Upholding the Right to Health: A Democratic Path in Taiwan

Taiwan’s commitment to universal health coverage exemplifies the nation’s dedication to ensuring equitable access to healthcare for all its residents. With a population of over 23 million, Taiwan introduced its pioneering National Health Insurance (NHI) system in 1995, which has since maintained an impressive 99.9% coverage rate. This system seamlessly blends accessibility, affordability, and comprehensive care, serving Taiwanese citizens, residents, and eligible foreigners alike. Its structure is designed to balance affordability—where premiums are approximately 5.17% of monthly income—and extensive service coverage, including inpatient and outpatient care, pharmaceuticals, dental services, traditional Chinese medicine, mental health day care, and home-based medical services. To promote health equity, low-income households are exempt from paying premiums, and contributions are scaled according to income and occupation, with premiums ranging from 30% to 100% of service costs. Overall, health premiums account for nearly 89% of the annual NHI budget, with government contributions capped at 36%. Taiwan’s healthcare expenditure of 6.54% of GDP remains below the OECD average of 9.2%, reflecting a sustainable system despite political debates over premium increases or coverage restrictions.

Although the NHI mandates participation from all citizens and eligible foreigners, its administrative rules include provisions for residents living overseas for more than six months, allowing them to temporarily suspend contributions. This suspend-and-resume mechanism benefits approximately 210,000 Taiwanese expatriates, enabling them to access Taiwan’s high-quality healthcare services without continuous premium payments while abroad. This flexibility demonstrates Taiwan’s recognition of its citizens’ diverse circumstances and their right to healthcare, even outside national borders.

The system’s operation relies heavily on privately run hospitals that generate revenue from both out-of-pocket payments and reimbursements from the NHI. Patients under inpatient coverage typically contribute co-payments ranging from 5% to 30%, ensuring shared responsibility. While the system provides affordable and comprehensive health services, its high utilization rates raise concerns about the long-term financial sustainability of the NHI. Proposals to cut costs—either by restricting coverage or raising premiums—face strong political opposition, as both the public and policymakers prioritize maintaining broad access to healthcare.

Healthcare workers bear a significant human cost in this system. Nurses, with a ratio of 1:8.6 patients—more than double the US ratio—and doctors working an average of nearly 60 hours weekly, manage the heavy workload required to sustain the system. Physicians and hospitals operate under a fee-for-service model that incentivizes more outpatient visits, which, while increasing accessibility, strains resources and workforce capacity. The pressure on medical staff underscores the importance of balanced healthcare policies that prioritize both access and provider well-being.

The influx of expatriates and international patients further complicates Taiwan’s healthcare landscape. Since the system’s inception, the rise in medical tourism and overseas travel has led wealthy expatriates to utilize Taiwan’s affordable, high-quality services. For example, procedures like knee surgery that cost around US$50,000 in the US can be performed in Taiwan for less than US$5,000, attracting those seeking cost-effective treatment. Under the suspend-and-resume scheme, these expatriates contribute minimally to the system’s funding but benefit from full coverage when they return for treatment. Hospitals often encourage this trend, offering services tailored for returning overseas residents—many of whom are retirees with sufficient means to travel comfortably. However, this practice introduces disparities, as some expatriates exploit the system by seeking excessive procedures, which places additional financial strain on the NHI. Such strategic use of healthcare benefits by non-residents raises questions about fairness and sustainability, especially as medical costs continue to rise.

A critical issue lies in the principle of equitable risk-sharing. The suspend-and-resume mechanism, while offering flexibility, inadvertently creates a dual-tier system: expatriates benefit from subsidized care with minimal contributions, while Taiwanese residents shoulder the lion’s share of healthcare costs through steady premiums. This arrangement disproportionately burdens domestic residents, who end up paying for medical expenses incurred by overseas residents, thereby challenging the fairness of the system. The rising costs and demographic shifts—particularly an aging population—compound these challenges, threatening the financial stability of the NHI.

In 2022, a landmark ruling by Taiwan’s Constitutional Court signaled a shift toward democratizing health governance. The case involved a Taiwanese expatriate who challenged the constitutionality of the suspend-and-resume scheme after her premiums were suspended during her time abroad. The court recognized that while participation in the NHI is essential for fulfilling the government’s obligation to provide healthcare, the administrative mechanism governing overseas residents’ contributions was unconstitutional because it bypassed legislative oversight. Drawing from the German legal doctrine of Gesetzesvorbehalt—which mandates that significant decisions affecting citizens’ rights be made through legislative processes—the court emphasized that policy decisions related to health coverage must undergo public deliberation and democratic accountability. This interpretation underscores that the right to health, although not explicitly enshrined in Taiwan’s Constitution, is a moral and legal imperative that must be shaped through inclusive democratic processes.

Following this ruling, the NHIA amended the administrative rules to phase out the suspend-and-resume scheme by December 2024. Despite the end date, the agency chose not to propose new legislation, effectively abolishing the scheme through administrative action. This move resulted in an estimated increase of US$70.59 million annually in the NHI’s revenue—an important step toward restoring fairness and financial stability. Public support for this abolition was strong, especially after exposure of abuse cases like that of Huang An, a Taiwanese celebrity residing in China who frequently accessed Taiwan’s healthcare system despite publicly promoting pro-China rhetoric. The public’s awareness of the need for fairness and shared responsibility reinforced the belief that contributions should be consistent and equitable to sustain the system.

The case highlights the importance of democratic participation in health policymaking. As Taiwan continues to evolve its healthcare system, ensuring that reforms reflect the collective will and uphold the moral right to health remains paramount. The court’s decision affirms that health rights should be subject to transparent, democratic deliberation, aligning with the broader principle that health is a fundamental moral good. It reinforces the idea that equitable health care distribution depends on public input and accountable governance, vital for maintaining the system’s integrity.

The future of Taiwan’s healthcare system hinges on ongoing political and legal commitment to fairness and sustainability. While the Constitutional Court did not explicitly decide whether overseas residents should contribute financially, its ruling underscores the necessity of democratic processes in determining health policy. Ensuring that all participants—domestic and expatriate—share responsibilities proportionally is essential for the system’s long-term viability. For more insights into the development of healthcare applications that can support such systems, see this guide on developing healthcare apps. Additionally, examining how different countries structure their healthcare can shed light on Taiwan’s unique challenges and opportunities, such as analyzing the effectiveness of the US healthcare system. As artificial intelligence increasingly integrates into health services, understanding AI’s role in healthcare becomes vital, especially in optimizing resource distribution and data management. Finally, a clear grasp of data integration in healthcare is essential for creating efficient, transparent, and fair health systems capable of adapting to demographic and technological changes.

Tsung-Ling Lee is a professor of law at the Graduate Institute of Health and Biotechnology Law, Taipei Medical University, Taiwan.

Yi-Li Lee is an associate professor at the Institute of Law for Science and Technology, National Tsing Hua University, Hsinchu, Taiwan.

Please direct correspondence to Tsung-Ling Lee at tl265265@tmu.edu.tw.

Conflicts of Interest: None declared.

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