With regard to the sustainability of Taiwan’s National Health Insurance (NHI) system, the more funding it gets, the smoother it operates — but the question lies in where that funding should come from. Managing NHI finances is similar to being the chief executive officer of a corporation — it requires pragmatically facing reality.
In service for three decades, the system is confronting structural challenges such as a mass exodus of physicians and nurses that specialize in urgent, critical and rare diseases, insufficient premium revenue, imbalanced payments for professional services, and misallocated resources. For the system to last, it cannot rely solely on increased funding — it requires managerial wisdom and human understanding.
The NHI handles nearly NT$1 trillion (US$32.5 billion) in annual revenues and expenditures, yet its allocation fails to meet the needs of the healthcare system. Outpatient services account for 70 percent of total spending, while inpatient care only accounts for 30 percent. Insufficient primary care resources make it impossible to provide care for chronic diseases, while major medical centers are overcrowded with patients suffering from minor illnesses. Many have grown accustomed to going straight to large hospitals to see renowned doctors, believing that the visit is covered by the NHI, tests are free and the medication is cheap, which causes medical institutions to be overwhelmed.
The key to tiered healthcare is trust, not punishment. Every patient hopes to see the best possible doctor, that is only human. If the public lacks trust in primary care physicians, no amount of public education can change their healthcare habits. To make a tiered healthcare system successful, achieving trust in primary care must be the priority — accurate diagnoses, attentive service and smooth referral processes. The public must be made aware that minor illnesses can be treated at local clinics, and that patients with serious conditions are referred to larger medical centers when necessary.
When the National Health Insurance Administration established the medical treatment cloud database known as Medicloud, it allowed patients at local clinics to access imaging results taken at major medical centers and integrated strategic alliances across healthcare systems. With the help of former minister of education Pan Wen-chung (潘文忠) and Tainan’s Hanlin Publishing, concepts such as tiered medical care and user copayments under the NHI were even included in fifth-grade elementary school textbooks. The plans were well thought out, but the real question is whether the authorities have made good use of these tools to promote health insurance reform.
There is a clear and fundamental difference between user-paid services and copayments. The copayments stipulated in the National Health Insurance Act (全民健康保險法) depend on the level of medical institution — for example, patients who go directly to a major medical center without a referral must pay an additional fee. The boost in NHI copayments we advocated for in 2021 focused on accountability for healthcare-seeking habits — particularly in relation to tests and examinations. It is not uncommon for patients at large hospitals to seek extra tests while they are at the facility. This “the more tests, the better” mentality has led to the overuse of medical resources, encouraging individuals to seek treatment at major hospitals.
If patients were made to understand the costs associated with each test, and if copayments were adjusted based on usage behavior rather than just the level of the medical institution, we could curb overuse of the central facilities and encourage people to return to local clinics.
At the time it was proposed, this policy received then-premier Su Tseng-chang’s (蘇貞昌) support and saw an 80 percent approval rating in public opinion polls. I found myself deeply moved by Su’s leadership. Unfortunately, the COVID-19 pandemic disrupted the plan after it had already been announced, short-circuiting its implementation. That the original copayment model from 30 years ago is being revisited, sociologists are likely to voice different opinions.
Finally, the sustainability of the NHI system cannot rely solely on legislation. Governing according to the law is the foundation of reform, but the vitality of any system stems from the human heart. The ultimate success of the NHI comes from it being a system of human understanding. When users are willing to pay their fair share, primary care doctors receive respect and major medical centers can focus on treating only the most critical cases, the entire system would regain balance. The NHI should not merely be a medical bill paid by all citizens, but a health charter collectively safeguarded by the entire nation.
Lee Po-chang is a chair professor at Taipei Medical University’s College of Public Health and former director-general of the NHI Administration.
Translated by Kyra Gustavsen
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