1 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. Chiang College of Public Health, National Taiwan University

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3 HEALTH TRANSITION IN TAIWAN Communicable Disease ControlHealth for AllHealthcare for All Crude Death Rate Crude Birth Rate Life Expectancy Traditional Public HealthNew Public Health

4 TAIWAN Socioeconomic background u population23 million u density637 persons per square km u GNPUS$17,576 per capita u education35% received higher education u aging10.4% population aged 65+ Population health u life expectancyM/F: 76/82 yrs u major killerscancer, heart disease, stroke, diabetes, accident

5 CONTENTS Taiwan’s NHI: An overview u Objectives u Main features What worked u Access to health care u Catastrophic health spending What did not u Inefficient use of health care resources u Widening health inequalities

6 Taiwan’s NHI

7 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

8 Equity in access to health care To provide equal access to adequate health care for all citizens in order to improve people’s health Macro-economic efficiency To control health care costs at a reasonable (or socially affordable) level Micro-economic efficiency To promote the efficient use of health care resources - better health outcomes and cost effectiveness OBJECTIVES OF TAIWAN’S NHI

9 MAJOR NHI FEATURES Universal coverage Comprehensive benefits u Western medicine, Chinese medicine u ambulatory care, EMS, inpatient care, home care u coinsurance rate of 10-20% plus … Public single-payer National global budget u Health spending as % of GDP - 6.4% in 2008

10 PUBLIC STATISFACTION W/ NHI Taiwan, Since 1995

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12 What worked

13 WHAT WORKED Equal access to health care u Ambulatory care u Inpatient care Prevention of poverty trap

14 ANY USE of PHYSICIAN SERVICES Before and After the NHI 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.

15 ANY USE of HOSPITAL SERVICES Before and After the NHI 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.

16 WHAT WORKED Equal access to health care Prevention of poverty trap u Catastrophic health spending

17 CATASTROPHIC HEALTH SPENDING* W/out and With NHI, 2004 * Out-of-pocket health spending exceeds 40% of household non-food consumption

18 CATASTROPHIC HEALTH SPENDING Asia Comparison, circa 2000 Source: Van Doorslaer E and EQUITAP team. Catastrophic payment for health care in Asia. Health Economics, 2007;16:

19 What didn’t work

20 WHAT DIDN’T WORK Meeting social expectations u Aging society and big tickets u Sustainable financing Tackling health inequalities

21 POPULATION AGING Taiwan,

22 SUPPLY OF ACUTE HOSPITAL BEDS Taiwan 1994 vs 2003

23 FINANCIAL STATUS OF TAIWAN’S NHI Accrual Basis, Since 1996 Deficits

24 WHAT DIDN’T WORK Meeting social expectations Tackling health inequality u Limitations of medical care u Widening social gap in health u Unequal treatment and mortality

25 PHYSICIAN SUPPLY AND HEALTH GAINS Taiwan,

26 LIFE EXPECTANCY AT VARIOUS AGES Taiwan, March 1, 1995

27 Years LIFE EXPECTANCY BY CITY/COUNTY Taiwan,

28 ALL CAUSES MORTALITY Before and After NHI

29 UNDER FIVE CHILD MORTALITY 1990 vs 2000 Birth Cohorts

30 CABG OPERATION & 1-YR MORTALITY NHI Policy Holders, Age-adjusted by using 2000 WHO standard population Source: Wu, Chen, and Chiang – unpublished.

31 Conclusion

Germany-SI 1948 UK-NHS 1961 Japan-NHI 1971 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-faireEfficiencyEquity in AccessCost Control World Trends in Health Care Reform 1911 Germany-RVO 2001 Thailand-Mix 201? USA-Mix

33 LESSONS FROM TAIWAN What worked u Equal access to health care u Prevention of poverty trap What didn’t work u Social expectations u Social inequalities in health Necessary but not sufficient

34 Thank You