National Health Insurance
in Taiwan
Achievements, Crises, and
Opportunities
Roundtable Presentation
Ching-yi Peng
Outline
- Features of National Health Insurance in Taiwan
- The achievements and crises
- Changes under NHI in
- Life expectancy
- Health disparity
- Providers’ and patients’ behaviors
- Conclusion
Where is Taiwan?
Taiwan
Characteristics of
Taiwan healthcare system
- Dominated by the private sector
- Closed-staff system for hospitals
- Patients are able to choose care providers freely
- No gate-keeper system
- High service volumes in outpatient department in
most hospitals
Milestones in Social Insurance
1950 Labor Insurance (40.12%)
1958 Government Employee Insurance (8.06%)
1985 Farmer Insurance (8.21%)
1990 Low-income Household Insurance (0.55%)
59%
1995 National Health Insurance
Enrollment eligibility: all citizens, foreigners with resident permits,
dependents of the aforementioned
Characteristics of NHI
- Mandatory enrollment
- Single-payer system
- Public administration
- Comprehensive benefit package
- Fee for service and case payment under
the global budget payment scheme
Characteristics of NHI (cont.)
- Payroll-related premium rate
- Contribution shared by the employer,
the employee and the government
- Co-payment for outpatient care, inpatient
care, and drugs
Copayment for Outpatient Care
Unit : USD
Outpatient Emergency Dental Care & Drug
Care Care Chinese Med. (20%)
Academic Medical
Centers 13 1. 5 0~6
Through Referral
6
10
Without Referral
Regional Hospitals 9 1. 5 0~6
Through Referral 4
Without Referral 7
District
Hospitals/Clinics 4. 5 1. 5 0~6
1.5
Through Referral
2
Without Referral
Copayment exemption: catastrophic diseases, child delivery, medical services offered at
mountain areas or offshore islands, low-income households, veterans, children under
the age of 3, aborigines
Major Achievements of NHI
-- Universal enrollment
• Staying abroad
• Homeless people are
hard to locate
Major Achievements of NHI
--Easy access
- In 2006,there were 18,289 healthcare providers
contracted with BNHI, representing 91.45% of all
providers
- Since 1996, an integrated delivery system (IDS Plan )
implemented to improve services in remote
mountainous areas and offshore islands.
Major Achievements of NHI
--High Satisfaction
05/95 09/95 06/96 01/98 04/98 11/98 05/99 03/00 10/00 06/01 12/01 05/02 11/02 07/03 12/03 0 4/04 09/04 12/04 06/05 12/05 06/06 12/06 06/07
Major Achievements of NHI
--low expenditures
12
National Health Expenditures as % in GDP
1983-2002
% of GDP
NHI
6.0
5.97 5.99
5.5
5.44
5.0 Total Health Expenditures 5.27 5.29 5.27 5.33 5.46
4.5 4.93
4.77 4.81
4.67
4.0 3.80
4.20
4.00 4.00 4.10 4.00
3.5 3.70 3.90
3.0
2.5
2.0
Health Insurance 1.89
2.00
1.5 1.65 1.85
1.0
0.5
0.0
Resource: Bureau of National Health Insurance, Taiwan
Crises faced by the NHI
-- Financial discrepancies
Unit: NT$bn Insurance Cost Average growth rate : 5.54%
382.2
400 367.4
1st financial 352.6
360 337.1 382.1
crisis 323.3 352.2 361.0
320 301.8
285.9 285.2 336.8
280 262.0 307.6
3rd financial
241.3 243.6
260.5 264.9
284.2 286.1 crisis
240
194.0 222.9 237.6 2nd financial
200
crisis
160
156.8
120 Insurance Revenues Average growth rate : 4.70%
80 Insurance Revenues
40 Insurance Cost
0
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Resource: Bureau of National Health Insurance, Taiwan
Trends in life expectancy before and
after the introduction of NHI
Research :
A 10-year experience with universal health insurance in Taiwan:
measuring changes in health and health disparity.
Ann Intern Med. 2008 Feb 19;148(4):258-67
Method:
- Dividing the country into 10 health class groups by mortality
rates before the introduction of NHI
- Comparison of life expectancy between the decade before NHI
(1982-1984 to 1992-1994) and the decade after NHI
(1992-1994 to 2002-2004)
Overall comparison of life expectancy change
Source: A 10-year experience with universal health insurance in Taiwan: measuring changes in health and health disparity. Ann Intern Med.
2008 Feb 19;148(4):258-67
Comparisons among 10 health class groups
Increase in life expectancy during the period Increase in life expectancy during the period
before NHI ( from 1982-1984 to 1992-1994) after NHI ( from 1992-1994 to 2002-2004)
Gaps in life expectancy for health class groups
2 to 10 versus health group 1
Source: A 10-year experience with universal health insurance in Taiwan: measuring changes in health and health disparity. Ann Intern Med.
2008 Feb 19;148(4):258-67
Difference between life expectancy at birth
before and after the introduction of NHI
Table 2. Difference between life expectancy at birth before and after the introduction of NHI and change
in disparity for 3 broad health classes (high, medium, and low)
Results in life expectancy and
health disparity
- Overall life expectancy did not change.
- Life expectancy increased faster in lower health
class groups than in higher health class groups.
- The gap in life expectancy in health class group 1
(the healthiest) and health class group 10 (the
least healthy) decreased 6% after NHI.
(0.62-year/ 10.03-year)
Changes in providers’ and patients’
behavior
Substantial increase in utilization and expenditure
Changes in providers’ and patients’
behavior
- Physician payment incentives have effect on how
medical trainees choose their specialties.
- Lay referral instead of professional referral.
- Higher utilities may be encouraged by the ease of
access.
Conclusion
- Universal national health insurance may reduce health
disparities, but only by a small amount.
- Utilization and expenditures on health care increased
after NHI.
- NHI is facing health care budget shortfalls and
increasing national debt, working on a reform of NHI.
Thank you!
chingyip@ucla.edu