臺大公共衛生學院健康政策與管理研究所

The Taiwanese health care system is known globally for its public health insurance system. Established in 1995, the National Health Insurance (NHI) program has been studied and lauded for providing universal coverage to the Taiwanese population with strong access and high patient satisfaction. However, no system is perfect. Over time, the NHI has faced substantial challenges, including budgetary strain, practitioner dissatisfaction, and coverage decisions that have created barriers to certain novel pharmaceuticals and therapies.

Together, these challenges have prompted efforts to reform the health insurance system. Among potential options, private health insurance is a potential solution for supporting more personalized and comprehensive health care. In fact, almost 70% of the Taiwanese population now possesses some form of private health insurance to supplement coverage under the NHI program. Although some plans cover services that are excluded by the NHI, the majority of private insurance offerings focus on defraying patients’ out-of-pocket costs (known as “cost sharing”) for covered services.4 However, current commercial offerings in Taiwan are very heterogeneous. They are also often insufficient for reducing cost sharing for some expensive therapies, particularly in the area of cancer care.

For instance, among different private health insurance plans, there are varying levels of cost-sharing reductions for different types of medications, surgical operations, and therapies. Some plans offer lump sum coverages that can be used more flexibly for medical expenses, but other plans do not. Some plans target or enhance coverage for certain treatments, but others may not. Actual coverage amounts can differ by up to 20-fold. Unsurprisingly, this heterogeneity in cost-sharing reductions provided by private health insurance has led to widespread confusion among the public.

Amid ongoing and persistent trends (such as an aging population, rising health care costs, and budgetary limitations), expansion of private health insurance or private financing is inevitable for Taiwan. In turn, its policymakers must urgently address existing and emerging issues to harness both public and private insurance in a strategy for improving population health care and outcomes. Despite the potential benefits of private insurance, however, harnessing it for public good could be challenging. What strategies might Taiwanese leaders consider?

One is to learn from the US experience with the Medicare program. Although Medicare and the Taiwanese NHI differ in many respects, there are also instructive overarching commonalities. Both programs provide health insurance coverage for defined populations. Both programs provide health insurance coverage for defined populations. In the case of Medicare, the program covers nearly all individuals over the age of 65 or experiencing specific medical conditions. In the case of the NHI, the program covers nearly all residents in Taiwan. Given their scopes, both Medicare and the NHI face budgetary challenges, necessitating policies that create coverage gaps.

Private insurance options have emerged in both countries as solutions for such gaps. In the United States, every beneficiary insured through traditional Medicare has the option to purchase additional coverage through Medicare Supplement Health Insurance, and over 40% of individuals have done so. Termed “Medigap,” these plans reduce cost sharing by reducing the cost gap between what Medicare covers and what patients would otherwise pay out of pocket in the form of copayments or coinsurance. Critically, the United States regulates Medigap plans in ways offering 3 lessons that can inform Taiwanese policymakers in their efforts to harness private insurance to promote better outcomes and health.

First, Medicare requires standardization within supplemental plans. In particular, Medigap plans are standardized across states into specific categories (named via letter from A to N). In turn, this standardization simplifies choices for consumers, while the presence of multiple plan types promotes some optionality for consumers. Given the status quo of variation and heterogeneity in private health insurance plans in Taiwan, its leaders can consider standardization to help reduce confusion and ensure certain quality and reliability in plan offerings.

Second, Taiwanese leaders could enact policies that promote consumer education and decision support in private health insurance. Doing so would be consistent with several efforts in the Medicare program. First, Medicare provides resources that educate beneficiaries about Medigap (eg, “Medicare & You” handbook) coverage options. In addition, Medicare provides funds to states to offer programs that give free, personalized counseling and assistance to Medicare beneficiaries to help them select plans, including Medigap.

Such state health insurance assistance programs can also include community outreach activities to educate the public about Medicare. Importantly, these resources are offered without precluding private entities (eg, brokers) from working with Medicare beneficiaries. In turn, both public policymakers and commercial entities in Taiwan could work, separately or in tandem, to promote education and support residents in private health insurance plan support decisions.

Third, policymakers in Taiwan could work to design private plans in ways that create consumer protections. Such steps could be particularly important for patients with chronic or other specific conditions because supplemental coverage is often most relevant for individuals who possess particular health care needs. For instance, leaders might consider adapting a strategy used in Medigap policies by offering coverage on a guaranteed issue basis, at least during certain periods of time. This so-called “guaranteed issue” could be implemented regardless of individuals’ preexisting conditions to preserve opportunities to enroll in, and potentially benefit from, private insurance. Meanwhile, dictating specified periods of time could enable insurers to use individual experience rating to protect against adverse selection and, in the worst-case scenario, collapse of the supplemental insurance market.

Another example would be to design private insurance in Taiwan based on health factors at the population level, such as average morbidity of individuals from a specific age group or residential area. In the United States, some Medigap plans base insurance premiums on community-level health factors, rather than on individual patient–level factors. An analogous type of “population rating” protects individual patients from discrimination based on sickness level and promotes fairer premium pricing.

To be fair, no single solution is a panacea. Although standardization and disclosure requirements are poised to address private insurance-related issues that have emerged in Taiwan, audit and oversight are needed to ensure that standardization and disclosures occur as intended over a period of time. Education and decision support can help individuals select private health insurance plans, but policymakers should also watch for predatory or unfair behaviors (eg, individuals who are given incomplete or misleading information from counselors or brokers). Plan design strategies, such as guaranteed issue and population rating, do not completely prevent adverse risk selection and other challenges in insurance policies. Taiwanese policymakers must monitor the market closely and consider adjustments going forward.

Although Medigap represents an instructive analog for the Taiwanese system, the Medicare program more broadly is also challenged by issues of complexity and costliness. Finally, the current iteration of private health insurance in Taiwan need not be a sole or final one. Private coverage could be offered through a separate, standalone private health insurance system or more direct integration of private pay options within the public NHI system. Evolution in one vs another direction could make the comparison to US Medigap policies more or less relevant.

Regardless, Taiwan could draw insights from Medigap to design and leverage private health insurance to reduce cost sharing for the benefit of its population. Within a broader raft of complementary strategies, these solutions are timely as the health insurance program celebrates successes and assesses challenges amid its 30th anniversary.

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