Last year, when foreign media came to Taiwan to see first-hand how its universal health care system is implemented, Taiwan's National Health Insurance (NHI) was touted as a success story. A South Korean television station praised the NHI as "health utopia for all." The US network ABC gushed that "these days in Taiwan, whatever the treatment, whether with modern or traditional medicine, Taiwanese will get it -- and get it cheaply."
Not anymore. At the Taichung Veterans General Hospital, many elderly patients arrive at the registration desk at 6am and lay down their walking sticks to line up for treatment. Many fear that if they come in late, they won't get to see a doctor.
Other patients suffering from rare diseases have wandered from hospital to hospital looking for appropriate care. Some hospitals in Kaohsiung stopped importing the costly but vital drugs such patients need. Some drifted from a hospital in Kaohsiung to another in Taipei.
"We can't even point out the name of the hospitals, or the patient will be turned away forever," said Yang Yung-Shiang (楊永祥), executive director of the Taiwan Foundation for Rare Diseases, who represents patients in negotiations with hospitals and the government.
A decade after the NHI was established, the once widely acclaimed system no longer ensures easy access to medical care. Instead of bettering public health, the flawed NHI is now widening the gap between urban an rural care.
Every year, the Bureau of National Health Insurance receives about NT$360 billion in insurance revenue but spends NT$390 billion. To rein in escalating spending, the bureau in July put a cap on how much reimbursement hospitals can get. The bureau also invited hospital representatives to organize the Hospital Global Budget Executive Committee. Under the umbrella commission, large and small hospitals vie for a share of the NT$254.6 billion budget.
"Everyone sits in their suits and neckties at the negotiating table, but it's the law of the jungle that holds sway," said Hsieh Wen-hui, (謝文輝) secretary general of the Taiwan Community Hospital Association. "Only the fittest survive."
Since then, hospital managers began to set quotas for doctors, and doctors began to limit their number of patients and prescribe only cheap drugs.
"Yes, we can see some costly drugs come up on the computer screen," said Kuan Shang-yung (
Patients say that their lives are threatened. Doctors say that they must obey the order from the top. Hospital mangers say that they must cut down spending to survive. And the bureau says that best arbiter for setting the price of drugs and care is the marketplace.
But at least one hospital president says medical care should not be governed by the same market forces as consumer products.
"The market works wonderfully when you want to sell more cars, cosmetics or computers," said Kang Yi-shen (
Under the market-based mechanism, the gap between large hospitals in cities and smaller ones in townships and villages has widened. For instance, Chang Gung Memorial Hospital, together with its eight branch hospitals, reaped NT$33.7 billion in 2002. Community hospitals in rural areas, meanwhile, say they're struggling to stay afloat.
Such disparities have a direct impact on patients lives in rural areas. While urbanites have the luxury of choosing which hospital to go to, many in the nation's less developed east rely on one small, local hospital for their care. Unfortunately, in the increasingly competitive health care industry fewer and fewer such hospitals can afford to operate.
"In 10 years, while 167 private, small hospitals went bankrupt, the number of corporate-funded hospitals soared from 24 to 50," said Chang Li-yun (
Growing tensions about the nation's health care system have recently spilled into the streets. Earlier this month, more than 2,000 health workers from community hospitals gathered to protest the inequality in budget allocations. Amid the fracas, Chang Hong-jen (
The fit of antagonism between hospitals and the government may have already passed. But there's still no cure in sight for the ailing NHI.
When some argue that higher insurance rates can help fix the problem, others counter that the government must improve the transparency of hospital finances before they ask people to pay more.
When some suggest that the Bureau narrow its insurance coverage by, for example, making patients pay for their own cold medicine, others reply that removing cold medicine from coverage will only save NT$7.4 billion a year for the bureau -- less than one week of its expenses.
The thorny issue will be put to a citizen panel by the end of the year. With the health care system facing a crisis in public confidence, all eyes will be on them to figure out how to revive the nation's "health utopia" -- without breaking the bank.
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