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Taiwan’s National Health Insurance:
What Worked and What Didn’t?
Prepared for Conference on Public Health and Preventive Medicine 2010, The World Federation of Chinese Public Health Professionals and The Hong Kong Tuberculosis, Chest and Heart Diseases Association, November 6-7, 2010, at the Hospital Authority Building, Kowloon
T.L. ChiangCollege of Public Health, National Taiwan UniversityE-mail: [email protected]
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3
0
10
20
30
40
50
1920 1940 1960 1980 2000 2020
Bir
th/D
eath
Rat
e (1
/100
0)
0
20
40
60
80
100
Lif
e E
xpec
tan
cy (
year
s)
HEALTH TRANSITION IN TAIWAN
Communicable Disease Control Health for AllHealthcare for All
Crude Death Rate
Crude Birth Rate
Life Expectancy
Traditional Public Health New Public Health
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TAIWAN - 2008
Socioeconomic background population 23 million density 637 persons per square km GNP US$17,576 per capita education 35% received higher education aging 10.4% population aged 65+
Population health life expectancy M/F: 76/82 yrs major killers cancer, heart disease, stroke, diabetes, accident
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CONTENTS
Taiwan’s NHI: An overview Objectives Main features
What worked Access to health care Catastrophic health spending
What did not Inefficient use of health care resources Widening health inequalities
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Taiwan’s NHI
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0
30
60
90
120
150
1960 1970 1980 1990 2000
per
cap
ita
GN
P i
n U
S$1
00
0
20
40
60
80
100
Co
vera
ge
rate
(%
)
per capita GNP Coverage Rate
Withdraw from UN
US De-Recognition
Democratic Progressive Party
Full Congress Election
President Election
Taiwan’s NHI
THE BIRTH OF TAIWAN’s NHI
NHI Law
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Equity in access to health careTo provide equal access to adequate health care for all citizens in order to improve people’s health
Macro-economic efficiencyTo control health care costs at a reasonable (or socially affordable) level
Micro-economic efficiencyTo promote the efficient use of health care resources - better health outcomes and cost effectiveness
OBJECTIVES OF TAIWAN’S NHI
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MAJOR NHI FEATURES
Universal coverage
Comprehensive benefits Western medicine, Chinese medicine ambulatory care, EMS, inpatient care, home care coinsurance rate of 10-20% plus …
Public single-payer
National global budget Health spending as % of GDP - 6.4% in 2008
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PUBLIC STATISFACTION W/ NHITaiwan, Since 1995
0
20
40
60
80
100
1995 1998 2001 2004 2007 2010
0
20
40
60
80
100
Satisfied Not satisfied
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http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/
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What worked
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WHAT WORKED
Equal access to health care Ambulatory care Inpatient care
Prevention of poverty trap
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ANY USE of PHYSICIAN SERVICES Before and After the NHI
0
10
20
30
40
50
Before (1994) After (1995)
Pro
bab
ility
of
use
Newly Insured Previously Insured
Source:Cheng HS, Chiang TL. The effect of universal health insurance on health care utilization in Taiwan – results from a natural experiment. JAMA 1997; 278:89-93.
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ANY USE of HOSPITAL SERVICESBefore and After the NHI
0
4
8
12
16
20
Before (1994) After (1995)
Pro
bab
ility
of
use
Newly Insured Previously Insured
Source:Cheng HS, Chiang TL. The effect of universal health insurance on health care utilization in Taiwan – results from a natural experiment. JAMA 1997; 278:89-93.
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WHAT WORKED
Equal access to health care
Prevention of poverty trap Catastrophic health spending
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0
10
20
30
40
50
Poorest Richest
Pro
po
rtio
n o
f p
eop
le
Total Health Spending Out-of-Pocket
CATASTROPHIC HEALTH SPENDING*W/out and With NHI, 2004
* Out-of-pocket health spending exceeds
40% of household non-food consumption
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CATASTROPHIC HEALTH SPENDINGAsia Comparison, circa 2000
Source:Van Doorslaer E and EQUITAP team. Catastrophic payment for health care in Asia. Health Economics, 2007;16:1159-84.
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What didn’t work
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WHAT DIDN’T WORK
Meeting social expectations Aging society and big tickets Sustainable financing
Tackling health inequalities
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0
20
40
60
80
1950 1970 1990 2010 2030 2050
Per
cen
t
0
200
400
600
800
Po
pu
lati
on
PcT Kids Pct Aged Aged Pop
POPULATION AGINGTaiwan, 1950-2050
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0
5
10
15
20
25
30
Medical center Regional hosp District hosp
Nu
mb
er o
f b
eds
(1,0
00)
1994 2003
SUPPLY OF ACUTE HOSPITAL BEDSTaiwan 1994 vs 2003
23
0
100
200
300
400
500
1996 1998 2000 2002 2004 2006 2008
Bill
ion
NT
$
Revenues Costs
FINANCIAL STATUS OF TAIWAN’S NHIAccrual Basis, Since 1996
Deficits
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WHAT DIDN’T WORK
Meeting social expectations
Tackling health inequality Limitations of medical care Widening social gap in health Unequal treatment and mortality
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0
30
60
90
120
150
1950 1960 1970 1980 1990 2000
Ph
ysic
ian
s p
er 1
00,0
00
40
50
60
70
80
90
Lif
e ex
pec
tan
cy (
year
s)
Physican Male LE Female LE
PHYSICIAN SUPPLY AND HEALTH GAINSTaiwan, 1950-2000
26
0
20
40
60
80
1985 1989 1993 1997 2001 2005
0
20
40
60
80
Age 0 Age 40 Age 65 Age 85
LIFE EXPECTANCY AT VARIOUS AGESTaiwan, 1985-2005
March 1, 1995
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60 65 70 75 80 85 90
Taipei C.Taipei Co.
Taichung C.Taoyuan Co.
Hsinchu C/Co.Penghu Co.
Kaohsiung C.Tainan C.
Changhua Co.Taichung Co.
Keelung C.Ilan Co.
Chaiyi C/Co.Miaoli Co.
Tainan Co.Nantou Co.
Kaohsiung Co.Yunlin Co.
Pingtung Co.Hualien Co.Taitung Co.
FemaleMale
Years
LIFE EXPECTANCY BY CITY/COUNTYTaiwan, 2005-2007
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0
100
200
300
400
High (Poor) Moderate Low (Rich)Area Deprivation
Dea
ths
per
100
0 p
op
ula
tio
n
1987-1994 1995-2002
ALL CAUSES MORTALITYBefore and After NHI
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0
2
4
6
8
10
0-9 10-12 13+Father's Education (years)
Dea
ths
per
100
0 ch
ildre
n
1990 Birth Cohort 2000 Birth Cohort
UNDER FIVE CHILD MORTALITY1990 vs 2000 Birth Cohorts
30
0
10
20
30
40
0-6 7-9 10-12 13+
Educational Attainment (years)
Op
era
tio
n a
nd
1-y
r m
ort
ality
(1/1
000)
Operation 1-Yr Mortality
CABG OPERATION & 1-YR MORTALITYNHI Policy Holders, 1999-2000
•Age-adjusted by using 2000 WHO standard population
Source: Wu, Chen, and Chiang – unpublished.
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Conclusion
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1883 Germany-SI
1948 UK-NHS
1961 Japan-NHI1971 Canada-NHI
1989 Korea-NHI
1995 Taiwan-NHI
Social Control Welfare State
1948 WHO
1974 Lalonde Report
1978 Alma Ata Declaration
1986 Ottawa Charter
2005 WHO CSDH
Laissez-faire EfficiencyEquity in Access Cost Control
World Trends in Health Care Reform
1911 Germany-RVO2001 Thailand-Mix
201? USA-Mix
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LESSONS FROM TAIWAN
What worked Equal access to health care Prevention of poverty trap
What didn’t work Social expectations Social inequalities in health
Necessary but not sufficient
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Thank You
