Pursuing Health Equity

Abstract

This chapter explains why National Health Insurance Administration (NHIA) decoupled the premium payment and right to health care to safeguard the medical right of the financially disadvantaged. Furthermore, various programs have been carried out to improve the accessibility and comprehensiveness of medical care for residents of remote and offshore islands. The National Health Insurance (NHI) has also progressively covered orphan drugs to meet the medical needs of patients with rare diseases.

In addition to eliminating geographic and economic health disparity, the NHIA strives to improve health literacy and knowledge of the health insurance system of the public. “My Health Bank” was launched to enable its users to query personal medical and health information in real time to encourage self-health management and enhance the safety and quality of medical care. The NHI was introduced to elementary school pupils to acquaint the younger generation with its concept and have a more profound influence.

Introduction

The purpose of Taiwan National Health Insurance (NHI) is to improve the health and secure the fairness of the medical rights of all citizens. To safeguard the health of the disadvantaged, the National Health Insurance Administration (NHIA) announced a full-scale unlocking of the NHI card to realize the universal right to equal medical care. In addition, the NHIA conducted various programs that encourage providers to supply rural medical services, hoping to improve the accessibility and comprehensiveness of medical care for residents of remote and offshore islands. As for patients with rare diseases, the Legislative Yuan passed “The Rare Disease and Orphan Drug Act” to offer more comprehensive care, making Taiwan the fifth country in the world to protect the medical rights of patients with rare diseases through legislation.

In addition to medical care for the disadvantaged, the health literacy of the public is also the top priority of the NHIA. My Health Bank system enables users to query their real-time medical and health information, which encourages self-health management and also improves the safety and quality of the medical care that they receive. The NHI is introduced in elementary school textbooks to familiarize the younger generation with its concept and create a more profound influence.

Removing Barriers to Health Care to Protect the Disadvantaged

With the spirit of improving the health and safeguarding the fairness of medical rights of all citizens, the NHIA not only implements measures to assist the disadvantaged in paying the premium of the NHI but also gradually decouples the payment of premiums from the right to receive medical care for the disadvantaged (hereinafter referred to as unlocking of the NHI card) (Fig. 5.1). The number of people whose NHI card was locked owing to overdue NHI premiums dropped from 693,000 in 2007 to approximately 42,000 in April 2016. Furthermore, the NHIA announced a full-scale unlocking of the NHI card in June 2016 to realize the universal right to equal medical care, and to build a comprehensive umbrella to safeguard the health of the disadvantaged.

Fig. 5.1

Since June 2016, the policy of a full unlocking of the NHI card has been implemented

Decoupling of the Payment of Premiums from the Right to Receive Medical Care

To ensure the fair burden and the sustainability of the NHI, the public bear the responsibility of paying the premiums while enjoying the right to medical care. Therefore, the NHIA has a statutory disgorgement mechanism for those who owe insurance premiums. The implementation of a full-scale unlocking of the NHI card means that no financially disadvantaged citizens will experience a delay in medical treatment because of their overdue premiums.

The NHIA combines the efforts from different sectors of the society and governmental agencies to assist the disadvantaged with premium payment and remove their psychological barriers when seeking medical treatment. Measures to provide those who are in need financially and care for the weakest in the society include (Fig. 5.2):

• 1. For low-income and middle-low-income households, the competent central social welfare authority subsidizes either all of or half their premiums respectively. The NHIA also acts as an agent to conduct subsidy projects from other government financial resources, including the premium subsidies for those who have physical and mental disabilities, and middle-low-income elderly aged 65–70 from each county and city government, the NHI premium subsidies for unemployed workers from the Bureau of Labor Insurance, and the NHI premium subsidies to new residents before their household registrations from the Ministry of the Interior.

• 2. Those who are unable to pay the premiums and overdue charges at one time owing to financial hardship may apply for an installment plan. For people with special circumstances, the NHIA approves a special installment plan that allows payment in up to 48 installments if the total annual individual income does not exceed personal exemption, standard deductions, and special deductions of income from salaries or wages for the most recent year.

• 3. Those who are qualify as financially difficult cases and who are unable to pay off the premiums may apply to the NHIA for an interest-free relief loan and start repaying from 1 year later. Eligible applicants include those who are legitimate middle-low-income households, and families whose main breadwinners suffer from major illnesses and injuries or who are unemployed for more than 6 months, etc.

• 4. The NHIA proposes the “Public Welfare Lottery Feedback Funds to Help the Disadvantaged to Defray Medical Expenses Plan” annually to obtain funding from the Ministry of Finance, to subsidize the premium of various financially disadvantaged groups.

• 5. The NHIA established a “Disadvantaged Notification Service Platform” that different sectors of the society can access to report information about cases that need assistance. The NHIA then connects external resources to assist the disadvantaged with their premiums by the NHI charity accounts, referrals to public interest groups, and public welfare lottery feedback funds.

• 6. For those who are financially disadvantaged with overdue premiums and meet the subject criteria of the Public Assistance Act (low-income households or middle-low-income elderly aged over 70), after confirming their inability to pay off the premiums, the NHIA will relieve their financial burden by not transferring their overdue premiums to compulsory enforcement.

• 7. The number of people applying for relief loans, installment payments, and referrals to public interest groups did not significantly decrease after the full-scale unlocking of the NHI card. This shows that the financially disadvantaged still need various assistance to alleviate the financial burden caused by overdue premiums.

Fig. 5.2

Assistance for the disadvantaged

The National Health Insurance Premium Deferment Paying Measures of the COVID-19 Epidemic

Considering that the global outbreak of COVID-19 may impact people’s finance and livelihoods and hamper their ability to pay the NHI premiums on time, the NHIA allowed insured units and individuals affected by the pandemic to apply for deferment of their premium payments of February to July 2020 and April to September 2021. The overdue charges, payment reminder, and transfer for compulsory enforcement are exempted during the deferred period, so as to tide citizens over any difficulties. The total amount of the application is about New Taiwan dollars (NTD) 2.6 billion in 2020 and NTD 4.7 billion in 2021.

By the full-scale unlocking of the NHI card and all the assistance measures, the disadvantaged are no longer afraid of being unable to receive necessary medical care owing to overdue premiums. The move not only relieves their financial pressure and paves the last mile toward comprehensive protection to medical rights, but also helps to improve the health of all citizens and stabilize society. As for those who have the ability to repay, the NHIA continues to collect the arrears effectively and transfer them to compulsory enforcement, in order to avoid deliberate arrears and ensure that the full-scale unlocking of the NHI card does not impact the finance and operations of the NHI.

Medical Services on Remote and Offshore Islands

The NHI is committed to improving the accessibility and comprehensiveness of medical care for residents living on remote and offshore islands. With this goal in mind, the NHIA has carried out various initiatives since 1999 to encourage providers to invest in rural medical services, including the “Integrated Delivery System (IDS),” “Improvement Plan for Medically Underserved Areas,” and “Upgrading Medical Services in Underserved Areas” plans, and others (Fig. 5.3). These initiatives are designed to incentivize more medical institutions and professionals to offer timely and affordable health care to under-resourced communities, with the full backing of the NHI system.

Fig. 5.3

The history of the National Health Insurance medical services promotion on remote and offshore islands

The Integrated Delivery System

The IDS coordinates and optimizes local medical resources, and provides diversified care appropriate to local conditions, including resident outpatient clinics, 24-h emergency services, night-time outpatient clinics, standby clinics for evenings and holidays, specialized medical care, specialized medical care bolstered by relevant medical staff, mobile clinic services, on-call medical services in the event of natural disasters, chronic disease management and prevention services, comprehensive home health care, and other medical services constituting a comprehensive network of care. Each IDS is unique to local conditions, implemented according to the distinctive needs of the community it services. Currently, there are 50 IDSs in full operation across Taiwan, buttressed by 26 large hospitals working in concert with local providers. In 2019 alone, the NHIA invested in a sum of NTD 5.04 billion in remote rural areas, of which IDS operations commanded NTD 1.17 billion. A total of 2012 specialist consultations were provided each month, serving more than 470,000 patients. From mountainous village clinics to offshore medical stations, IDS medical staff travel to wherever they are needed to provide high-quality, comprehensive health care to Taiwan’s residents in remote areas.

In 2019, average visits per person in remote areas were 14.9 and 16.4 visits on offshore islands and mountain areas respectively. Notably, these averages were higher than that of the entire population (13.1 visits/person), of which a majority live on the main island, particularly in urban areas. Personal medical expenses in IDS areas were also comparable with those of the entire population (Tables 5.1 and 5.2). Since the program’s inception in 1999, the IDS has attained a public satisfaction rate of more than 90%. The statistics above reflect gradually disappearing inequities in healthcare access and quality between highly populated urban areas and remote communities, as the NHIA looks beyond solely using IDS support to truly close the distance.

Table 5.1 The average number of Western medicine outpatient visits per person per year

Table 5.2 The average relative value units (RVUs) of Western medicine outpatient visits per person per year

Improvement Plan for Medically Underserved Areas

Beyond deploying highly effective IDS networks across Taiwan, in order to mitigate inconvenience experienced seeking care in medically under-served areas, the NHIA has devised specialized initiatives to encourage medical professionals across the spectrum—traditional Chinese medicine doctors, Western medicine physicians, and dentists—to establish resident and mobile practices in areas still lacking adequate medical infrastructure. The Improvement Plan for Medically Underserved Areas was implemented in a total of 374 villages and towns in 2019 (Table 5.3), enabling an impressive 40,357 specialized consultations serving 710,144 patients.

Table 5.3 Outcome of the Improvement Plan for Medically Underserved Areas for Western medicine, Traditional Chinese medicine, and dental in 2019

Upgrading Medical Services in Underserved Areas

To further enhance local healthcare services for residents in mountainous towns, offshore islands, and areas with insufficient medical resources, the “Upgrading Medical Services in Underserved Areas” initiative was implemented in 2012 to establish comprehensive health coverage in these communities, such as 24-h emergency services, inpatient services, as well as care spanning the disciplines of Internal Medicine, Surgery, Obstetrics and Gynecology, and Pediatrics. In total, 92 hospitals participated in providing needed care to underserved communities in 2019.

National Health Insurance Strives to Remove Barriers to Medical Treatment

The Kinmen IDS network implemented by the Taipei Division of the NHIA exemplifies the innovative work the NHIA has undertaken to remove all barriers to medical treatment, be them financial, economic, or geographical. The Taipei Veterans General Hospital (TVGH), as the pillar of the Kinmen IDS, deploys specialists to enhance the capabilities of Kinmen Hospital, so that major operations, such as craniotomy and cardiac catheterization, can now be performed in Kinmen. Patients suffering an ischemic stroke can receive thrombolytic therapy, and cancer patients can receive chemotherapy right on Kinmen Island—they and other Kinmen residents can rely on timely, potentially life-saving treatment without needing to travel to Taiwan’s main island by boat.

Ms. Zhang, a Taiwanese citizen living abroad, was rescued from the grips of death by the IDS Kinmen team, an experience she shared on 17 December 2020, at a NHIA press conference reporting on the results of the Kinmen and Matsu IDS programs. Driving on a visit to Kinmen in July 2020, she encountered a serious car accident, which dealt her a traumatic intestinal injury, sternum fracture, chest contusion, blunt head injury, and severe laceration. Fortunately, the IDS medical team of Taipei Veterans General Hospital stationed at Kinmen Hospital, was available to give Ms. Zhang emergency life-saving treatment, afterward sending her to the TVGH main campus in Taipei for follow-up treatment. Ms. Zhang’s full recovery from this otherwise fatal accident is one of many incredible testimonies to the importance of establishing equitable, comprehensive health care in remote and offshore areas.

Prospects

Beyond implementing an array of targeted, localized plans to improve the accessibility of no-compromise, high-quality medical services in remote and offshore areas, the NHIA ultimately aims to cultivate self-sustaining healthcare ecosystems in these areas. To this end, the NHIA leads efforts to recruit talents from a variety of specializations to provide resident services locally. A “National Physician Manpower Demand for Rural Areas Platform,” featured on the homepage of the NHIA’s official website, has been established to match physicians with fully reimbursed service opportunities in mountainous and offshore communities across the country. This platform is expected to foster a dynamic forum for mutual mentorship and progress, in which resident and visiting physicians learn from each other’s experiences, in turn deepening the quality and longevity of health care in remote, under-resourced areas. At the same time, to avoid improper use of precious resources of the National Health Insurance and ensure the quality of medical services in underserved communities, the NHIA continues to monitor the service capacities and perform on-site visits to assess the quality of the on-the-ground services delivered by both resident clinics and mobile stations alike, and regulates hospitals that deviate from the central goal of serving still under-resourced communities, e.g., by fraudulently claiming compensation.

National Health Insurance Stands by Patients with Rare Diseases

To care for patients with rare diseases more comprehensively, the Legislative Yuan passed “The Rare Disease and Orphan Drug Act” in 2000. In the past two decades, the NHI has served as the patients’ strongest support. As of 2019, there are 9600 rare-disease patients receiving drugs covered by the NHI.

Rare diseases are uncommon diseases with a low prevalence rate, and according to “The Rare Disease and Orphan Drug Act” the definition of “rare disease” is “diseases with prevalence lower than the standard announced by the central competent authority (1 in 10,000).” Under special circumstances, a disease could be recognized as a rare disease through review by the Review Committee for Rare Diseases and Orphan Drugs (hereafter referred to as the Review Committee) and designated and publicly announced by the central competent authority. Orphan drugs are used to prevent, diagnose, and treat rare diseases, under the premise of being recognized through review by the Review Committee and announced by the central competent authority. The same Act also stipulates that after obtaining designation or special approval from the central competent authority, orphan drugs can be submitted for listing in the National Health Insurance Pharmaceutical Benefits and Reimbursement Scheme. As of the end of December 2020, the NHI covered 207 drug items that had either been announced by the competent authority as drugs eligible for special importation (manufacture) or those qualified for orphan drug licenses under the Rare Disease and Orphan Drug Act.

Rare Diseases Are Categorized as Catastrophic Illnesses to Waive Patient Co-Payments

Given that patients with rare disease are uncommon, they have higher and more urgent medical needs owing to the severity of their health conditions, the NHIA has classified all individuals with rare diseases as having catastrophic illness. In this way, their co-payments for medical care could be waived, reducing the heavy financial burden of families with a member who has a rare disease. As of the end of May 2020, the Ministry of Health and Welfare has announced a total of 223 categories of rare diseases. According to the statistics in 2019, the largest number of patients with rare diseases who applied for a catastrophic illness certificate comprises multiple sclerosis patients with brain or nervous system lesions, a total of 1445 patients (Table 5.4).

Table 5.4 Number of patients with rare diseases applying for the ten most common catastrophic illness certificates

The NHIA has always been very concerned about the medical rights of patients with rare diseases. Since 2005, it has strived for a dedicated budget for orphan drugs to avoid rare-disease cases from being squeezed out by the Global Budget owing to the high medical expenses. Expenditures for orphan drugs increased from 1.738 billion RVUs in 2010 to 6.167 billion RVUs in 2019, and the average growth rate of annual cost in the past 5 years is about 11.2%. We further analyzed the medical resource utilization of various rare diseases. Taking 2019 as an example, patients who contributed the highest average drug costs are those with mucopolysaccharidoses (9.938 million RVUs per patient), followed by Gaucher’s disease and Fabry’s disease (9.832 million RVUs per patient and 7.753 million RVUs per patient respectively).

Because of the scarcity of patients with rare diseases, the pharmaceutical companies are often unwilling to invest in the development of drugs for rare diseases owing to the economic scale. As a consequence, production costs and unit prices for rare-disease drugs are extremely high. Without alternative treatments on the market, the drugs for rare diseases are also called “orphan drugs.” In response to patients’ demand, the NHIA proactively includes orphan drugs in its benefit package. For example, Spinraza, a drug for the treatment of spinal muscular atrophy (SMA), has been covered by the NHI since 1 July 2020. This not only brings good news to patients, but also starts a new page for NHI’s coverage for SMA treatments.

Strengthening Control Measures for Orphan Drugs

However, considering that the medical expenses of rare diseases have increased year by year recently, the NHIA has begun to strengthen control over orphan drugs. Starting from 1 September 2019, only patients with rare diseases recognized by the Health Promotion Administration are eligible for orphan drugs. It is hoped that with assistance from medical institutions, patients with rare diseases could obtain their catastrophic illness certificates promptly. By doing so, their financial burden could be reduced or eliminated, and they could qualify for using orphan drugs and be treated properly.

Another control measure is the routine review for the prices of orphan drugs. According to Article 24 of the Regulations on Drug Price Adjustment of the NHI, the payment for orphan drugs should be reviewed and adjusted every 2 years. In addition, Article 35, Item 2 of the “National Health Insurance Pharmaceutical Benefit and Reimbursement Scheme” also stipulates: “Orphan drugs included in this scheme without drug license must acquire drug license or documents certifying their safety and efficacy from the competent authority within 3 years, or they will be subject to delisting. However, drugs that have obtained the US or EU market approval are exempt from this requirement, and their prices may be reduced by 5% annually.” The NHIA will continue to collect opinions from experts and scholars and revise the orphan drug payment regulations according to clinical evidence. For example, the review of the orphan drugs payment for mucopolysaccharidoses and Fabry’s disease was carried out and implemented in December 2018 and September 2019 respectively. In addition to the abovementioned policies, we will evaluate the efficacy of high-priced orphan drugs constantly in the future to ensure the rational allocation of NHI resources.

Changes in health status are often unpredictable. The offspring of healthy persons may also be at risk of suffering from rare diseases. Therefore, the NHIA always treats patients and their families with empathy. Life is valuable for everyone to pursue their own opportunities. Even though the medical expenses of patients with rare diseases are high, we uphold the spirit of caring for the disadvantaged and allocate limited resources fairly. In consideration of medical rights, fairness and justice, and social ethics, we firmly support patients with rare diseases by fulfilling medical needs that their lives depend on. We call on everyone to cherish medical resources together, so that every dollar of the premium of the NHI contributed by each citizen can benefit more insured people in need of medical care.

My Health Bank—Promoting Self-Health Management

My Health Bank Guards Our Health

To realize “people-centered health care,” the NHIA applied the concept of My Data to establish “My Health Bank” in 2014. People can browse their medical and health information of the past 3 years on their mobile devices, including outpatient records, inpatient records, surgical data, medication records, allergy data, examination and test results, imaging and pathological examination, test reports, hospital discharge summaries, willingness for organ donation, hospital palliative care, adult preventive care, vaccination records, physiological measurement, hepatoma risk prediction, evaluation of end-stage renal disease and other information. Possessing personal health records not only encourages their self-health management but helps them to communicate with medical providers, and thereby improves the safety and quality of the medical care they receive.

Rapid Cell Phone-Based Certification Allows Users to Manage Their Medical Information Easily

The NHIA integrated personal health information of “My Health Bank” into “National Health Insurance Mobile Easy Access” mobile application (NHI Express app). The function of rapid cell phone-based certification for users’ identity was further added in May 2018 under the premise of information security. The rapid cell phone-based certification function of the NHI Express app makes it the first application that government agencies use on a large scale for identity certification through cell phones because of its safety and convenience.

To allow people to search information related to the National Health Insurance quickly in a more intuitive and user-friendly way, the NHIA continues to optimize the operation surface and the service process of the NHI Express app. A modified vision was introduced in March 2021, aiming to enhance the quality and efficiency of these convenience services.

Family Member Management Function Added to Safeguard Family Health

The family member management function was added to the My Health Bank system in May 2019. For the elderly and children under 15 who are less familiar with electronic products, a designated person can access the My Health Bank system for the elderly and children on his or her own cell phone through the family member management function to assist their health management (Fig. 5.4).

Fig. 5.4

Family member management function safeguards our family’s health

Software Development Kit Connects Health Services Better

To further apply the use of the My Health Bank system to more diversified settings, the NHIA developed the Software Development Kit (SDK) of the My Health Bank system in May 2019, so that third-party apps can connect with the My Health Bank system through the SDK. After authorization, users can select personal medical treatment, medication, test results and other information within a specific period in the My Health Bank system freely, download and store it on mobile devices and bridge it to trusted third-party apps. The third-party apps can combine their original functions with medical information so that the user can receive more value-added healthcare services, such as online medical consultation, chronic disease management, while using the apps they are already accustomed to. The data from the My Health Bank system integrated to the third-party app enhances the completeness and value of health information, and therefore makes it easier for its user to manage their health.

As of 9 November 2021, a total of 130 manufacturers (306 apps) have applied, 23 of which (47 apps) have been officially launched. Among them, 11 are health information management software companies, 9 are medical institutions, 2 are medicine and medical device manufacturers, and 1 is a government agency.

Supporting Name-Based Mask Distribution System to Assist the Country in Epidemic Prevention

The global pandemic of COVID-19 continued to heat up in 2020. The name-based mask distribution system was implemented in February 2020 to ensure a stable supply of anti-epidemic masks, granting people equal opportunities to purchase masks, and the NHI card was used as the ID for purchasing masks at pharmacies. The name-based mask distribution system 2.0 was implemented in March of the same year and the NHI Express app is utilized for mask preorder processing, and a review of purchase history. In this way, purchasing masks is much easier for populations such as office workers and students so that they no longer have to wait in a long queue at pharmacies.

The function of the My Health Bank system also continues to increase. The total number of medical visits and a detailed history of medical visits were added to the system (Fig. 5.5). By displaying the total number of medical visits in each of the past 3 years, as well as the number of RVUs claimed by medical institutions and co-payments paid, we look forward to helping the public to understand and cherish the resources of the NHI overall (Fig. 5.6).

Fig. 5.5

My Health Bank—overview function of medical visits

Fig. 5.6

In September 2020, the National Health Insurance Administration (NHIA) celebrated the 25th anniversary of the National Health Insurance and over 5 million logins to My Health Bank. Premier Su Tseng-Chang, Health Minister Chen Shih-Chung, and NHIA Director General Lee declared the opening of the ceremony together. (From Executive Yuan. https://www.ey.gov.tw/Page/AF73D471993DF350/a3b1039f-ad86-4571-a713-f2cb7eb986cb)

The Significance of Including National Health Insurance in Elementary School Teaching Materials

It has been 27 years since the inception of the NHI in 1995. If we personify the life course of the NHI, it is already a college graduate who has entered the workforce. However, even though many people rely on the NHI, their understanding of it is still at the “kindergarten” level. Some people think the NHI is just like private medical insurance, life insurance, and accident insurance; some people think that because they pay the NHI premium every month, it is a waste not to use it and even want to earn their money back; some people think that the NHI will take care of them when they are sick anyway, so they neglect their obligation to take care of their own health. Therefore, we hope that pupils can understand the meaning and value of the NHI through the articles and lectures in the elementary school Chinese curriculum to cultivate the concept of cherishing the NHI resources in the younger generation.

When organ donation was actively promoted at National Cheng Kung University Hospital, an organ recipient Mr. Chao-jung Huang wrote about his life experience in an article “Love Doesn’t Die.” After being rewritten by the National Institute for Compilation and Translation and Hanlin Publishing Company, the article was included in the fifth-grade textbook. When promoting a concept with activities such as field trips or speeches, the audience reached is limited because of time and space constraints. However, by integrating the concept into textbooks that are read by tens of thousands of students every year, the idea takes root from generation to generation, creating a more profound influence.

The establishment of the concept of the NHI must start at an early age. By incorporating it into elementary school textbooks, the concept can be conveyed from teachers to students, from students to their families, and then spread from close family members to other relatives and neighboring communities. The NHIA has always emphasized and promoted the value of “cherishing the resources of the NHI.” Officials of the NHIA visited the Ministry of Education to explain this idea in person. The Minister of Education, Wen-chung Pan, also recognized further incorporating the concept of the NHI into education (Fig. 5.7). Both disciplines of Health and Physical Education and Society in the 9th year and the 12th year include related topics such as understanding of the NHI and medical system and avoiding resource abuse.

Fig. 5.7

On 15 December 2017, Director Po-Chang Lee visited with Minister of Education Wen-chung Pan

By introducing and discussing the social phenomena presented in the texts, teachers can gradually foster students’ sense of citizenship. Although the two subjects of Health and Physical Education and Society touch upon the concept of the NHI, the Chinese course, for 5 h per week, allows children to have more time for reading and thinking. Therefore, the ultimate goal is to include the NHI in a Chinese subject textbook.

The NHIA has visited several publishers to discuss these ideas. As Hanlin Publishing Company has adapted the article describing the experience of organ donation, “Love Doesn’t Die,” it highly recognizes the educational concept of the NHIA, and strongly supports including it in Chinese subject textbooks. After many discussions, Hanlin assisted in the drafting of “The Most Admired Health Care System in Asia” and included it in the “Reading Paradise” unit of the fifth-grade Chinese subject textbook. In addition, Nani Publishing also promised to include two articles about the NHI in the Chinese subject workbook of the fifth grade in elementary school, so that children can also be exposed to the concept of the NHI when practicing new words learned in the class (Table 5.5).

Table 5.5 The topic of National Health Insurance is included in Chinese elementary school textbooks

In these textbook articles, Ms. Shu-chu Chen’s childhood experience is used to illuminate that because of the medical care provided by the NHI, no Taiwanese are unable to seek medical treatment owing to economic barriers. We also mention the current development of information technology and provide students with a preliminary understanding of the convenience brought about by the “National Health Insurance MediCloud System (NHI MediCloud System),” so that they can have more confidence in tiered medical care. The functions and advantages of “My Health Bank” are introduced to strengthen the ability of self-care. The most precious thing is using this opportunity to explain the spirit of “mutual assistance” of the NHI with easy-to-understand wording and inspire both older and younger readers to internalize the concept of cherishing the resources of the NHI.

The incorporation of the concept of the NHI into Chinese subject textbooks was carried out in 2020. We believe that the goal of cultivating the concept of cherishing the NHI resources in the general public will be achieved step by step from now on (Table 5.6).

Table 5.6 The content of the elementary Chinese subject textbook about Taiwan’s National Health Insurance published by Hanlin Publishing Company (From Hanlin Publishing Company. https://www.hle.com.tw/index.html)

The Most Admired Health Care System in Asia Author: Su-Ling Chen A vegetable vendor in Taitung, Ms. Shu-Chu Chen, was ranked as the eighth place among the top 100 influential people in the world by American Time Magazine in 2010, as her selflessness moved people all over the world. She has been hardworking and thrifty all her life, but generously donated to those in need. However, there are several sad stories behind her kindness.	Reading Paradise 2 Try to answer the question before you start reading. Please describe what items are needed when you visit a clinic or hospital by yourselves or accompanied by your family members.
Ms. Shu-Chu Chen’s family was poor. When she was 13 years old her mother died in childbirth because her family couldn’t make up the NTD 5000 deposit for the hospital. Later on, her third brother suddenly had an unknown disease. Her family missed the best time to rescue him and lost him because they couldn’t make up the medical expenses immediately. Even after many years, Ms. Chen Shu-Chu couldn’t help but fill her eyes whenever she recalled these memories: “Because we were too poor. If we had money, our family member would not have left us. It was because we could not come up with money for medical expenses...” This is the true story from Ms. Chen Shu-Chu’s miserable and helpless family. It is also a portrait of many poor families in the era when there was no health insurance system—they did not have savings or the means to pay for the medical care they needed.
Only those who have suffered understand the taste of bitterness. Therefore, Ms. Shu-Chu Chen is willing to endorse the NHI for free. In the short film “It’s nice to have the National Health Insurance,” she said with sentiment: “When there was no National Health Insurance you had to borrow money from others when you get sick, …… you won’t understand the hardships of no money for saving lives until you encounter it.” Indeed, if you haven’t experienced the hardships, it is difficult to truly understand. We Taiwanese enjoying the comprehensive health insurance system now should know more about and support the National Health Insurance. Logo of the National Health Insurance You can find a circular logo on the top of the NHI card. There are two “little green persons” in the middle of the logo. It is not the little green man traffic sign that helps us to cross the road, but a logo of the NHI! Take a closer look, the logo shows a man and a woman shaking hands, which means:
“Help each other and take care of each other, and then everyone will be healthy.” Let’s further imagine, which English letter does this male and female shaking hands pattern look like? Yes, it’s the English letter “H”! Do you know? This “H” implies three special meanings, which are “Help” each other, “Health,” and “Happy.” It means that: “If everyone helps each other, everyone can be healthy and happy!” Isn’t this sign very interesting and meaningful?
Features of National Health Insurance Help each other and care for the disadvantaged Let’s start form the meaning of “Help.” The National Health Insurance is a compulsory program. Since its inception in 1995, the insurance has been financed mainly by the premium contribution of the public, employers, and the government. It is worth mentioning that the NHIA has allowed people who owe premiums to seek medical treatment in time when necessary, since June 2016. The purpose is to prevent life-long regrets just like Ms. Chen Shu-Chu’s relatives, who were unable to go to the doctor owing to financial difficulties.
At the same time, it also allows better-off people to contribute more to maintain the sustainability of the National Health Insurance and benefits everyone continuously. Technology integration safeguards our health The NHIA has built the National Health Insurance MediCloud System to provide physicians with patients’ medical information and access to more sophisticated medical examination images. This is also a major prerequisite and guarantee for the implementation of the “tiered medical care system”—if the patient needs to be referred, the medical history information can be exchanged smoothly. Everyone can also obtain his or her medical and medication records within the past 3 years by checking their “My Health Bank” online, and fully understand their personal health status. It is a good aid to self management of health!	In the “tiered medical care system,” treatment of minor illnesses such as colds and minor injuries are taken care of in clinics; large hospitals focus on treating severe illnesses and contributing to medical research.
All people are satisfied, feeling happy inside out Taiwan’s National Health Insurance system is based on the concept of goodness: “care for each other and help each other.” It aggregates the power of everyone to realize the goal of providing equal rights to medical care. In recent years, more than 80% of people surveyed are satisfied with the service of the National Health Insurance. The comprehensive and continuous medical care provided by the National Health Insurance contributes to healthy bodies, and further brings physical and mental wellness. Taiwan is widely recognized by the world for its National Health Insurance In 2008, the US Public Broadcasting Service produced a special report that compared the health insurance systems of five countries, including the United Kingdom, Taiwan, Germany, Switzerland, and Japan. The report praised Taiwan’s healthcare services, smart NHI cards, and low medical costs, which are less than half of those in the United States. These strengths have all become the focus of discussion.
After reading this article, if you want to design a new logo for the National Health Insurance, what will your elements be? In what way will it be presented? Please draw the pattern and explain it.	Taiwan’s National Health Insurance system has also become the model for countries around the world because of its high satisfaction rate. Various reports from international media and journals brought Taiwan more attention and affirmation from people around the world.