Can Compulsory Health Insurance Be Justified? an Examination of Taiwan's National Health Insurance
Wu, Chuan-Feng, Journal of Law and Health
I. INTRODUCTION II. TAIWAN'S NATIONAL HEALTH INSURANCE (NHI) A. Background B. Debates on the Constitutionality of the Compulsory NHI III. THE SIGNIFICANCE OF THE FREEDOM TO PURCHASE OR DECLINE HEALTH INSURANCE IV. HUMAN RIGHTS IMPACT ASSESSMENT FOR THE COMPULSORY NHI V. STEP 1: EXAMINE HUMAN RIGHTS BURDENS OF THE COMPULSORY NHI A. Taiwanese Constitution B. Individual Autonomy C. Moral Powers D. Historical Development VI. STEP 2: CLARIFY THE POLICY PURPOSES OF THE COMPULSORY NHI VII. STEP 3: EVALUATE THE EFFECTIVENESS OF THE COMPULSORY NHI VIII. STEP 4: ASSESS TRADE-OFF RELATIONSHIPS IN COMPULSORY NHI (IMPORTANCE TEST) A. The Importance Test B. The Importance Test Revisited C. The Importance for the Individual Mandate without Insurance Package Option (Taiwan's Case) 1. The Compulsory NHI's Impacts on Moral Powers 2. Trade-off under the Compulsory NHI D. Importance Test for Individual Mandate with Insurance Package Options IX. CONCLUSION
In March 2010, U.S. Congress's enactment of a comprehensive health care reform bill, the Patient Protection and Affordable Care Act, (1) along with the Health Care & Education Affordability Reconciliation Bill of 2010 (2) (collectively referred to herein as the "Health Care Reform Act"), adopted the "individual mandate," a requirement that every American possess a certain level of health insurance (3) through which universal access to health care can be achieved. (4) The individual mandate no doubt is the most important yet most controversial linchpin of the U.S. Health Care Reform Act. The mandate drew scrutiny regarding its constitutionality because a direct and unconditional requirement for an individual to transfer money to one or more health insurance programs (5) for health or economic purposes seems to violate individual liberties (or individual autonomy), (6) especially the "disenrollment freedom" (the freedom to refuse to enroll in a health care program). (7) still today, there is much disagreement about whether the individual mandate could be considered justified as "regulating" individual liberties.
Therefore, a systematic examination of Taiwan's health care reform, which is a single-payer system based upon regulated competition but has a compulsory scheme that contains a mandate, might interest u.s. policymakers and scholars who either support or oppose universal coverage. First, similar to the new U.S. Health Care Reform Act, (8) Taiwan's National Health Insurance (NHI) also requires all citizens to subscribe to health insurance. (9) Basically, all residents are required to subscribe to the public mandatory health insurance (10) or are subject to a fine of no less than NT$3,000 (about US $94.25) and no more than NT$15,000 (about US $471.25). (11) Second, similarly to the u.s., Taiwan also faced intense debate about the constitutionality and morality of the individual mandate when the NHI was launched in 1995. (12)
No doubt, Taiwan's NHI system seems to satisfy most citizens' needs because the participation rate (otherwise known as the enrollment rate or coverage rate) is high, (13) and public satisfaction with the NHI has always been high since its inception in 1995. (14) In addition, the system also has one of the lowest administrative costs in the world (15) and still maintains a relatively high perception of quality (16) by using proper regulations and monitoring mechanisms. (17) However, Taiwan's Grand Justices Council (the Constitutional Court) expressed concerns about the constitutionality of compulsory national health insurance because the individual mandate would significantly deprive individuals from freely allocating their resources and from choosing their own insurance. (18) Therefore, even though the Court agreed that compulsory subscription of health insurance conforms to the constitutional purposes of "improving national health" (19) and "promoting national health insurance," (20) it nonetheless required authorities to "conduct at [the] appropriate time [a] full-range evaluation and implement improvement measures in aspects of the insurance operations [i. …