NHI and the Taiwanese Population

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promote domestic fertility. Did none of the policies, from parental leave, to maternal capital, to child cash benefits, have any effect on domestic childbearing decision-making? Because of the bundling of cash and noncash benefits, it is difficult to compare the effectiveness of the

individual policies from historical analysis alone.

Analysis of the fertility effects of healthcare policy implementation or reform, on the other hand, often benefits from the availability of information about timing and benefits of individual policy changes. In addition, policy initiatives like Medicaid eligibility reform or Taiwanese NHI implementation affect a large portion of the population in a relatively short period – this lends itself more readily to empirical assessment.

3.2 NHI Implementation and Taiwan

3.2.1 NHI and the Taiwanese Population. Of studies addressing the effect of NHI

implementation on population in Taiwan, only two have focused on increased prenatal

healthcare, one of the program’s key offerings in 1995. An initial study by L. Chen et al. (2008) focused on the different ways women perceive prenatal care access pre- and post-NHI along the urban/rural divide, given that NHI implementation dramatically increased the number of

facilities where women could seek prenatal care nationwide. Using national survey data from two cohorts before (1990-1992) and after (1998-1999) NHI implementation, L. Chen et al.

(2008) examined where Taiwanese women sought prenatal care and the perceived convenience of that care for urban and rural residents. The study found that post-NHI provision rural women increased their demand for prenatal care in big hospitals, while urban women had no change in usage; there was no perceived change in convenience of transportation to care facilities by rural women, however, urban women did report increased convenience. Differences in transportation

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convenience are ascribed to the tendency of rural women to seek prenatal care in large hospitals rather than local clinics, due to their higher perceived value.

C.-S. Chen, Liu, and Chen (2003) further analyzed changes to Taiwanese prenatal care usage before and after the 1995 NHI implementation, finding increased usage of healthcare services primarily among unemployed women and various aboriginal communities of central Taiwan. Data from the Taiwan Maternal and Infant Health Survey included two cohorts of Taiwanese women from all 23 administrative districts, the first who gave birth during May 1989 and the second who gave birth during February 1996. Using a two-part negative binomial model to estimate the effect of NHI on prenatal care patterns in Taiwan, C.-S. Chen et al. (2003) found that maternity clinics experienced the highest volume of visits post-NHI, previously uninsured working women and government employees increased their care use compared to female labor workers and farmers, and care use increased most dramatically in central Taiwan. The authors imply that some of the consumption patterns seen in the study might have been due to societal trends, such as women delaying marriage, and as a result, more frequently turning to high technology solutions to help them conceive for multiple births at higher ages. This supports the hypothesis that increased access to prenatal care from NHI implementation would influence women’s fertility choices, as argued in the present study.

L. Chen et al. (2008) and C.-S. Chen et al. (2003) both indicated a significant uptake in care usage by rural women after NHI implementation, especially of in central Taiwan (a more rural area), despite different data sources and methods. At the same time, L. Chen et al. (2008) notes that the probability of rural women seeking prenatal care in large hospital increased 6.54 times between 1990 and 1999, which seems to contradict C.-S. Chen et al. (2003)’s finding that medical clinics saw a greater increase in demand for prenatal services in the post-NHI period.

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Both of these studies analyze usage of prenatal care services and various demographic

characteristics – location of residence, insurance, industry of employment. These discrepancies possibly stem from unobserved differences in the birth cohorts selected by the two studies, or from recall bias issues. While NHI introduction overall increased demand for Taiwanese prenatal care overall and especially among rural women, it is unclear where exactly that demand was concentrated (in clinics or hospitals) and what reasons underlie women’s treatment preferences.

Chou, Grossman, and Liu (2014) went beyond examining the effect of NHI on prenatal care usage by analyzing the impact of NHI on Taiwanese post-neonatal infant mortality. Using 1990 census data instead of randomized surveys, the study incorporates insurance data from the public and private sectors from before and after NHI implementation to determine whether NHI provision lowered infant mortality. Before NHI implementation, only government employees had full insurance coverage for childbirth and infant healthcare, but after 1995, coverage was extended to private sector and agricultural workers via NHI. Results show that NHI introduction decreased neonatal mortality by 8-16% for those born in farm households, but not in other sectors. Farm families in general have fewer financial, educational, and health advantages than those in other sectors; the findings of this study thus “suggest that health insurance improves infant health outcomes of population subgroups characterized by lower levels of education, income, and health” (p. 90). A final finding notes the marked reduction in the mortality rate of preterm infants in the post-NHI data, a difference of between 20-41% (p. 89). Overall, Chou et al. (2014) conclude that Taiwanese national health insurance improved neo-natal infant mortality rates in Taiwan, but not equally among different industries and population subgroups.

Besides its direct effects on infant mortality and healthcare usage, Chou, Liu, and

Hammitt (2003) also studied the indirect effect of NHI implementation on precautionary savings

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in Taiwan, using difference in differences methodology. They posited NHI as an ideal natural experiment to test the effect of insurance on savings, given the universality of its implementation and its lack of means-tested eligibility. Rather than redirecting healthcare savings into household savings, national health insurance decreased savings by 8.6-13.7%, with this reductive effect particularly strong for households with the highest financial risk—those in the lowest savings bracket. This study also uses a control group based on joint employment of husband and wife, where households with at least one government employee constituted the control group, like the present study does.

The effects of NHI on precautionary saving may be tied back to fertility through the concept of “yang er fang lao” (養兒防老), or raising children to provide for family members in old age, as discussed by Lai and Tung (2015). In Taiwan, familial transfers have long been a primary source of income security for the elderly, along with personal savings and public (state-sponsored) programs. Lai and Tung (2015) found that even as consumption level of the elderly increased between 1985 and 2005, and health consumption costs increased from 9% to 17%

during this period, the role of family transfers decreased significantly. If NHI constitutes a public program that reduced income uncertainty enough to affect precautionary savings, it may also have affected childbearing decisions that formerly played an important part in long-term financial planning.