Cost of Care
Different Cultures, Different Systems: Comparing Health Care in the U.S. and Taiwan
A daylong symposium in Research Triangle Park gave participants perspective on how the health care systems in the U.S. and Taiwan are different – and, in some ways, similar.
By Rose Hoban
Imagine you go to the doctor – a physician you haven’t seen before – and you pull out a card with a memory chip in it. The doctor runs it through a machine and instantly has access to your medical history, what drugs you take and what happened during your last hospitalization.
That’s not science fiction – it’s the reality for the 22 million residents of Taiwan.
“You just swipe your card, and that’s it,” said Maggy Coufal, who holds dual Taiwanese and U.S. citizenship and works at UNC in the School of Public Health.
Coufal was one of about 100 people who attended a lunchtime presentation Monday at RTI International in Research Triangle Park that discussed comparisons between the Taiwanese and U.S. health care systems.
The event was part of a weeklong visit by a Taiwanese health delegation sponsored by Duke University’s Center for International Studies. The delegation includes the director general of medical affairs for the Taiwanese Ministry of Health, Wui Chiang Lee.
“Every citizen in Taiwan has a smart card,” Lee told the gathering. In the next few years, he said, all of that information will be uploaded to a central hub. “So all of the health data will be in the cloud.”
While many people in the U.S. think of Taiwan as the place where cheap electronics are made, the island located a little more than 100 miles from mainland China is light years ahead of its larger neighbor in terms of technology and infrastructure.
And since 1995, Taiwanese have had universal health care.
In 1947, Lee said, the Republic of China established in its constitution a system of insurance to promote social welfare.
Until 1995, the government added groups of people piecemeal to the system – from public employees to fishermen and farmers – but about 40 percent of Taiwanese remained uninsured.
The government then switched to a single-payer system, with universal insurance, paid for by taxes and premiums determined by income.
“Since I’m a health officer, I pay 30 percent of my insurance premium and my employer pays the other 70 percent,” Lee said.
Many of the poor, he said, are 100 percent, or nearly so, subsidized by the government. The subsidy depends on income and profession.
Lee explained that co-pays are also subsidized for the poor and very sick or disabled people, and the Taiwanese system covers all prescription drugs up to a monthly cap of about $70 U.S.
The Taiwanese system uses barcodes on patient wristbands and records to keep from making mistakes, and all of the hospitals have electronic medical records linked into the main system, a concept health care planners in the U.S. say they want and which is being pushed by the federal Affordable Care Act.
“All hospitals need to report, upload their quality data to the central warehouse,” Lee said. “The expert from the accreditation commission will review the data every three months and give real-time feedback and comment for hospitals and quality improvement.”
According to the World Health Organization, overall life expectancy in the U.S. is 77.9 years; in Taiwan, it’s 78.2.
Lee said Taiwan has some of the same problems as the U.S., including “overutilization” of health care services.
“The delivery system is so convenient to everyone,” he said. “You just walk down the street, there’s a primary care clinic, and a couple of miles away there’s a hospital, and there’s no limitation for any accessibility.”
Co-payments, he said, are so low that they seldom offer a financial barrier to services. And patients can visit a specialist without a referral.
In the U. S., many preferred provider plans, or PPOs, function in the same way, and high utilization of care concerns many planners. That’s part of the reason North Carolina lawmakers set a limit on Medicaid patients of 20 visits a year before having to get prior authorization to see a doctor.
But Lee explained that easy access is a factor in the high satisfaction rate Taiwanese people have for their health care system.
“No party – neither the ruling party nor the opposition party – wants to limit the accessibility,” he said.
Lawmakers did, however, recently enact some limits on care: When patients reach 30 visits in a year, they get a call from a health insurance department care manager asking what the problem is and if better care can be coordinated.
Despite the high utilization, Taiwan spends only about 6.6 percent of its gross domestic product on health care, as compared to the U. S., which spends more than 17 percent.
That easy access to care is what Maggy Coufal likes about the Taiwanese health care system. She also worries that the U.S. system could cause her to go bankrupt. Even though she’s lived in the U. S. for nine years, and has a job with insurance, she pays about $25 a month to maintain her Taiwanese insurance.
“I’m afraid of the U.S. health care system,” Coufal said. “If I need it, I can go home and have things taken care of that way.”
“Insurance companies can turn away anyone with a pre-existing condition,” said Patrick O’Carroll, an assistant surgeon general for the U.S. Public Health Service and another of the panelists at the event. “Even if they have the money and are ready to pay, [the insurer] would say, ‘No, we’re not taking you.’
“This makes sense if you’re a private insurance company, because your job is to maximize the return for shareholders of the company, and taking on sick people knowingly is a very foolish way to maximize your profits.”
And O’Carroll pointed out that while the U.S. has quality health care, it doesn’t necessarily result in better outcomes or longer lives.
In contrast, said both Lee and Coufal, is the cultural value of sharing risk between rich and poor that exists in Taiwan.
“The healthy take care of the sick and the rich will take care of the poor, so everyone should be involved in the coverage,” Lee told the gathering. “If you are clear on this basic question, then you move on to how to design the system.
“I think Americans need to ask yourself, are you willing to share risk, the risk of the others,” he said, adding that he understood that Americans value their individualism.
“That’s maybe the basic difference between our different countries,” Lee said.