at South Korea, which politicians often cite in comparison with Taiwan. How much does South Korea’s national health insurance pay for premature infant care, and how much does the NHI pay? Only when Taiwanese travel abroad do they discover how cheap healthcare is at home, but have they fulfilled their obligations?
The third historical factor is the governing principle of Taiwanese politicians, which is to take the path of least resistance rather than doing what should be done to sustain the nation and the happiness of the majority.
For example, initial plans for the NHI included the establishment a medical referral system, but this idea was dropped in the face of public opposition, because people were used to going to medical centers. Consequently, the government has yet to set up a medical referral system as stipulated in the National Health Insurance Act (健保法).
Another issue to consider is the DRG system, which people have been arguing about for some time now. Why is it that a system that works well in other countries could be the straw that breaks the camel’s back in Taiwan?
The difference is that in advanced countries, rights and duties are clearly defined and health insurance services are not cobbled together in patchwork fashion. Those countries also have rational coverage rules and complementary measures whereby when state insurance does not pay for treatment, private insurers or individuals pay instead.
What of international medical zones? Are they a remedy or a poison for the nation’s crumbling healthcare system? Should healthcare be commercialized? Would the provision of medical services in free economic zones contravene medical workers’ original mission and thus be incompatible with medical ethics? Or does liberalization offer hope for emancipating healthcare service workers?
Until such a time as the various historical factors have been resolved, the introduction of international medical services in the free economic zones would be a poison chalice.
As things stand, the NHI remains in a patchwork state and the government is dodging its responsibilities. On the one hand, the government uses the unsuitable global budget and DRG systems to deprive healthcare institutions of the labor revenue that they should receive for providing medical care in accordance with NHI contracts, while it allows medical institutions, at the same time as marketizing their supply side, to obstruct safeguards for working conditions — safeguards that are essential under a free-market economy.
As long as these conditions remain unchanged, medical facilities in the free economic zones will be more of a poison than a remedy. Free economic zones are not the remedy for Taiwan’s collapsing healthcare system. The solutions are to be found elsewhere.
First, the government’s role should be strengthened by increasing the share of public spending in funding healthcare and ceasing to exploit hardworking staff through unsuitable systems like global budgets.
Second, healthcare institutions’ responsibilities to the public need to be rationalized. A medical referral system should be implemented, and if revenue from insurance premiums is not enough to cover expenditure and does not reasonably reflect the costs involved, coverage will have to be restricted to pay for the treatment of serious maladies, not mild ones.
Third, working conditions must be safeguarded by applying the Labor Standards Act (勞動基準法) to physicians and legislating to set a minimum nurse-to-patient ratio. If hospitals violate these regulations, their management should be banned from running international medical care businesses.
If we appreciate the historical background of the nation’s healthcare problems, the question of whether healthcare providers should operate in free economic zones is no longer so important in itself.
Chien Jien-wen is a pediatric nephrologist and director of the Taiwan Medical Alliance for Labor Justice and Patient Safety.
Translated by Julian Clegg
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