Governing universal health insurance in Korea and Taiwan

This article examines policy responses to the rising costs of healthcare in the Republic of Korea and Taiwan from a governance perspective. It tries to answer why the two countries responded differently to a similar set of challenges facing their National Health Insurance (NHI). While Taiwan – in an attempt to contain costs – introduced a global budgeting system, Korea failed to do so. Governments in both countries attempted to establish a new mode of governance, bringing multiple stakeholders to health policy making in order to build social consensus. But the Korean government, as this article shows, could not resolve its policy deadlock because of a loss of trust between the government and the medical profession, caused by the separation reform of 2001. Even though Taiwan was better able than Korea to address the financial challenges of its NHI, the new mode of health governance is still on shaky ground. This article argues that because neither government now enjoys the exclusive power over health policy that they once did under the developmental state, it is essential to find a way in which different stakeholders can make the necessary compromises that will enable the NHI to run on a sustainable path for the future.     

The Fiscal Crisis of National Health Insurance in the Republic of Korea: In Search of a New Paradigm

In 2001, National Health Insurance (NHI) in Korea, the social insurance system for health care with universal population coverage, experienced a serious fiscal crisis as its accumulated surplus was depleted. This fiscal crisis is attributed to its chronic imbalance: health care expenditure has increased more rapidly than have insurance contributions. The recent failure in implementing pharmaceutical reform was a further blow to the deteriorating fiscal status of the NHI. Although the NHI has since recovered from the immediate fiscal crisis, this has mainly been because of a temporary increase in government subsidy into the NHI. The strong influence of the medical profession in health policy‐making remains a major barrier to the introduction of policy changes, such as a reform of the payment system to strengthen the fiscal foundations of the NHI. Korea also has to restructure its national health insurance in an era of very rapid population ageing. A new paradigm is called for in the governance of the NHI: to empower groups of consumers and payers in the policy and major decision‐making process of the NHI. The fiscal crisis in Korean national health insurance sheds light on the vulnerability of the social health insurance system to financial instability, the crucial role of provider payment schemes in health cost containment, the importance of governance in health policy, and the unintended burdens of health care reform on health care financing systems.     

Social health insurance development in Mongolia: Opportunities and challenges in moving towards Universal Health Coverage

Mongolia achieved high population coverage under mandatory health insurance relatively quickly. This fact was viewed by policy‐ and decision‐makers as a central issue for health financing reform in Mongolia. Health insurance brought many new features for health service planning, provision, funding and resource management. Based on initial achievements, health insurance came to be strategically considered as the vehicle for achieving universal coverage. The article analyses developments in Mongolia's health insurance over the last decade along with the core policy dimensions of Universal Health Coverage. It examines various reform approaches and the numerous amendments to laws that have been implemented during this period and discusses new opportunities as well as challenges. The analytical review and findings discussed suggest that Mongolia has a need for evidence‐based policy decisions and informed political support, with health insurance backed by robust institutional and administrative capacities. More generally, it also emphasizes that health policy goals and objectives can be attained by strengthening and making transparent and publicly‐accountable all health system financing functions and arrangements. The policy analysis, experiences, lessons and proposed strategies presented with regard to Mongolia intend to stimulate wider discussions on health insurance development as well as promote continuing focused research on specific aspects of health insurance and public financing reform.     

Health Policy in the Asian NIEs

This paper compares the health policies of Hong Kong, South Korea, Singapore and Taiwan with the purpose of drawing policy lessons. The study finds two distinct policy clusters: Hong Kong and Singapore on the one hand, and Korea and Taiwan on the other. With respect to provision of health care, the former rely largely on public hospitals for delivering inpatient care while the latter rely on private hospitals. In matters of financing, they are similar in that out‐of‐pocket is a major source of financing in all four countries. However, they are also different because Korea and Taiwan have universal health insurance while the city states do not. The study concludes that public provision of hospital care, as in Hong Kong and Singapore, yields more favourable outcomes than many mainstream economists would have us believe. Conversely, private provision in combination with social insurance, as found in Korea and Taiwan, severely undermines efforts to contain health care costs.     

Familialisation Effects of the State Welfare: Focused on the National Health Insurances in S. Korea and Taiwan

The national health insurances in Korea and Taiwan have maintained the dependent system that includes the insureds and their families. These two cases explicitly exemplify the familialism in East Asian welfare regime. However, comparing the two systems in detail, we can easily note the variation in their familialisation effects despite similar family realities in the two societies. To explain why Korea and Taiwan adopted the NHI of different institutional arrangements, this article focuses on the historical combination of the state's political and fiscal concerns and families' rational choice, which led to the variation in family policy.     

Citizens' attitudes towards economic insecurity and government after the 2007 financial tsunami: A Hong Kong and Taiwan comparison

Wang KY‐T, Wong C‐k, Tang K‐L. Citizens' attitudes towards economic insecurity and government after the 2007 financial tsunami: A Hong Kong and Taiwan comparison The purpose of this study was to investigate people's attitudes to economic insecurity and government in Hong Kong and Taiwan after the financial tsunami of 2007. Random sampling telephone surveys were conducted in July 2009. These are the main conclusions: First, the most vulnerable groups hurt by the financial crisis were low‐income families and people who had lost their job or were afraid of losing it. This implies that the old policy issue of social stratification and the emerging policy issue of employment insecurity coexisted during the financial crisis. Second, personal experiences of economic insecurity had an influence on people's perceptions of the severity of the economic crisis at the societal level. Third, citizens had ambivalent feelings about public interventions during the crisis. Fourth, there were both convergence and divergence between Hong Kong and Taiwan with regard to attitudes to particular issues. The policy implications of these findings are discussed in the final section of this article.     

Gender and proposed Auto‐enrolment in the Republic of Ireland: Lessons from the UK

The introduction of “soft” compulsion in the form of Auto‐enrolment into non‐state pensions has been seen as a key policy response to the challenges presented by an ageing population and concerns about under‐saving for retirement in the UK. Since its introduction in 2012, amongst eligible employees in the private sector, pension participation had risen by over 31 percentage points to 73% of eligible employees in 2016. Despite these trends, Auto‐enrolment in the UK has not been without criticism, particularly in terms of its exclusion of certain groups, including carers, amongst whom females are over‐represented. The Republic of Ireland (ROI) has recently announced its intention to implement an Auto‐enrolment pension scheme. As such, this article examines the UK's experience of rolling out Auto‐enrolment policy and considers lessons that could be learned by the ROI from the UK in its pursuit of Auto‐enrolment, with a particular focus on women's pensions. Initially it outlines the current Irish pension system, the gendered nature of pensions, and the proposed Auto‐enrolment system in ROI. Then it discusses the UK's experience of Auto‐enrolment, with a particular focus on gender, before examining the lessons the ROI can learn from the UK's Auto‐enrolment policy in relation to women and pensions. Finally, it concludes that Auto‐enrolment alone will not resolve the gendered nature of pensions in the ROI and calls for a gender‐based assessment of the proposed policy of Auto‐enrolment in the ROI.     

Women's Organizations,Social Learning,and the Federal State: A Case Study of Canadian Pension Policy

The various ways which federalism influences gender policies has recently received a surge of academic interest. This article contributes to this literature by moving beyond formally adopted policies to study the influence of federalism on social learning amongst women's organizations. Using a most‐likely case study design, this exploratory work traces the policy positions held by women's organizations in Canada during a seven‐year period now known as the Great Pension Debate. Focusing on four empirical indicators of issue attention, participation in policy discussions, specificity of policy proposals, and consensus for reform, the findings suggest that the plurality and temporal proximity of successive policy venues – such as royal commissions and parliamentary committees – created by various governments offered women's organizations an optimum environment to engage in ongoing exchanges leading to the development, and greater specification, of policy positions.     

Diverging Paths? A Comparative Look at Childcare Policies in Japan,South Korea and Taiwan

This article compares state policies to support childcare in Japan, South Korea and Taiwan, using fuzzy set ideal type analysis to determine the nature of institutional arrangements with respect to labour, money and time provisions. We then note their implications for familialization and defamilialization in the three countries. Our analysis suggests a common pattern towards the increased use of financial support amongst the three countries over time; however, this commonality does not mean their childcare policies are converging, as the financial supports differ in focus, with Japan concentrating on familialization by valuing family care, and Korea exclusively employing policy to facilitate the use of market‐based care services. For its part, Taiwan has been strengthening familialization by increasing the leave compensation to value time off to provide care. The different labour, money and time dimensions vis‐à‐vis the familialization/defamilialization matrix suggest varying implications of institutional arrangements for gender.     

The public pension system in Taiwan: Equity issues within and between systems

This article analyses the challenges facing the New Public Service Pension Fund System in Taiwan, China. After less than two decades of operation, this young system is facing financial imbalance and is embroiled in controversy regarding the generosity of its benefits provisions. The article first introduces Taiwan's different systems for old‐age security, with a focus on that for general public‐sector employees. It then addresses the financial challenges facing the general public‐sector pension system, including the rising cost of its benefits for all taxpayers. Finally, a number of possible reform directions are suggested, including lowering benefit levels, making qualifying criteria more stringent, or establishing a new system. With regards to the latter, any proposed new system must seek to satisfy the goal of longer‐term financial soundness while realizing optimal fairness among all stakeholders including taxpayers.     

Healthcare financing reform and the new single payer system in the Republic of Korea: Social solidarity or efficiency?

In July 2000, national health insurance in the Republic of Korea was transformed into a single insurer system. This major reform in healthcare financing resulted from the merger of more than 350 health insurance societies. Inequity in healthcare financing and the chronic financial situation of the health insurance societies for self–employed workers in rural areas have been the driving forces leading to the unified health insurance system. The unique institutional context together with political change opened the window of policy change, and various stakeholders such as politicians, rural self–employed workers, trade unions and civic groups were involved in the healthcare reform process. Fair income assessment of the self–employed and the role of the single insurer as a prudent purchaser of medical care will be vital for the new system to achieve its intended goal and improve social solidarity and efficiency of healthcare.     

Welfare regime change – or lack of change – in unemployment compensation

Drawing on theoretical accounts of institutional change, this study explored the politics of welfare regime transformation in regard to Turkey's unemployment compensation system. By using the institutionalist approach, the study shows that the process of welfare regime change was one of “institutional layering” of unemployment insurance (UI) over severance pay. Also, the study demonstrates that the economic bureaucracy played a key role in pushing the establishment of UI (state‐centric approach) in contrast to the class‐based organizations that focused their struggles on the severance pay scheme (power‐resource perspective). However, the economic bureaucracy preferred a rudimentary UI design, which prevented UI from undermining the vested interests behind the severance pay scheme. Furthermore, subsequent attempts at the reformation of the severance pay scheme were not successful because the social welfare bureaucracy lacked the capacity to develop a policy alternative to resolve the stalemate between the societal actors. Lastly, the study used the successful severance pay reform experiences of South Korea and Austria to locate the Turkish case within a broader comparative framework.     

‘Reasonable and necessary’ care: the challenge of operationalising the NDIS policy principle in allocating disability care in Australia

Disability reform in Australia centres on a National Disability Insurance Scheme (NDIS), which aims to provide lifelong, individualised support based on the principle of ‘reasonable and necessary’ care. As a universal rights‐based scheme it represents a historical shift in allocation principles in Australia's disability policy. Nonetheless, attention will be on determining who receives what care given the diversity of personal and family contexts. The aim of this paper is to discuss the operational complexities of a principle of reasonable and necessary care with reference to the findings of a three‐year study on the experiences and perspectives of disability care of 25 adults with acquired disability, their 22 nominated family members and 18 service providers. Evidence from this study suggests enacting the principle of reasonable and necessary care and support will be problematic, in particular as it relates to personalising the level and scope of services, balancing formal and informal care, and principles of equity. The paper contributes to the literature about allocation principles in social policy and the challenges of implementation. Further, it provides an empirically informed discussion of some of the specific policy implementation challenges concerning the NDIS.     

Reaching universal coverage by means of social health insurance in Lesotho? Results and implications from a financial feasibility assessment

This article discusses the process, results and implications of a financial feasibility assessment of social health insurance (SHI), as one part of Lesotho's exploration of how to move towards achieving universal health care coverage. Quantitative data from government and other sources, and qualitative data from discussions with stakeholders, were entered into SimIns, a health insurance simulation software, through which SHI revenue and expenditure for 11 years was projected. In principle, the assessment reveals that through a mix of tax financing and SHI contributions, all citizens of Lesotho could be covered with a defined benefit package of health services under the defined policy assumptions. Such a financing scheme would provide financial risk protection and enhance equity in access and health financing.     

Introducing social insurance for long‐term care in Taiwan: Key issues

Nadash P, Shih Y.‐C. Introducing social insurance for long‐term care in Taiwan: Key issues Taiwan will shortly complete its comprehensive social safety net, which includes national health insurance, retirement security, and unemployment insurance, by introducing long‐term care (LTC) insurance – putting it ahead of the many countries that rely on a patchwork of policies to address the need for LTC. The program, to be implemented in 3 to 5 years, will cover all citizens on a primarily social insurance basis. The range of LTC policy options considered is discussed, particularly how to structure the program, how to finance and regulate it, and how to develop its inadequate LTC infrastructure and workforce. Particularly thorny issues include the choice of social insurance, the feasibility of cash benefits, and how to address Taiwan's heavy reliance on foreign workers. Taiwan's increasingly democratic character, along with high levels of public support for the program, creates significant pressure on politicians to deliver on their promises to implement LTC reform. Key Practitioner Message: ?Emphasizes the importance of policy learning from other environments; ?Highlights the need for a strong regulatory and provider infrastructure for delivering long‐term care services; ?Emphasizes the need for training, support, and appropriate regulation of the long‐term care workforce.     

Improving outcomes for children in out‐of‐home care: the role of therapeutic foster care

How best to support children and young people in foster care remains a challenge for child welfare. There has been little Australian research on the outcomes for children and young people placed in therapeutic foster care (TFC). This article aims to address this knowledge gap, presenting the evaluation of a state‐wide model of TFC known as the Circle Program operating in Victoria, Australia. Data sources for the study were case assessment analysis; surveys of foster carers, program workers and other stakeholders in the sector; and both focus groups and individual interviews with foster care workers. The evaluation found that the Circle Program lessened the number of unplanned exits of children from foster placements compared with generalist foster care. Another important finding was that the Circle Program positively influenced foster carers' decisions to stay in the carer role. Key components perceived as contributing to outcomes of the Circle Program included enhanced training of foster carers, intensive carer support, specialist therapeutic support to the child and carer, therapeutic service to family members and a network of services to provide support to the child.     

An Analysis of Taiwanese Immigrants' Health Care Choice – Obamacare or Taiwan National Health Care

Due to recent policy changes in the USA and Taiwan, Taiwanese immigrants residing in the USA face a choice of continuing to receive health care in the USA or returning to Taiwan for treatment care. This study uses a quantitative survey to explore the association between recent health policy changes and the health care choice of Taiwanese immigrants residing in the USA. These findings indicate that there are statistically significant associations between a variety of factors and the Taiwanese immigrants' desire to return to Taiwan for health care under the new national health insurance plan (2nd NHIA). The variables positively associated with a desire to return to Taiwan for health care include the length of domicile and residence required to receive benefits, a nostalgic desire to return to Taiwan, the lower cost of health care in Taiwan, and if the respondents had come to the USA before 1996. The negatively associated variables include having a job in the USA, having a desire to return to Taiwan to live after retirement, the language preference in communications with a doctor, and a preference about the best place to receive dental treatment. The study reveals the dynamics behind the health care decision‐making of Taiwanese immigrants and particularly their choice of whether to seek care in the USA or in Taiwan.     

Economic well‐being of low‐income single‐mother families following welfare reform in the USA

This study explored changes in net disposable income for low‐income single‐mother families before and after the 1996 welfare reform in the USA. Although many studies on welfare reform have focused on employment or total family income as a way to measure low‐income single‐mother families’ economic well‐being, little is known about their net income after expenses related to entering the workforce. This study analyzed net disposable income after tax deductions and childcare costs to provide a more accurate understanding of income changes using data from the Survey of Income and Program Participation conducted by the US Census Bureau. The results revealed that while low‐income single mothers were working more after welfare reform, their net disposable income decreased during this time because their earnings were low and offset by an increase in childcare costs and a decline in means‐tested benefits, including Temporary Assistance for Needy Families benefits. Key Practitioner Message: ● To understand effects of the 1996 welfare reform on low‐income families’ economic well‐being; ● To understand comprehensive income sources and work related expenses of low‐income families; ● To provide policy suggestions for comprehensive childcare subsidies to support low‐income single mothers’ employment.     

Well‐being among employed and non‐employed caregiving women in Taiwan

Chou Y‐C, Kröger T, Chiao C, Pu C‐Y. Well‐being among employed and non‐employed caregiving women in Taiwan This study addressed various groups of non‐employed/employed and non‐caring/caring women in Taiwan. Data from the 2006 National Taiwanese Women Survey (at age 16–64, n= 6,017) were analysed to determine whether there are differences in terms of well‐being, as measured by self‐rated health and family life satisfaction, between women who work and/or care and between different carer groups. Other factors associated with well‐being of carers of young children (n= 1,697) were also analysed. The results showed that non‐employed carers of disabled adults stood out as the most disadvantaged group. However, the importance of work has been replaced by support among carers of young children. This study suggests that unpaid carers, particularly carers of disabled adults who are non‐employed, ought to be supported by policies. To improve carers' well‐being, care–work reconciliation among working‐age women needs to be included in the future care scheme in Taiwan.     

Welfare Reform and Child Fostering: Pinpointing Affected Child Populations*

Objective. The objective of our research is to examine the impact of New Jersey's welfare reform called the Family Development Program (FDP) on child fostering among children on welfare. Methods. The research and analytical methods we use include an experimental design and probit regressions. Results. Our results show that FDP impacts are confined to children of short‐term welfare recipients (new cases) but affects both African‐American and white children in this welfare group. Among new cases, FDP decreases the probability of African‐American children living in foster families, resulting in a 28 percent change from the baseline prevalence rate of 7.2 percent. In contrast, FDP increases the likelihood of white children living in foster families, leading to a 70 percent change from the baseline occurrence rate of 1.4 percent. Conclusions. We conclude by discussing the policy implications of such segmented impacts of welfare reform for vulnerable child populations.