Health Care Must Be More Than a Pretext for a Crucifixion

Health Care Must Be More Than a Pretext for a Crucifixion
China Times editorial (Taipei, Taiwan, ROC)
A Translation
January 6, 2011

The Second Generation Health Care Bill has become law. The Department of Health estimates that once health care premiums and coverage are adjusted, the health insurance system will remain solvent for the next five years. It will not have to raise premiums. The main intention of the bill passed by the Legislative Yuan was to make premiums fairer, to cover the shorfall in the health care system budget, and to make the system more egalitarian. The amended law gets a passing grade.

But as predicted, Director of Health Yang Chi-liang has stepped down. Once again, health insurance rate hikes have become an excuse to crucify the Director of Health. The political environment on Taiwan has once again subjected experienced professionals to undeserved abuse.

Seeking new sources of income, Second Generation Health Care has undergone a major change, from a single-track system to a dual-track system. The current system calculates monthly premiums entirely on the basis of income. This is the standard premium. The new system calculates monthly premiums on the basis of dividends, interest, and business income as well. This is the supplementary premium. The fee base has been expanded. As a result, annual premiums will increase 20 billion NT. According to Department of Health estimates, the dual-track system will obviate the need for health insurance rate hikes for the next five years. As a result of the new supplementary premium system, highly-paid professionals, major investors in the stock market, company bosses worth hundreds of millions of dollars, highly paid performing artists, and highly-paid talking heads will have to pay higher premiums. This is consistent with public demands for social justice.

In addition to increased premiums, Second Generation Health Care includes other reforms. For example, expatriates usually do not need to pay premiums. But they often make special trips to Taiwan each year. They renew their policies, pay the premium for one month, and immediately begin enjoying exactly the same benefits as everyone else. The new system requires expatriates to return for a six-month waiting period. Only then can they begin receiving benefits. These reforms will reduce the extent to which people exploit the health care system's limited resources. For underprivileged families and victims of domestic violence, Second Generation Health Insurance will continue to honor their cards even if they cannot pay the premiums, even if they are late in their payments, and if they are sick and unable to receive medical care.

Yang Chi-liang and other medical professionals have certain ideals. Second Generation Health Insurance failed to nullify six categories and 14 items defining the status of policy holders. Instead it adopted a "total household income" policy for calculating premiums. This amounts to a major failure. Nevertheless it mandated increased premiums. Health insurance rates for the majority of salaried and working class policy holders were reduced from 5.17% to 4.91%. Approximately 83% of all policy holders will have their premiums reduced. This is probably the best compromise possible between ensuring a solvent health care system, and minimizing the financial burden on the public. It was also a major achievement for long-suffering Director of Health Yang Chi-liang. Unfortunately, he was still forced to step down.

Look back at the history of health care. Every Director of Health understands that when the NHI was created, no one had any experience with national health care. Estimates for premiums, for dependents, for fees and other items were still very rough. They soon had to be adjusted upwards. But no one dared to make the first move. Anyone who did, would be blasted by the Legislative Yuan. The Executive Yuan, needless to say, cowered and did nothing. In 2002, Li Ming-liang was the only Director of Health who dared call for a rate hike. But as soon as it was passed, he too had to step down. Add to this the example of Yang Chi-liang, and health insurance rate hikes have become synonymous with Directors of Health stepping down!

But the most ridiculous aspect of Yang Chi-liang's resignation was that he was not forced to step down due to pressure from the opposition party or the public. He was forced to step down because he was sabotaged and attacked by the ruling party executive and legislature. The most popular official in the cabinet was forced to tender his resignation. Last March, health insurance premiums were hiked. Concerned about the five cities elections, Premier Wu Den-yih pressured Yang Chi-liang not to increase rates as much as planned. In November, the Second Generation National Health Insurance Bill was submitted to the Legislative Yuan. Amazingly, KMT legislators were the ones who blocked the bill. Then, over the past two days, KMT legislators were the ones who asked teary-eyed, that Yang Chi-liang stay on. Their two-faced behavior was truly disgusting.

Li Ming-liang defended Yang Chi-liang. Li said that when he proposed dual increases in health insurance premiums, there was a public outcry, A number of NGOs and trade unions took to the streets. The pressure was immense, and hard to imagine. But at least he had the support of the Presidential Office and the Executive Yuan. Public opposition to the current increase was comparatively mild. But ignorance on the part of the ruling party and deliberate distortions spread by the opposition party left Yang Chi-liang all alone, hung out to dry, surrounded by enemies, front and rear. He had no choice. Not leaving would merely have made him a glutton for punishment.

Yang Chi-liang's resignation has been approved. He asked to be relieved, and he was. The public sees him as a man with the courage of his convictions, as a political appointee with the guts to defend his own policies. Over the past two years, the Ma administration has used and abused three Directors of Health in rapid succession, including Lin Fang-yu, Yeh Ching-chuan, and Yang Chi-liang. All three were well thought of by the medical community. All three were capable professionals. Yet their average tenure was less than one year. They did not step down because they committed major errors in medical policy. Yeh Ching-chuan was ordered to resign and wage an unsuccessful campaign for elective office. This underscores the alarming rate at which Directors of Health are being used up.

Yang Chi-liang has quit. His departure reveals the cruel logic of Ma administration rule. It persistently trumpets its idealism, its assumption of total responsibility, its commitment to public policy objectives, and to cabinet officials who have earned the public trust. But when push comes to shove, all it ever does is back down. How can the public not be disillusioned?

別再讓健保議題 變成署長絞肉機
2011-01-06 中國時報

二代健保修法過關，根據衛生署估算，這次調整保費費率及費基範圍後，可保五年健保財務平衡，不會再談費率調整。綜觀立法院通過的法案內容，最主要的精神是保費計算更趨公平，既可補健保財務大洞，也更符合社會公平原則，算是一次差強人意的修法結果。

只不過，一如預告，衛生署長楊志良下台走人，再一次的，健保費率調整變成了衛生署長絞肉機，也為台灣政治生態霸凌專業再添一例。

為了替健保找財源，二代健保一大變革是費基從單軌變雙軌；現制只就月投保薪資計算保費（一般保費），新制把股利、利息、執行業務所得等也計入（補充保費），費基擴大，一年可以因此多收到二百億保費。根據衛生署試算，雙軌制因此可以使健保在五年內不必再調整保費費率，而領高額獎金的業務員、股市大戶、億萬身價的大老板，還有高所得的藝人與名嘴則因為補充保費的設計而要多繳保費，符合社會公平的呼聲。

除了補充保費，二代健保還有多項改革。例如，目前海外僑民平常不繳保費，但一年專程回來一次，幾天內辦好加保、繳了一個月的保費，馬上就可以和你我享受完全一樣的健保待遇。新制則要求，僑胞回國要經過六個月等待期，之後才可以加保看病，以此減少「占便宜」式的健保資源消耗。對於弱勢家庭、家暴受害者等經濟弱勢對象，二代健保有不鎖卡的規定，以免他們因繳不起保費或遲繳而有病沒法醫。

雖然，從楊志良和部分醫界人士的理想來看，二代健保未能取消六類十四目投保人身分分類、改從「家戶總所得」的概念計算保費，仍是一大敗筆。但因為補充保費的制定，適用廣大受薪及勞工階級的健保費率反而由現行五．一七％降低為四．九一％，約有八三％的投保人保費會降低，這個結果應該是健保財務與民眾負擔二者間最大的公約數，也是奮鬥多時的衛生署長楊志良的大功一件。遺憾的是，他竟然還是辭職下台了。

回顧國內的健保歷程，每一任署長都知道，當年健保開辦，國內沒有經驗，儘管經過各種精算，費率、眷屬、費基等重大項目仍很粗率，必須調整、調高。但沒有人敢碰，一碰，立法院就罵、行政院就龜縮。民國九十一年，唯一調漲健保費率的衛生署長李明亮也是法案一通過就下台，加上楊志良，健保費率調整與衛生署長下台成了同義詞！

然而，楊志良下台最令人感到荒謬的是，他並非因反對黨或社會壓力而下台，他之所以走人，絕大部分因素是執政黨行政、立法部門的掣肘或打擊，才讓這位內閣人氣最高的政務官大唱驪歌。去年三月，現行健保費率調漲，因五都選舉考量，行政院長吳敦義硬是要求楊志良降低調漲幅度；同年十一月，二代健保草案在立法院闖關，竟然是國民黨立委封殺草案。但這兩天又是國民黨立委出面哽咽慰留楊志良，前後嘴臉令人作嘔。

李明亮替楊志良叫屈，他說，當年他提出健保雙漲，輿論大譁，各種民間團體、工會走上街頭，壓力之大，難以想像，但他至少還有總統府和行政院的支持。這次調漲，來自社會力量的反彈相對輕微的多，但因執政黨的愚昧畏縮及反對黨的刻意扭曲操作，楊志良只能孤軍奮戰、腹背受敵，不走人，是自取其辱！

楊志良請辭獲准，是他求仁得仁，民眾也看到一個敢於堅持理想、替政策辯護的政務官。而馬政府二年多來，已經消耗了三任衛生署長，從林芳郁到葉金川到楊志良，都是醫界風評不錯，也有相當能力的專業人士，但他們平均任期不到一年，下台原因也並非醫療政策有重大錯誤─葉金川甚至是啣命辭官參選卻敗選！反映了衛生署長驚人的消耗率。

楊志良走人，反映了當下馬政府治國團隊中的一個殘酷邏輯，一路堅持理念、任事負責、達成政策目標並獲民意肯定的閣員，最終還是「不如歸去」，如何不令人喟嘆！