Chi Pang Wen, MD, DrPH; Shan Pou Tsai, PhD; Wen-Shen Isabella Chung, MSc
Disclaimer: The views expressed in this article are those of the authors and do not represent those of the National Health Research Institutes.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Chi Pang Wen, MD, DrPH, Center for Health Policy Research and Development, National Health Research Institutes, No. 35, Keyan Road, Zhunan Town, Miaoli County 350, Taiwan; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Wen and Ms. Chung: Center for Health Policy Research and Development, National Health Research Institutes No. 35, Keyan Road, Zhunan Town, Miaoli County 350, Taiwan.
Dr. Tsai: University of Texas School of Public Health, 1200 Herman Pressler, Houston, TX 77030.
Author Contributions: Conception and design: C.P. Wen, S.P. Tsai.
Analysis and interpretation of the data: C.P. Wen, S.P. Tsai, W.S.I. Chung.
Drafting of the article: C.P. Wen, S.P. Tsai, W.S.I. Chung.
Critical revision of the article for important intellectual content: S.P. Tsai.
Final approval of the article: C.P. Wen, S.P. Tsai.
Provision of study materials or patients: W.S.I. Chung.
Statistical expertise: S.P. Tsai, W.S.I. Chung.
Administrative, technical, or logistic support: W.S.I. Chung.
Collection and assembly of data: W.S.I. Chung.
Universal national health insurance, financed jointly by payroll taxes, subsidies, and individual premiums, commenced in Taiwan in 1995. Coverage expanded from 57% of the population (before the introduction of national health insurance) to 98%.
To assess the role of national health insurance in improving life expectancy and reducing health disparities in Taiwan.
A before-and-after comparison of the decade before the introduction of national health insurance (1982–1984 to 1992–1994) with the decade after (1992–1994 to 2002–2004).
All townships (n = 358) in Taiwan were ranked according to overall mortality rates before the introduction of national health insurance and then ranked into 10 health class groups in descending order of health (groups 1 [healthiest] to 10 [least healthy]).
Health improvement (change in life expectancy after the introduction of national health insurance) and health disparity (reduction in the difference in life expectancy between the highest- and lowest-ranked health class groups).
After the introduction of national health insurance, life expectancy increased more in health class groups that had higher mortality rates before the introduction of national health insurance and health disparity narrowed, reversing an earlier trend toward widening disparity. The major contributors to the reduction in disparity were relatively larger reductions in death from cardiovascular diseases, ill-defined conditions, infectious diseases, and accidents in the lower-ranked health class groups. However, death from cancer increased more in the lower-ranked health class groups. Utilization of medical services increased, whereas cost remained at 5% to 6% of the gross domestic product. The per capita average annual number of visits to the physician's office was 14.
The interpretation of comparisons before and after the introduction of national health insurance assumes that the changes were entirely due to the effect of national health insurance rather than secular trends.
Life expectancy after the introduction of national health insurance improved more for lower-ranked health classes, resulting in narrowed health disparity. The magnitude of the reduced disparity was small compared with the size of the remaining gaps. Relying on universal insurance alone to eliminate health disparity does not seem realistic. To further reduce health disparity, universal insurance programs should incorporate primary prevention, focusing on lifestyle risk reductions.
The effects of implementing universal national health insurance are largely unknown.
Taiwan imiplemented national health insurance in 1995. In the decade before national insurance, differences in life expectancy between the healthiest and least healthy regions were increasing. Afterward, they decreased, but the gaps in life expectancy between the healthiest and least healthy regions remained large. Utilization and expenditures on health care increased, whereas the percentage of gross domestic product spent on health care remained at 5% to 6%.
The authors could not prove that universal national health insurance alone reduced health disparities.
Universal national health insurance may reduce health disparities, but only by a small amount.
Appendix Table 1. Population, Number of Townships, and Range of Standardized Mortality Ratios for the 10 Health Class Groups
Table 1. Difference between Life Expectancy at Birth before and after the Introduction of National Health Insurance and Change in Disparity*
Secular trends of life expectancy at birth for the 10 health class groups (HCGs), 1982–1984 to 2002–2004.
Gain in life expectancy during the period before (1982–1984 to 1992–1994) and after (1992–1994 to 2002–2004) the introduction of national health insurance (NHI).
*Increase in life expectancy during the period before NHI (from 1982–1984 to 1992–1994). †Increase in life expectancy during the period after NHI (from 1992–1994 to 2002–2004).
Difference between changes in life expectancy at birth before and after the introduction of national health insurance (NHI).
Pre-NHI was 1982–1984 to 1992–1994, and post-NHI was 1992–1994 to 2002–2004. Error bars represent 95% CIs.
Gaps in life expectancy for health class groups 2 to 10 versus health class group 1.
Table 2. Difference between Life Expectancy at Birth and at Age 45 Years before and after the Introduction of National Health Insurance and Change in Disparity for 3 Broad Health Classes (High, Medium, and Low)*
Cause-specific contribution to gain in life expectancy during the period before and after the introduction of national health insurance (NHI).
HCG = health class group. Results are based on a modified cause–deletion life-table method, which assumes independence for each cause of death. Not all possible causes of death are included. Bars extending below the horizontal axis indicate that deaths from those causes contributed to reduced life expectancy, whereas bars extending above the horizontal axis contributed to improved life expectancy.
Appendix Table 2. Decomposition of Gap during the Period before the Introduction of National Health Insurance, 1982–1984 to 1992–1994
Appendix Table 3. Decomposition of Gap during the Period after the Introduction of National Health Insurance (NHI), 1992–1994 to 2002–2004
Table 3. Comparison of Selected Statistics between Health Class Groups 1 and 10 in 2004
Appendix Table 4. Outpatient and Inpatient Medical Care Utilization and Expenditure under National Health Insurance in Taiwan, 1995 to 2004
Appendix Table 5. Number and Expenditure of Physician Visits per Person in 2004, by Age
Table 4. National Health Care Expenditures in Taiwan
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Wen CP, Tsai SP, Chung WI. A 10-Year Experience with Universal Health Insurance in Taiwan: Measuring Changes in Health and Health Disparity. Ann Intern Med. 2008;148:258–267. doi: 10.7326/0003-4819-148-4-200802190-00004
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Published: Ann Intern Med. 2008;148(4):258-267.
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