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Strengthening or Weakening? The Impact of Universal Health Insurance on Intergenerational Coresidence in Taiwan

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Demography

Abstract

In this article, we exploit a unique natural experiment—the implementation of National Health Insurance (NHI) in Taiwan in 1995—to examine how the introduction of universal health insurance increases or decreases the likelihood of intergenerational coresidence. Five waves of surveys from the Survey of Health and Living Status of the Elderly in Taiwan between 1989 and 2003 are employed, and models with various specifications are estimated. Our results indicate a mixed relationship between the likelihood of intergenerational coresidence and the enactment of NHI. Although NHI on average reduces the probability that elderly parents live with their adult children by approximately 6.6 %, the likelihood of intergenerational coresidence increases among families benefiting most from NHI, such as those with unhealthy elderly mothers and fewer children.

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Notes

  1. To cite an example, in the East Asia and Pacific region, “. . . nearly all countries provide benefits for old age, disability and survivorship. Most countries provide coverage for work injury. Programs covering sickness, maternity benefits, family allowances, and unemployment benefits are not yet common. Access to health care varies considerably. Korea is notable in the region for providing insurance for long-term care. China, Indonesia, and Vietnam are examples of countries that, relatively recently, have begun the task of integrating social security reform initiatives” (Pallares-Miralles et al. 2012:56–57).

  2. It was found that the provision of the Union Army pension program (Costa 1997) or the Social Security program (Engelhardt et al. 2005; McGarry and Schoeni 2000) reduced intergenerational coresidence in the United States. However, Edmonds et al. (2005) found no evidence that social pension income is used to maintain the independence of black elders in South Africa.

  3. Some research has studied the substitution effect between public and private care directly. For example, the Medicaid home care benefit (Ettner 1994) or publicly provided home care (Pezzin et al. 1996) substitutes for family care in the United States. However, these studies do not study the effect of public care on living arrangements.

  4. According to the Ministry of Health and Welfare in Taiwan, a low-income family in a specific year is defined as a family in which the average income of a family member is less than the lowest living index for that year published by the responsible agency of the family’s municipality or county (city). For example, the lowest living index in the City of Taipei in 2014 is 14,794 New Taiwanese Dollars (approximately $493.13 US dollars) per month.

  5. According to the Taiwan Statistical Data Book 2014 (National Development Council, Taiwan 2014), the national income per capita (national income per person) in Taiwan is $18,373 (US dollars) in 2013.

  6. Despite a wide array of empirical literature on intergenerational transfers, no consensus has been reached on whether altruism (need-based; more need, more help; less need, less help) or exchange is the dominant motive. For instance, Lee et al. (1994) documented that an altruism model best portrays the intergenerational transfers from children to parents in Taiwan. Park (2003) found that intrahousehold transfers are the result of a mixture of altruism and exchange motives in Malaysia.

  7. Several recent cross-European comparative studies support the hypothesis of “complement” or “mixed responsibilities.” Motel-Klingebiel et al. (2005) found that senior citizens received the most help and support in generous welfare state regimes (the “complement” hypothesis), but there was relatively little total support in countries with the most pronounced family orientation. Brandt et al. (2009) found that public and family supports are complements, with each specializing in different tasks in order to provide the best quality and quantity of care for the elderly (“mixed responsibilities” hypothesis).

  8. Many studies have documented that living arrangement is influenced by cultural factors and traditional values (Cameron 2000; Chaudhuri and Roy 2009; Richards et al. 1987). Takagi and Silverstein (2006) indicated that the effect of social transformation cannot be ignored when studying the elderly’s living arrangement in Asia, especially in economically developed but traditional countries, such as Japan, South Korea, and Taiwan.

  9. For example, 66.19 % of interviewees in the first wave of the Survey of Health and Living Status of the Elderly in Taiwan stated that “living with children” was the ideal living arrangement.

  10. Details of the data set and its survey years will be provided in the “Data” section.

  11. This survey was originally conducted by the Taiwan Provincial Institute of Family Planning (renamed the Bureau of Health Promotion at the Department of Health in Taiwan in 2001, renamed again the Health Promotion Administration at the Ministry of Health and Welfare in Taiwan in 2013) and the Population Studies Center at the University of Michigan, Ann Arbor (PSC, UM) in 1989.

  12. The SHLSET used a stratified three-stage sampling design without replacement at each stage to obtain a random sample of the elderly population in Taiwan.

  13. The percentage of elderly citizens staying in nursing homes and other institutions is approximately 0.6 % in the 1989 wave. Because quasi-coresidence (parents and their children live separately but in close proximity) is a possible option of living arrangement for the elderly, we also run a regression using the indicator of quasi-coresidence as the dependent variable (similar to Eq. (6)). The result from the entire sample shows that the probability of quasi-coresidence does not rise significantly relative to those of other living arrangements after the implementation of NHI.

  14. We use the other four waves’ information about insurance to do retrospective matching and make our definition of “the control group” as precise as possible.

  15. A respondent has two additional options to choose in the 1989 survey: 4, I do not know the level of difficulty; and 5, I have never done the task. These answers are coded as missing. To evaluate its impact on the results, we measure the percentage of missing values for each health indicator in each wave. Overall, the score of functional limitation has a better quality than the other two health indicators in terms of missing values and the question(s) used to construct the health indicator.

  16. Results with the other two health indicators are available from the authors upon request.

  17. Those results are available from the authors upon request.

  18. Propensity scores are based on variables included in X in Eq. (6) and years of schooling of the respondent’s father.

  19. This question is absent in the 1993 wave. Moreover, the categories of answers are adjusted to reflect the slight difference in answers between the 1989 wave and other waves.

  20. To ensure the robustness of the results, we restrict the sample to people with at least one son and reestimate the regressions in all tables. The results are qualitatively the same as those displayed in the article.

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Acknowledgments

We thank the Editor, the Deputy Editor, the four anonymous referees, and the participants of the 2012 Annual Conference of the Southern Economic Association for their comments and suggestions. This study is based on data from the Survey of Health and Living Status of the Elderly in Taiwan provided by the Health Promotion Administration, Ministry of Health and Welfare, Taiwan (R.O.C.). The descriptions or conclusions herein do not represent the viewpoint of the Health Promotion Administration. We are grateful to the Health Promotion Administration for providing data.

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Authors and Affiliations

  1. Department of Economics, Northern Michigan University, 1401 Presque Isle Avenue, Marquette, MI, 49855, USA

    Hsin-Ling Hsieh

  2. Department of Economics, Lehigh University, 621 Taylor Street, Bethlehem, PA, 18015, USA

    Shin-Yi Chou

  3. Department of Health Management and Policy, Saint Louis University, 3545 Lafayette Avenue, St. Louis, MO, 63104, USA

    Echu Liu

  4. Department of Public Finance, Taiwan Study Center, National Cheng-Chi University, 64, Sec. 2, Zhi-Nan Road, Wenshan, Taipei, 11623, Taiwan

    Hsien-Ming Lien

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  1. Hsin-Ling Hsieh
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Correspondence to Hsin-Ling Hsieh.

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Hsieh, HL., Chou, SY., Liu, E. et al. Strengthening or Weakening? The Impact of Universal Health Insurance on Intergenerational Coresidence in Taiwan. Demography 52, 883–904 (2015). https://doi.org/10.1007/s13524-015-0387-0

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