This section was mostly about the problems of the system and the ideals for the system. This was where the most meaningful differences came up between the three groups.
Taiwan Question 12: Describe the most important problem with the Taiwan healthcare system? elicited an interesting variety of responses. This research ended up coding these responses as one or several of fifteen different codes. These codes identified common themes.
The most frequently cited problem was “waste,” or as the Chinese speakers said,
“藥物濫費,” meaning “medication that gets prescribed but not used.” This was a near universal complaint among subjects from Group A with six out of the seven respondents in Group A listing it as a problem. For example, A4.2 had this to say, “When they see the doctor, whether or not they need it, they get provided with medicine. We call this ’藥物濫 用.’” This was a common complaint among Group A, but it was only cited by three of the ten people in Group B. When it was cited, it was described in the same fashion. B8 expressed it like this,
“People abuse the system. It’s not good. Wasting a lot of money. A lot of patients take their medicine home and they don’t take it. It’s a lot like… When I get sick, I get a cold, I don’t go to the doctor. My friends do. They go to the doctor, they come back with a bag of pills. I say Dude, you just have a cold. Man, why do you have to take 20 pills a day?”
B8's response shows how this idea was coupled with the idea that people go to the doctor when they don't need to. That sentiment was echoed by five subjects who all deplored Taiwanese people going to the doctor unnecessarily. This idea was also linked to the idea of the system being too convenient both in terms of being too easy to go to the doctor in Taiwan and not being expensive enough to discourage frequent use. C2
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described this idea as being the “expert perspective.”
“Just like going to 7-11, it's too convenient, so there must be some waste inside.
We call this expert perspective, we have a lot of waste, seeing doctors for very many minor illnesses, but the patients, they feel great, they feel relieved, They say
’Oh my god, I have nothing to worry about.’ Just like that, it's totally different from the system even in the UK and it's totally different from the US.”
It certainly was, because three of the five members of Group C brought up the convenience of the Taiwan system as a problem but only two members of Groups A and two members of Group B did likewise.
While this was the expert perspective according to C2, the biggest difference between experts and laypeople was that all five health policy experts talked about the political obstacles to reform. C2 who worked in the health ministry described it this way:
“It's hard. All of the changes have to go through the political procedure. If we want to increase the copayments, it's tough for a political reason. The major thing is, because we have elections almost every two years and that's totally political.
This kind of issue cannot be accepted by those political players. So that's the most important thing. For scholars, for researchers, we can write up reasonable
recommendations... ’Ah this is good, but don't tell me we have to raise the premium or copayment rate... just forget about it.’ That's the situation in Taiwan, we are struggling. We have to do something else to maintain the financial
balance.”
C3 echoed that sentiment, pointing out that the best the NHI can hope to do is maintain current funding levels.
“The pressures always there, the government say, ’every year the increase is so much, the government income cannot follow that, so you guys have to take care of yourself.’ The government, the company makes those kind of money from society, most of those guys come from executive, 'Oh you guys, should pay more and more.' Now, every year is different, but the direction it's shifting is a trend. It's about the same. One line is going up, one line is keep going down, which is the government. Simply, they cannot allow them, afford to have them go down.
Politically, it's not possible to make them pay more, so the best way is to keep
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things the same.”
Only one of the laypeople, B2 from Group B pointed out the same concern when asked how to fix the problem of the Health system in Taiwan being too convenient. He suggested raising the fee but immediately dismissed it as being “too political” to happen.
Another problem was unique to Groups B and C which was the way the doctors behaved with patients. Subject B7 explained what he meant by describing how his chronic condition was treated.
“Umm, I think Taiwan, I went to lot of different hospitals, and it just seems to me they take a quick look at it. One major problem, they have seen it all, and they look at it and they are already sure, without any tests. They never ask for recheck.
The lack of, can I say, professionalism?”
Two subjects from Group B mentioned problems with doctors while two health experts also expressed similar sentiments.
When asked US Question 10: What the best aspect of the American healthcare system?, four members of Group B listed the thoroughness and professional demeanor of the US doctors. B2 explained the contrast between US doctors and Taiwan doctors thusly:
“I mean, like I said, I think, um, doctors there are very thorough they ask questions very carefully, very thoroughly and, um, they put a lot of detail into analysis and that's a good thing. Whereas I wouldn't say they're not as
professional in Taiwan, but most of the time I go to the doctor in Taiwan, I don't think they would ask that much questions and they tend to get annoyed if the patient asks too many questions. It seems as if the patient is undermining the doctor to ask.”
C3 also expressed a similar sentiment, but he placed the blame on systemic reasons:
“Let me give you an example, if you go to the hospital, we say that the waiting time is long, that there are so many things that we consider 'long.' That we see the patient and there's a hundred people or fifty people over there, but you have one 'short'.... which is that you can only spend a few minutes with the doctors. You have some lists of long lists, but when you come to the mean of seeing the doctor, the doctor is in such a hurry. I don't whether you've seen any doctor here or not,
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but they really can have you before the seat is even warm, you're out! Next patient.”
When it came to diagnosing the most important problems with the Taiwan system, those who had lived in the United States had views that were slightly closer to those of policy experts. People in Group B were slightly more likely to list convenience as a problem and they were slightly less likely to list waste. They also complained about doctors’ demeanors and had the only layperson to talk about the political constraints.
When it came to fixing problems, most people wanted an administrative change usually in regard to waste. When asked Taiwan Question 12.1: How do you think it could be fixed?, A1 wanted the government to limit the amount of times someone could go to the doctor to two times per month. Five out of the seven people in Group A saw some change in the structure of the NHI as being important. One subject, A7, said that there should be an organization within the NHI dedicated to eliminating waste.
Group B didn't all answer this question. One person responded that it would take a paper to answer it, two people left it blank, and one more said she didn't know. That said, Group B was more likely to suggest raising the premium as was Group C. The two groups differed, though, on the rationale for raising it. Two people in Group C emphasized the need to raise the premium in order to keep revenues in line with expenditures while the people in Group B who suggested raising the premium talked about it as a way to reduce frivolous use by raising the cost of care.
The Policy experts all talked about the need to raise the premium legislatively but three of them also talked about the importance of policy marketing and raising the public consciousness. C4 had made a laundry list of difficulties when asked what the biggest problem was, saying,
“Waste. Going to three hospitals for the same illness... Doctors prescribing medication that people don't take. Cost... Financial problems for the entire insurance system. The system is not well. This is a political problem. Because the legislature doesn't want to pass it.”
Her solution, though, was towards changing the perception and point of view of the people, citing the need for education and policy promotion. .
Ideals Question 1: What do you think is the primary purpose for a national
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healthcare system? elicited several responses that shared similar ideals about the goals of the National Health Insurance system, These ideas were coded as Equity, Universality, Financial and Public Responsibility.
The two most cited purposes for a national health system were protecting poor people from financial ruin; four of the five health experts said something that emphasized the need to protect poor people from spending all their money on healthcare. C1 said, “It is to protect people from falling into poverty because of being ill.” This idea appeared in the responses of four out of seven people in Group A and three out of ten people in Group B.
The second most cited ideal was the right to have healthcare or Universality. B8 explained it like this:
“I think it’s … everybody won’t get sick. I think the government is doing the right thing to pay for it, the majority of the health, because they need to make the health, going to the hospital affordable. Nobody wants to get sick but people do get sick once in a while eventually, so this type is something that is a must to have, healthcare that people can afford.”
This was an ideal that appeared much more often among people in Group B. Eight out of ten people in Group B cited some variation on this with two from Group A and one from Group C. The important thing with these answers was the emphasis on the right to access healthcare. The quality of the care was sometimes mentioned but the most
important emphasis was on getting the treatment. A4.1 wrote, “The ideal... taking care of each citizen’s medical care.”
A few people mentioned how important it was that everyone receives the same treatment. Those were categorized under Equality. It was a similar idea to Universality but the emphasis was on everyone being the same. A7 is a good example, “No matter who you are, no matter your income or position in society, you should be able to get suitable treatment.”
The most dramatic difference between Groups A and B came about when asked Taiwan Question 13: What is the best aspect of the Taiwan healthcare system? I had postulated that living in the United States would make Taiwanese people appreciate their own system more. This was the question where this sentiment really became apparent.
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The answers that people gave to this question mirrored the answers to Ideals. There was Universality, Convenience, Efficiency, Quality, Coverage, and Cost.
By far, the most commonly cited aspect was Convenience. Three out of seven people in Group A, five out of ten people in Group B and three out of five people in Group C all pointed out Convenience. Sometimes, Convenience was the only aspect in their answer, like A1, who said,
"The best aspect… the best aspect… this you can expect to go to the hospital and it’s very convenient. If you have any problem, you can go to the clinic and it’s convenient. If you want to call ahead, that’s easy so you can instantly go get treatment.”
C2 was conflicted about convenience, saying,
"I would say accessibility, a very, very high degree of accessibility and free choice.
I would say that's what our people enjoy the most. I can go to see doctor A in the morning and doctor B in the evening, because I am not satisfied. No one, you can imagine, in the whole world, has this kind of system. It's crazy, but anyway, that's the situation that Taiwanese people enjoy a lot.
Matthew: I'm speaking as an American, saying "It's so good."
C2: Come on... It's wasteful.
As mentioned earlier, convenience was seen as a problem by some health experts because of the waste. Still, most people said the convenience was the best part.
Another aspect that was common for both Groups A and B was the idea of
Universality. Three people from Group A and two people from Group B made a mention of how the Taiwan system covers everyone. According to A2, the best aspect of the NHI was that it covered everyone who lived in Taiwan. For others, they supported the
sentiment and also added in an element of public responsibility. B1 cited the convenience but also stated that it put the burden of paying for healthcare on the entire population and that this was a good thing.
Just like for Ideals, two people cited the idea of protection of poor people from financial ruin. It wasn’t cost per se, but about allowing poor people to get healthcare. A5 cited convenience at first but then went on to elaborate, “If you’re talking about normal
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care, then you want convenience, but if you have any of these very serious diseases, then the amount to pay is huge so the NHI become welfare.”
One person from each group cited the quality of the care. B3, in a written response said, “Cheap, fast, well cared for.” C3 cited the convenience, cost and the
“above average” quality. B2 made an explicit comparison with the United States and said he thought Taiwan’s coverage of a wide variety of procedures was the best aspect.
This was also the question with the most clear difference between Group B and A.
Of the ten members of Group B, five people pointed out the cost of NHI as being the best aspect or among the best aspects while no one in Group A did. This is a huge result. The spur for this research was wondering if living in the United States would make Taiwanese people realize how cheap their own care was. This question showed that, for many people, it definitely triggered this realization. B3, B7, B8, B9, and B10 all pointed out that it was cheap. B7 explained how living in the United States had given him expectations that caused him to view the Taiwan system differently. He wrote,
“The costs definitely. It was 1800 NTD when I was hospitalized for ten days and I thought it was going to be very costly. Even without NHI, I told you how I went into the hospital for four days when I first got here, it was 6,000 NTD. In the US, my Gout situation was like 150$ for a single visit. After I got the insurance card, it went down only 600 NTD.”
B8 also made an explicit comparison with the United States when he said,
“I think the health system is way, way better than the States. It’s convenient, it’s cheap. There’s lots of hospitals. Going to the hospital it’s like… In the States, it’s so big, to drive to the hospital ,it’s like half an hour. Here, there’s one hospital like three minutes from here. In this area. I can count four or five in a two mile radius. It’s crazy. There’s one right across the street, there’s like four, five, there’s one by the roundabout that is famous for bones and babies. It’s very popular.
Half of Group B pointed the cost as being the best aspect and two of those people pointed out how they were making explicit comparisons based on their direct experience in the United States.
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Group B also said more positives about the system than Group A. Group A had seven people and touched on nine positive aspects while Group B had ten people and listed fifteen positive aspects. Group B also listed positives like the breadth of covered services and the efficiency, which no subject in Group A touched on.
7 Analysis
This study asked four research questions and it made four hypotheses.