This month, the National Health Insurance (NHI) is to implement a major policy change by eliminating the suspension-and-resumption mechanism for Taiwanese residing abroad. With more than 210,000 Taiwanese living overseas — many with greater financial means than those in Taiwan — this reform, catalyzed by a 2022 Constitutional Court ruling, underscores the importance of fairness, sustainability and shared responsibility in one of the world’s most admired public healthcare systems. Beyond legal obligations, expatriates have a compelling moral duty to contribute, recognizing their stake in a system that embodies the principle of health as a human right.
The ruling declared the prior suspension mechanism unconstitutional, citing a lack of statutory authorization and potential inequities in its application. While the ruling affirmed citizens’ right to manage their health risks autonomously, it placed significant weight on the collective responsibilities inherent in Taiwan’s compulsory social insurance model. The decision highlighted how selective participation undermined the equitable distribution of costs and the system’s financial stability.
Under the previous framework, individuals could suspend contributions while abroad and reactivate coverage upon returning to Taiwan, often when medical needs arose. This created a dual-tier system where expatriates could game the system to access subsidized healthcare at minimal cost, while domestic residents paid premiums consistently, regardless of usage. The court’s emphasis on the principles of equality and proportionality justified a policy overhaul, ensuring that all participants contribute fairly to the NHI.
The NHI is not just a public service; it is a social contract. Participation in the system reflects a moral commitment to collective welfare, a principle enshrined in the country’s healthcare ethos. Expatriates benefit from the system’s existence, whether by using its services when visiting Taiwan or through the peace of mind that coverage provides in emergencies.
Consider the practical implications. An expatriate who delays treatment abroad due to high costs and flies back to Taiwan to access subsidized care places undue strain on the system. Their selective participation exploits a loophole that not only disadvantages consistent contributors, but also risks eroding the system’s financial viability. According to the NHI Administration (NHIA), such behavior undermines the system’s core principle of equitable risk-sharing.
The NHI faces mounting challenges, including an aging population, rising healthcare costs, and incidents of fraud. A 2019 report warned that without intervention, the system could face insolvency within years. Recent increases in premiums were necessary to stabilize the system, but they also underscored the need for equitable contributions from all eligible participants, including expatriates.
Cases of abuse further highlight the need for reform. Fraudulent reimbursement claims and selective use of NHI services during brief returns to Taiwan place disproportionate burdens on the system.
By requiring consistent contributions, the new policy aligns financial incentives with system sustainability. The NHIA estimates that the abolition of the suspension mechanism would generate an additional NT$2.3 billion (US$70.86 million) annually, a critical infusion for a system that provides world-class care at a fraction of the cost of other countries.
The decision mirrors international practices that emphasize solidarity in healthcare funding. Many European nations maintain strict contribution requirements for citizens abroad. They recognize that consistent participation prevents inequities and ensures that healthcare is accessible to all.
Conversely, systems that allow selective participation often struggle with financial instability. For example, the US’ Medicare system faces solvency issues partly due to similar disparities in contributions versus utilization. Taiwan’s proactive approach positions it as a global leader in balancing accessibility with financial responsibility.
At its core, the NHI embodies the principle of health equity, providing universal access to care regardless of income or residence. This equity relies on the collective commitment of all participants. Allowing expatriates to selectively contribute undermines this principle, creating a system where those with higher financial means or international access benefit disproportionately at the expense of consistent contributors.
The updated NHI policy is a necessary step to safeguard the system. By requiring expatriates to pay premiums, it affirms the principle that healthcare is a collective right supported by shared responsibility. This change ensures that the system remains equitable, financially stable and accessible for future generations.
The policy is not just a legal obligation but a moral one. It reflects an acknowledgement of expatriates’ stake in Taiwan’s healthcare and its preservation. As Taiwan continues to set an example in global healthcare, all citizens — wherever they are — should embrace the shared commitment to fairness, equity, and solidarity.
Y. Tony Yang is an endowed professor and associate dean at George Washington University.
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