Improving Taiwanese Health Care: Some Suggestions

As most Taiwanese and expats in Taiwan are aware, our fair country boasts one of the best healthcare and health insurance systems in the world. We have care that is comparable to that in a Western country - I've never felt as though the care I received in Taiwan was substandard or not as good as what I'd get back home. We also have a government-sponsored insurance program that, while expensive for the government, is not nearly as expensive as for the Canadian and British governments, who control care as well as payment - or for the USA, where we bear the cost of a broken insurance system and astronomically priced care later on, in the wasted money of inefficient and unproductive workers who can't perform better because they can't afford treatment for what ails them. It may cost Taiwan a lot of money to run its program, but it's still a step ahead of the USA where even greater costs are invisible (or at least we'd like to pretend they are).

It was wise for Taiwan to have a public insurance plan but allow for private care clinics that do accept insurance, alternative plans and non-insured clinics to exist. It takes the burden of paying to build the infrastructure off the government and allows basic supply and demand to determine the availability of care. As such it's less expensive and there are more care options without long waiting periods.

I'd like to see the USA adopt a system similar to Taiwan's, which does mean that everyone would be obligated to have insurance, just as everyone pays taxes to fund education and then has access to that educational system. Generally, we have a great system in Taiwan that deserves accolades, study and emulation globally.

There is definitely room for improvement, though. There are a few aspects of the system that I would like to see changed...now. Here are my thoughts:

- Women's health: cover more reproductive health options and preventive osteoporosis testing.

In terms of women's health in Taiwan, there is a striking dichotomy. On one hand, pelvic exams for women over 30 are covered at a rate of one per year. OB/GYN services are covered, birth in a hospital costs a bit more but does receive coverage, prenatal care (I believe) is covered, mammograms and other women's health issues are covered and there is excellent coverage for treatment of illnesses that affect women.

On the other, birth control is not covered. This is ridiculous, seeing as it's a $450-$600/month proposition, or more - that's more than you'd pay for a weeklong hospital stay if you have a shared room! Granted it's still only US$20 a month, but it should still be covered. I've heard two reasons as to why it's not: the first is that contraception is "elective" (excuse me?!) - you don't "need" birth control, apparently (yeah, you don't "need" it according to people who are deeply out of touch with modern society). The second is more sadly pragmatic: the government wants to increase the birth rate - something I personally don't think they should be encouraging, in fact, I think it's short-sighted and idiotic - so they are happy to push women to become mothers in any way they can.

This second reason is downright sexist: if a woman is sexually active, as most adult women are, she has to bear the full price of contraception. For me, NT$600 is not a lot of money but for a college student who doesn't feel she can talk to her parents about the issue? A new graduate in her first job earning NT $25,000/month? A working-class woman, whether foreign (such as a domestic care worker) or Taiwanese who may earn far less? A foreign bride who can't or doesn't want to communicate with her husband on the issue? NT$600 is a bigger burden for them, and yet the government doesn't seem to care. Considering the general attitude towards condoms in Taiwan, that's hardly a solution.

It also pushes women who can't afford the pills to risk pregnancy when they are not necessarily in a position to become mothers.

Abortions are only covered in certain circumstances (in the case of rape, incest, a health threat or "seduction" - whatever that means - I believe it does receive coverage, but if you claim "psychological duress" it's not, as far as my research showed). They should receive coverage regardless.

Osteoporosis preventive testing is only covered after a fracture, and you are only covered at a rate of 2 or 3 for life. It's not an expensive exam, and should be covered for women over a certain age.

Also, cover iron supplements (NT$800 per bottle, generally) for menstruating women and calcium supplements for women at risk of osteoporosis. This is an important component of good female health. Many women suffer from anemia during certain points of their cycle and this is a simple way to boost overall health and as a result, productivity (a woman who is not anemic is going to be more attentive, alert and efficient at work than a woman who can't think straight and feels dizzy, as I used to before I realized that it was caused by cyclic anemia).

- Have a payment plan offering so that those who need an emergency procedure but don't have the money can pay it off gradually.

Right now, if you need a procedure you're expected to pay for it more or less immediately. If you can't pay, in theory you can't get the procedure. For those who need immediate care and have no money, there are charities that can help pay or defray the cost. Generally if you have family they will also step in to help if you don't have the money. This is insufficient, however, and not always available to foreigners. A system in which, if you require expensive treatment (or inexpensive treatment but you happen to be below the poverty line), you can get it and pay it off in regular monthly installments would be a great improvement in terms of health care availability for the poor, working class and struggling.

- Pay for the most effective procedure or medication, not the cheapest

Also not necessarily the newest, most expensive or most advanced: do more objective research into the most effective procedures and cover those, even if they are not the cheapest option. This will save money down the road, as people who receive more effective care generally need less care later. This includes procedures or medications with the least side effects or recovery time.

Here's a real life example: when I first came to Taiwan, I ended up with a severe herniated disc in my lower back - so severe that it required surgery. There are two surgical options: a multi-hour ordeal with a full opening of the back and two-month recovery period, and microsurgery, which takes an hour, has a one-week recovery and is easier on everyone from doctor to patient to employer. NHI only covers the first option, which seems downright medieval when better technology exists. The second option is out-of-pocket and costs NT$80,000. Still cheap by American standards (that's what it would cost in the USA with many insurance plans) but still a few thousand US dollars.

I had the microsurgery. Rather than keep someone out of work for over a month and have the doctor do an operation that takes up half a day when he or she could be seeing other patients, I truly do not understand why they don't just cover microsurgery. In terms of economic productivity, someone who can be back to work in a week and a doctor who can see more patients is better in the long run, even if microsurgery is more immediately expensive.

The same is true for medication: for septic shock, the most effective medication costs NT$300,000 a dose (I believe it works in one to three doses) - NHI doesn't cover it unless the patient has suffered two organ failures. If they covered it before the organ failure(s) though still as a second-string option, sure it'd cost a lot up-front but in the long run, you'd have two less organ failure treatments to deal with - and those can get expensive.

Along these lines, cover procedures that greatly increase patient comfort, even if they cost more. Obviously some are more effective than others, but occasionally a slightly more expensive procedure can drastically improve patient comfort, especially for the elderly. A more comfortable citizen is a more productive citizen.

- Cover preventive care.

A popular new benefit offered by Taiwanese companies is an annual check-up. As a foreigner, I have to get a check-up on my own dime every year to renew my work permit. I don't mind this, as physical exams are good to have regardless, and by American standards it's not that expensive (NT$800-$1600 depending on the hospital). Preventive care for Taiwanese should be covered - one inexpensive check-up per year could save thousands, if not millions, of NT dollars per patient down the road. I'm happy that many people have this option through work, but many don't, and most don't want to pay out of pocket so they simply forgo preventive care. This really ought to be addressed.

- Cover better dental care.

Cleanings and fillings are covered, but root canals and crowns are not. Why? How is that "elective" in any way? If your tooth is abscessed or infected and you need a root canal and crown, how can you not get it? As someone with three crowns (I blame the water in China), I can say that you really can't eat or do much of anything without one, if you've undergone a root canal.

Why on earth is this not covered?

At least vision care receives pretty good coverage.

- Consider not covering certain elective Chinese medical practices.

I don't mean "stop covering Chinese medicine" because, while I do believe it's a good holistic method of preventive care and yet not good for acute treatment, it is a part of local culture and as such deserves respect and coverage for people more comfortable with that option. Chinese herbal medicine should definitely be covered (especially for preventive care). Things like suction, acupuncture etc. have not been proven to work, however, and don't deserve coverage while other important things, such as more effective procedures, women's reproductive health and preventive care are neglected.