Jesse Lin 0:19
This episode, we wanted to take you back to our homeland and explore a key thing there that is not here, which is a centralized, quote unquote socialized health care system, which covers everybody in the country and provides them access to pretty nice health care. And I think that this is something that we’ve wanted to look into for a while because it is something that’s really cool coming from a small nation island of like less than what 35 million people. And we we thought it would be interesting to take a look at how their system is formulated. And maybe how we can take some of the learnings from that and see if a system of that kind could ever be rolled out here in the US. So just to kick things off, I think that we’re going to go through a few key pieces of information about the national healthcare system in Taiwan. First of all, it’s been around for a while now, especially since Taiwan hasn’t been a country for very long. The system was launched in March of 1995. And overall, I think it’s proven to be very effective. And I think before the National Health System was set up, there was a lot of gaps in insurance coverage similar to here in the US, it was something like only 57% of the population in the country was covered by some form of health insurance. And it wasn’t even very clear if those were plans of equal parity, meaning that everyone had the same access to the same coverage, the same cost. So in fact, a good amount of people in the nation, the island nation did not have insurance coverage. And one of the one of the main things we want to talk about is like how this system came to be in Taiwan, it seems like before that they placed the system in place, it was very similar. I was reading an article where they had like different kinds of insurance for like different kinds of laborers so they had like, my mom talks about it Actually, she says she has, she has the jian bao, but she also has like Farmers Insurance or something like that. And the article that I read said, like each job type had their own kind of like specialized industry insurance. And so part of the reason they rolled out this system was to improve the efficiency by just like streamlining everything into like one administrative, like one administrative entity. And there was a second piece that was in the article that I read that was talking about how the other part of it was kind of advancing social justice, although social justice I guess you may consider is like a newish term or newishly more popular, but it was the idea that they wanted to be able to cover everyone and give everyone the opportunity to access health care.
Full Transcript (Note: Transcribed via AI, may contain errors)
Angela Lin 3:11
I think a lot of people when they hear the term like universal health care, they think it’s just free health care for everyone. And that’s not the case, at least in Taiwan. What we are talking about here is just that everyone in the country is part of this program, this national health insurance program. And they have the same level of access to doctors and you know, services, but there is still like out of pocket payment involved. And we can get into like, generally how much and whatnot. But it’s not free. And it’s not. It’s not free to taxpayers, certainly. And it’s not necessarily free for a patient when you just you don’t like walk out of a hospital without paying anything, right. But anyways, is still infinitely more unified and simplified than our current system. But I just want to put that out there because I think I fell into that where I was like, oh, when I hear the term universal health care, I just think it’s like free for everything. Yeah, yeah. And part of the history also of how Taiwan came to be with the system is they knew that they wanted to reform their health care system, which is fucked up like ours back in the 80s. And then they basically looked around the world and looked to other countries to see which ones had like better systems and what they could adopt. And in particular, they looked pretty closely at the UK’s single payer system and that’s what I guess this, this type of function is called single payer system, which is basically like there was no like Blue Cross and Kaiser And like all this stuff, it’s just like there’s like one facilitator. It’s that kind of systems called the single payer system. Some random Princeton dude help them.
Jesse Lin 5:11
I saw his name was like, Reinhardt or something.
Angela Lin 5:14
Yeah, something like that. Yeah. So US had some influence apparently in this I yeah, I think his last name was Reinhardt and he was a Princeton professor or something. But he was married to a Taiwanese woman. So that’s where the connection came. But for some reason, Taiwan was like, hey, what do you think? And he was like, you should do the single payer system and they were like, okay. But hey, I don’t know it worked out, I guess. But that’s a fun fact of like, randomly how they landed on the current system. To be fair, I think he did already write a few papers about how fucked up the US healthcare system was, and sort of like analysis on other global competitive systems. And that’s probably why they tapped into him, but it was just so funny that they’re just like, hey, US rando
Jesse Lin 6:06
You random person. Well, as Angela mentioned, I think it’s very interesting to look into how each of the systems works. And so we’re going to look into specifically how healthcare in Taiwan is covered under the system here. Because as Angela mentioned, it’s not free. And so it’s a good idea to understand what healthcare for all actually looks like in Taiwan. So, overall, there’s like a mix of government subsidies and premiums paid from the taxpayers or the citizens. And it’s actually interesting, because I didn’t quite understand the difference, but they’re like, it’s not a tax, you pay a premium instead, which I’m like, I don’t really see what the differences like but you’re paying for it one way or the other. So yeah, so you do get you do pay the government for the insurance. For needier individuals, there are subsidies so like everyone is able to get covered regardless of their income and things like that. Um, but as it relates to like other pieces of how the insurance works, I didn’t actually know this for a while, I thought that like all the doctors and stuff were like public employees, and they’re actually not. So like, a lot of the studies also said that most of the general practitioners and most of the operators in the insurance in the health care industry are actually private, with the exception of like large government hospitals, and they basically compete with each other for the money that’s paid by the government for all the services and I think a key difference again, between the UK, UK single payer system and the one in Taiwan is also that in Taiwan, you don’t need to see a you don’t need to referral to see any doctor. Whereas in the UK, they use general practitioners to like if like an HMO like it is here, you have to see the general practitioner and they have to clear you to see refer you to see a specialist. But in Taiwan, this is not the case. And you can see basically, whoever you want, provided they have the slot open.
Angela Lin 9:31
And then the copayments and stuff as we mentioned, it’s not free to go to doctor’s visits and to stay in the hospital, but it is a lot more reasonable than in the US. With that said we’re obviously looking at this from a Western mindset. So we’re paid US dollars and looking at this thing like wow, it’s so cheap, but I don’t know if it’s really you know, I’m sure it’s not like gonna break anyone’s bank. But I don’t think people look at it as like as dirt cheap as we do because we’re paid in dollars. But anyways, um, in the US a big reason that people go bankrupt is hospitalizations. And you can’t control how long you need to be in the hospital. If you’ve been in an accident or you have like chronic illness or all that, and that can easily rack up to be like five, six figure bills pretty quickly. In Taiwan, I saw that the coinsurance for inpatient care is capped at about $1200 US for any like, single visit, even if you stay for multiple days. And then if you have a chronic illness that you’re in there a lot, then they even have an annual ceiling and it doesn’t go over $2100, which is likeā¦
Jesse Lin 10:54
That’s pretty legit. I think my deductible was $2000.
Angela Lin 10:57
Yes, yeah. It’s comical compared to what we rack up like, you. I remember when I had food poisoning in the middle of the night when I was at NYU, I thought I was gonna die. Like it felt like I was dying. And they were like, Oh, we could take an ambulance. Or you could wait for the like NYU shuttle to public safety. Yeah, the public safety bus to take you to the hospital. But the ambulance will cost you like $3,000? No, it was 1000s of dollars. And I was like, I will wait for this free shuttle bus because I’m not gonna pay for freaking 1000s of dollars for an ambulance. So yeah, just to get used to the hospital would be more than this annual ceiling of chronic illness being treated for weeks on end in a hospital. So that for sure is like huge round of applause for making that happen.
Jesse Lin 11:51
So I mean, we’ve covered a lot about how this system works. So it sounds like a natural segue into like, what are the great things, and we were touched upon a little bit before and what are like the not great things about this system. Um, I think, obviously, since it is a universal system, one of the benefits is that almost everybody in the country is covered by the system. Everybody has like a national national ID card health card used for paying for services. And one of the big benefits of this is that when you go get services done, you use the card, and the payment, and the service transaction happens very quickly. And I think that’s also a big issue that we have here, which is that you never know how much a service is going to cost here, you go to the doctor, they’re like, Oh, it’s $15 copay. Four weeks later, you get a bill that’s like $500. And you’re like, what the hell. So I think that’s also one of the great things is that like, all the services are negotiated and the card basically, you can pay and you know immediately how much you have to pay. And I think as I mentioned before, you don’t need a referral to see a specialist. So you can basically go to any hospitals see any doctor you want, provided that they have the you know, available time slots to see you.
Angela Lin 13:05
And going back to the card just so that people aren’t totally lost. With our episode title, it’s the card itself is called Jian Bao. So that’s why our episode is named as such our favorite kind of bao. But yeah, and another pro, which is not perfect by any means. But at least a step in the right path is with your Jian Bao card. Another benefit is that any doctor who has it when they put the chip in to the reader, they see the last three months of your medical history. So it is also a digitization of your medical record, at least to a certain extent. It’s not perfect because I looked up it was basically like it’s only three months. And then you can find up to three years of history through a different system. It’s like, you know, comically the same as the US and that there’s like 5 million different systems that don’t connect but at least the Jian Bao is everyone has it. And at least for like your most recent history, any doctor you go to can see that which you’d have to just repeat verbally and like get paper, you know, documents and shit if you really wanted to do that in the US. So that is definitely a step in the right direction that Taiwan also has.
Jesse Lin 14:25
Nice. Well, I think we did talk a lot about how the system works and kind of in connection to that, like a lot of the good parts of it. So maybe it’s worth visiting like which parts of it are not good as well in thinking about how the system might work here in the US.
Angela Lin 14:41
For me what I think is the worst part of their system is exactly what you said is the good part which is from the patient point of view, the ability to go see any doctor you want and without a referral any specialist in the whole country sounds Fantastic, and you’re covered, and you have no problem saying, theoretically, that’s fantastic. From a doctor standpoint, it’s terrible. Like I was reading articles where healthcare workers are like, the patient is in heaven, and the doctor is in hell.
Jesse Lin 15:15
Yeah, I saw that one.
Angela Lin 15:16
Yeah. Because they don’t have time to do anything. Like they’re constantly seeing patients, which in the US is also the case. But can you imagine if there is zero gatekeeping at all, so the doctor’s time, there would just be like, an overflood of it. And one good example I read was like, the ER, the emergency room is like, there’s no delineation of what’s an emergency and what’s not an emergency, which is really bad. Actually, if you think about it, like if someone just got run over by a car, and they’re like, on the brink of death, but there’s all these old people, and they’re just like, I have a cold, and I just want to see the like doctor in this hospital. So then they’re waiting and like clogging up the queue. And, as far as I read, one of the complaints from the ER doctors was like, I can’t prioritize between those things. Like, it’s just, I have to see all of them. So then, you know, arguably, some lives are more at risk, because of this, like kind of no prioritization. And also from my own experience, too, because I got sick when I was in Taiwan a few years ago, nothing big. I just, I literally had like, bronchitis or whatever. But I didn’t go to a big hospital, I just went to like the neighborhood clinic. One of the drawbacks is that the doctors have zero time for you. So like, they’re just rotating you in and out, you’re literally a cog in their wheel, you know, like, the, it’s like, it’s both because of the way the system works. And in terms of like, their incentive, and also just like the number, the volume of patients that they have to see, but they have no incentive to build any rapport with you. Because it’s just like, I need to get like 50 patients through my door in the next hour. So I’m giving you literally two minutes of my time. So I saw that essentially every visit is between two to five minutes, which is like absurd, because in the US, at least they try to build some rapport like I do, you know, one medical and these Urgent Care things all the time in the US. And it’s always doctors I don’t know very well, or at all right, but they always tried to be like, Hi, I’m Dr. Johnson, blah, blah, blah, you know, like, whatever builds a little bit of rapport with you. And that in and of itself takes like five minutes. And this doctor, I had bronchitis and I waited, it was not a short wait, by the way. Because, yes, as we mentioned, lots of people going to any doctor all the time, I think I waited like an hour. And I only saw him for five minutes, or whatever. And it really I felt like I wasn’t even a human. Like I walked in, he like pushed the patient out. And I like he was like, come and come in and like wave, like, push me in the same chair that that patient just came out of. And then he just started like shooting random things up my nose and like taking my temperature. Like he wasn’t asking me for anything. He’s just like doing all this shit. I was like, What is happening? And then he just like, pushed me out. You know? Like, it was just like, Okay, I’m done. Here’s your prescription. Goodbye. I’m like, Okay, bye. What just happened. Um, so I think if you’re not able to go to one of those big hospitals and get like, really well known doctors or whatever, there are a lot of downsides with just like, access to a doctor doesn’t mean it’s access to a good doctor. That’s one of the biggest complaints that I saw from the patient side is just like quality is not well controlled. It’s it’s extremely variable, from doctor to doctor hospital to hospital. And then like I said, for the healthcare workers, it’s like, I don’t get why anyone wants to be a doctor. tbh. Yeah. Which is not good for the future of healthcare in Taiwan.
Jesse Lin 19:06
Yeah, I also did read that the fact that it’s so cheap, incentivizes people to go a lot, but there was also some, like, some of the articles were saying, like, it may or may not be like a uniquely Taiwanese thing to do that. Because it like, for example, in the UK, I don’t see I don’t think they see the same level of GP visitation just because people have free access to the GP. So they’re saying like, it’s kind of like a uniquely cultural thing where people like, as soon as they feel unwell, they’re like, we’re gonna go to the doctor. And so because there’s no, the GPs are not in charge of sorting people out, as you mentioned, like there’s all all the points of the system are overloaded by like the person making the choice of where they want to go.
Angela Lin 19:50
Yeah, I think the cultural thing is interesting. My speculation is that it has to do with and we’re just making broad strokes stereotypes, but some of that’s true, right is that Asian people respect authority a lot. And if you’re a doctor, you have quite a bit of authority because you know, way more than the general human about how to stay alive and to live as long as possible. So I especially if your first visit or whatever, you found anything wrong, I’m sure that’s why people keep going back. It’s just like, hey, it’s free. And you said, something’s wrong. I’m gonna go back until it’s fixed. Yeah, versus you actually mentioned a while ago that your mom hates going to the hospital in the US, right? Like she won’t go get checked up on ever in the US?
Jesse Lin 20:42
I mean, it’s yeah, I think it’s just a variety of factors. But she doesn’t really enjoy.
Angela Lin 20:46
I read this in the articles, but I know from firsthand as well is that I think a lot of that is literally just language and cultural and, and monetary, monetary to right? But my parents have held back on like, minor to semi big surgeries or like procedures that were needed until they were back in Taiwan, because they would feel more comfortable, they knew that they could get like some of the best health care that was available if they went to like one of the big hospitals in Taipei, and that it would be covered largely by the health insurance. So they would like draw out some of the, you know, the pain and the shit that they were going through to wait until they were back in Taiwan. And apparently, this is very common for people who live abroad who are not in Taiwan all of the year.
Jesse Lin 22:20
For the fortune cookie, we wanted to talk about whether or not we felt like health care for all if it’s something that could be successfully implemented in the US. And I think we’ve touched upon a few things that are interesting to start with. I want to primarily start with the culture component of it. Because I do think that a system of socialized health care does rely on some user responsibility to some end. And we can definitely see that in the Taiwan case, because we do see a lot of people over using the system visiting specialists visiting hospitals, in situations that they don’t need to do that. So it is very interesting to see that like there’s a system in place that covers everybody, but it really does rely on some personal responsibility, like personal exercise of judgment. I do feel like we have like, there’s very much I mean, we’ve talked about this in the past before, like related to work stuff, but there’s very much this culture of like work yourself to the bone and like don’t take care of yourself. And I feel like that’s the kind of thing where people would still not like even if there was free universal health care, like people would not necessarily over utilize it. But also like I you know, in the past recent years, I’ve gotten access to telehealth, and actually, I think a lot of people do now because of COVID. And I don’t feel like I’ve like utilize telehealth in more frequent way than I would normally see like a regular doctor. So like even though I have access to this and telehealth can give me like antibiotics and prescribe all these other things. Like I don’t really call them unless I unless I was like really needing to go to the doctor.
Angela Lin 23:57
Oh, I used it. I mean, it’s not like it was like a speed dial every week. I’m gonna call the doctor but I definitely there’s once there’s a lower barrier to it because they also weren’t charging the way.
Jesse Lin 24:09
It’s free. It’s free.
Angela Lin 24:10
Yeah. I remember I think I was talking to you when it happened or like the day after, but I got like a second or third degree burns from from cooking like burgers or something in the hot oil like spat. And I had like bubbles on my arm and yeah, anyways, like I could’ve treat it I did end up treating it at home myself. But I was kind of freaking out. So I sent a message to my you know, one medical people because I was like you can treat they have an option where it’s like treat me now I’m like, Yeah, why don’t you fucking treat me now? You know, I mean, and they did and I was like, whatever it is. You didn’t tell me anything I didn’t know but like I feel better knowing that a doctor telling me my the way I’m treating my burn is fine. I would definitely use it more for little stuff. Like I think I think you’d be surprised how much more someone would use health care if the barrier to entry is a lot lower. And by that I mean ease and cost. Yeah, there’s also the flip side because this is something I actually talk a lot with Ramon about, which is a huge gap that’s missing in the US healthcare system. And I’m I don’t think it’s really addressed in the Taiwanese one either, but we’re just talking about like, ideal future, right? Is preventative care. There’s no preventative care, like when you go to a doctor, it’s like, something’s already wrong with you. And they’re just trying to like patch the thing that’s wrong with you. Versus like, right now I recently did a program called Parsley Health that’s for it’s a women’s health program, and you pay out of pocket your own money, whatever, there’s insurance can cover part of it, too. But it’s fully preventative where you have a doctor, a medical doctor assigned to you, as well as a health coach. And they’re really focused on like, Okay, what are some like big health concerns in your lifestyle in general, so like, maybe you’re just like, I’m always tired, or I’m like, I have a bunch of acne that this has never gone away, or like you know, things you want to address that are not like life or death. And they will work with you on figuring out your diet, your habits, get bloodwork preventative bloodwork taken to see what your baseline is to like find the root causes of these just like things preventing you from having your best life, and like helping you to get towards that best life, I think that is like very missing in current health care. And if that were free, I would fucking go all the time like that would you know, I would be on a call with my doctor or my health coach, like every two weeks, because it would be a maintenance thing, where you’re just trying to, like maintain good health, not like, fix little shit that’s wrong with you.
Jesse Lin 27:05
What other parts of this, I think may or may not work here in the US. I think in reading a lot of the articles, there was a good one in Vox about it. Another thing related to culture is that the Vox article kind of mentioned all of the not nice parts about the system, like you don’t really get to see the doctor a lot, not being able to access specific treatments. But in the article, they were saying like a lot of people recognize that these are the problems but like in order to serve like the, the need of the most people, they recognize that they need to try to like work to like improve the system, and that it’s not going to be like everything for everyone all the time. And I also see that I think from a cultural perspective, that’s not how it is here. But because it’s very individualistic, right? It’s all about me, and like when can I get access to this for me now? Rather than, like, how can the most people benefit from this system? So from that perspective, I think it’s also very much a barrier. And I think we already see that in some of the conversations around people like, oh, we’ll lose losing your private health insurance. You know, people are very scared about that. And yeah, I don’t want to lose my private health insurance, like it works fine. But it’s very much that kind of thing where it’s like, Whoa, but we could move to something that could work just as good for everyone. And there’s some fear in committing to that, because we’re very, like individualistic society.
Angela Lin 28:37
Yes, I completely agree in general, because we’ve talked about this so many times, but in general, Asian, Eastern versus Western culture is way more community oriented than Western culture. That is true. And at the same time, I don’t know if they mentioned in the Vox article or a different article. But it’s good to note that before this system was first adopted, when the government announced that it was going to go into action. 80% of the population was against it. So actually, it was not like a Kumbaya. Everyone was like, Oh, yeah, let me just like give up my things so that everyone can be great together. Like everyone opposed it until it actually started working. And they realize like, Oh, actually, it’s probably this is better. Yes. So I want to throw us a bone in that, like, no one reacted that way in Taiwan either. I think the other related piece about individualistic attitudes, though, is I mentioned the word incentives. I genuinely believe that is the biggest barrier to getting us on this single payer system. Because America is centered on capitalism and you what incentives drive individuals. And there is a lot of different incentives for every single part of this system that is going to inhibit the ability to move to this kind of system. And one of the biggest is what doctors are paid in the US compared to what doctors are paid in Taiwan, in the US, doctors make shit until they are practicing but once they’re practicing, they’re making high six figure, right, to compensate for the fact that they work tirelessly. And under the single payer system, the way that Taiwan has it is that there’s a fixed budget for every year. And that’s spread out to cover every potential thing that any citizen wants to do with regards to their health in that year, which means that there was a fixed sum to go across every single doctor in America. And that means realistically, salaries are going to go down. And that that’s going to be the case for both doctors and the insurance companies. Because the insurance companies are like a mafia right now. Like, there’s a reason why it’s been really difficult for us to break the current system, it’s because insurance companies make a shit ton of money right now from us. And so for the government to be able to negotiate properly with doctors and insurance companies to make them feel like they’re still going to earn like, as much or almost as much as they currently make on this, like free market system. I just don’t believe that. Because if they’re gonna really be able to pay them as much as they currently make, it means that we the citizens, which is the other incentive, that’s fucked, is we’re going to be paying a shit ton of money out of our taxes to cover this if we’re really going to pay out the current prices of what doctors and insurance companies make today. So that’s my biggest worry is that it’s just the money doesn’t make sense from all different places.
Jesse Lin 32:11
Yeah, I think the incentive thing is a huge piece, because like to what you’re saying, there are many parts of the healthcare system where the incentive is not oriented towards a person’s health. And rather, it’s like oriented toward towards something completely different. And I also think it’s really hard for people to accept, like, under this single payer system, there are no insurance companies in Yeah, in Taiwan, their government is the insurance company, basically. So I can’t say that crunching the numbers. But like, in theory, I guess it could be possible for the doctors to be paid the same if you just removed the administrative waste on the insurance part, and made the money go to actually the people who are part of the health care transaction, meaning the doctor and the patient. But obviously, there’s a huge industry lobby to not have that happen, because they’re large companies that generate good amounts of profit. So I do agree with you, I think it’s a big problem, because it’s a, the incentive, it’s not set correctly, to keep people healthy.
Angela Lin 33:15
And then of course, that’s a whole other topic. But I do want to throw out that the taxing thing is going to be because taxes are the biggest recurring topic for any US new policy you want to pass is like, how is that going to work? And how is that going to be fair between citizens? And what does fair mean, based on every individual? Right?
Jesse Lin 33:40
Yeah, I that’s a good point. And one of the things I was just thinking about is just kind of like, at the end of the day, the legislative Yuan made the decision, and like, they kind of made that decision, knowing that it wasn’t popular, but that they believed it was the right thing to do. And just based on that alone, I just don’t think it will happen. Because like, think about the people who we have in the Congress right now, nobody is going to put their ass on the line to do the right thing, which is like the unfortunate truth. But I do want to say that like, I think the and I’m looking at the Wikipedia, maybe Wikipedia is not a great source. But there was a there was a quote in the Wikipedia that said, in 2009 interview, Michael Chen, Vice President and CFO of the National Healthcare Service, explained that one of the models that they did investigate was the United States, and that fundamentally, the health service is modeled after Medicare in the US. And it’s basically the same thing, except that their program covers all of the population, and Medicare only covers the elderly. So it doesn’t, it really doesn’t seem like that much of a stretch, because they’re saying that they have essentially the same system. They just cover more people under it. But I do believe based off of what you’re saying about the economic incentives and the political willpower, that I think it will be a very difficult thing to achieve. Well, on that note, I guess we can we can conclude this episode. As always, if you guys have any questions, comments, maybe you’re actually an expert on this topic to weigh in and correct us anywhere where we did not accurately reflect the factual situation or the actual opinion of the people living in Taiwan about the health system write us in?
Angela Lin 35:27
Or you are very knowledgeable of different reasons why it could or could not work in the US to adopt something like this. We also want to hear from you because we should have started with this – I genuinely think we should start this with any topic where we research stuff but – recurring disclaimer that we’re not experts at anything. And we are just talking about topics that we’re interested in that we do some like as much research as we can, as you know, lay citizens, but we are not experts by any means. So we’re always open to corrections and real expert opinion.
Jesse Lin 36:05
And you can send all those to our email at telluswhereyourefrom@gmail.com or you can dm us on Instagram, @Whereareyoufrompod and a reminder that we’re still looking for listeners story submissions, so if you haven’t already write us in we’re eager to read your story
Angela Lin 36:25
About anything. It can be about literally anything about everyone. Okay, well then come back next week for a fresh new episode.