A Proposal to Prevent Healthcare Grab and Go in Taiwan

In April 2020, a Taiwanese woman tested positive for COVID-19 after her flight from the United States back to Taiwan. This case sparked controversy because she has been residing in the United States since 1990 and did not once return to Taiwan during this 30-year span.[1] Even before the COVID-19 pandemic, however, non-resident citizens who reside overseas for extended periods of time have been taking advantage of Taiwan’s high-quality and affordable healthcare.  Local residents found it unfair that they are shouldering the cost of non-resident citizens’ medical care expenses. In light of these controversies, we must ask the question of what society owes to their non-resident citizens. Even though they live abroad, given their status as citizens or even just as humans, to deny them of healthcare seem to be at odds with our moral intuition. Do they deserve to be treated equally?

After outlining the particulars of Taiwan’s National Health Insurance policy, I will puzzle through this morally ambiguous situation by considering Dworkin’s idea of equality of resources and forbiddance of gamble. I end with proposing a strict egalitarian approach that requires all foreign nationals to always be enrolled in the NHI even when they are abroad.

Introduction to the National Health Insurance Program

Taiwan recently celebrated the 25th anniversary of its National Health Insurance (NHI) scheme, a compulsory program that strive to ensure all citizens are provided with affordable healthcare starting from birth. Behind this social insurance program is the concept of mutual assistance between citizens and the government, for it depends on the insured paying their monthly payroll-based premiums and the government to provide affordable medical resources. According to the National Health Insurance Administration (NHIA), “every Taiwanese citizen with official residency or foreign national living in Taiwan with an Alien Resident Certificate (ARC), regardless of age, gender, or employment status, must enroll in the program.”[2] This highlights the principle egalitarian and non-discriminatory spirit and that underlies the NHI, for not only does it protect its own citizens, it also extends its care to the potentially disadvantaged as well as foreigners residing in the society.

The National Health Insurance act includes detailed conditions regarding the NHI subscription of overseas citizens. Those that will be abroad for over six months are given the choice of whether to continue or suspend their NHI coverage. Re-registration will be approved and healthcare coverage will be restored on the day of return. Withdrawal is required for those that had departed without return for more than two years. Re-enrollment in the NHI program is possible under the condition that their household registration is re-established for a minimum of 6 months.

These specific conditions demonstrate the government’s attempt to prevent occurrences of medical “grab and go”. Yet these conditions still make it possible for foreign nationals to take advantage of the system. Specifically, the choice to “opt out” of the NHI program indicate that non-resident citizens, who did not pay their monthly premiums during their time abroad, still have access to affordable healthcare immediately upon return. Do these citizens deserve to benefit from Taiwanese healthcare despite not contributing as much and as consistently as the local residents?

Applying Dworkin’s Luck Egalitarian Framework

To think through this moral puzzle, I turn to political philosopher Ronald Dworkin’s luck egalitarianism framework. Dworkin advocates for equality of resources: a system that holds individuals responsible for their choices and argues that they should be compensated for situations out of their control. Dworkin writes, “under equality of resources, however, people decide what sorts of lives to pursue against a background of information about the actual cost their choices impose on other people and hence on the total stock of resources that may fairly be used by them.” (Dworkin 1981, 288). While he argues for individual choice to be taken into account, Dworkin also asks people to be mindful of the cost of their decisions on others and the society’s resources.

Tangent to his idea of individuals being responsible for the outcomes of their choices, Dworkin  introduces the concept of option luck versus brute luck. According to him, option luck is a “deliberate and calculated gamble turn out” (Dworkin 1981, 293) because individuals are informed of the risks of their choices but still choose to gamble. On the other hand, brute luck “is a matter of how risks fall out that are not in that sense deliberate gambles” (Dworkin 1981, 293). People are struck by bad brute luck when they find themselves disadvantaged by situations over which they have no control. People who fall victim to bad brute luck and are thus left in an undesirable situation the Dworkin deems as unequal. By making this distinction, Dworkin tries to draw a line between luck and not luck in order to understand how inequalities brought about by individual choices should or should not be eliminated.

In the case of non-resident citizens, Dworkin would argue that their choice to live abroad and to discontinue NHI subscription means that they are responsible for the outcomes of these decisions, even if the outcomes may not be fair. For example, someone who choose to live abroad and also choose to suspend his NHI plan may save money because he does not have to pay the monthly premiums. This illustrates a positive outcome of his decision. But upon being diagnosed with illnesses that require expensive surgery, he returns to Taiwan and ask that his medical expenses to be the same as those who are enrolled in the NHI. If this person does not receive the same discounted medical bill as the locals, he claims this situation to be unfair towards non-resident citizens. Dworkin would, however, reject his challenge that such distribution of resources is unequal on the grounds that this person made the calculated gamble of withdrawing from the NHI to save money. His situation cannot be categorized under brute back luck, because he was presented with the opportunity to mitigate potential bad brute luck by subscribing to health insurance. In choosing to forego this option, this person thereby falls under the category of bad option luck. He gambled, but he lost. Thus, he should be the one taking responsibility of his choices, instead of asking for the premium-payers, the government, and the NHI program to shoulder the cost of his medical expenses.

Sympathetic Attitude and a Firm Proposal 

Yet, while Dworkin’s harsh stance that society do not owe non-resident citizens anything might be satisfying for the locals, our moral intuition may still be at odds with this approach of abandonment.[3] After all, as “foreign” as non-resident citizens may be, they are still identified as citizens. Should a society allow its members to be disadvantaged economically (by paying the medical expenses in full) just because they live abroad? Especially considering that the NHI program allows foreigners who study, work, or reside in Taiwan to receive the same healthcare benefits as the locals, perhaps we should think about treating our non-resident citizens with equal respect. Or, at the very least least, include them under the egalitarian spirit of the NHI.

I thus propose a straightforward solution that seeks to balance both sides of moral intuitions using Dworkin’s idea that certain gambles should be forbidden. According to him, there are certain rights, such as religious or political rights, that should not be up for gamble (Dworkin 1981, 295). I propose to include health as one of these rights and eliminate the policy that allows or requires non-resident to withdraw from the NHI program. The NHI is designed in a way so that locals, regardless of citizenship, do not get to gamble with their health. As stated in the beginning, everyone is required enrolled in the NHI since birth. For the locals, they do not get to “opt out” of the NHI  because they want to save money on the monthly premiums. Why, then, should foreign citizens even receive this option in the first place?

Therefore, my recommended solution would be for non-resident citizens to continue paying their premiums even during the period that they are abroad. The only way to truly “opt out” of the NHI program is by signing a contract, stating that one has no intention of returning for medical care. Regretting the contract is permissible under the condition that one pays back the missed premiums in full. In doing so, an equality of starting point is achieved because both locals and non-resident citizens are required to pay monthly premiums. The equality of outcome is also achieved because everyone can receive affordable healthcare. This solution continues to uphold the NHI program’s egalitarian spirit and manages to appease the local community while not abandoning any non-resident citizens.

Conclusion 

This debate of healthcare for non-resident citizens reveals uneasy sentiments surrounding the meaning of citizenship. The idiom “a near friend is better than a distant kinsman” illustrates the complicated attitudes of local residents and government policies when determining the appropriate treatment towards non-resident citizens. Amidst all the moral ambiguity, perhaps the first and best rule of thumb is to treat others with equal respect—without any concern of citizenship status, but simply because we are human beings.

 

References 

  1. Dworkin, Ronald. “What Is Equality? Part 2: Equality of Resources.” Philosophy & Public Affairs, vol. 10, no. 4, 1981, pp. 283–345.
  2. Everington, Keoni. “Woman leaves Taiwan for 30 years, returns with coronavirus.” Taiwan News, 14 Apr. 2020, https://www.taiwannews.com.tw/en/news/3915729
  3. 2020-2021 Handbook of Taiwan’s National Health Insurance, by the National Health Insurance Administration, Ministry of Health and Welfare

[1] Everington, Keoni. “Woman leaves Taiwan for 30 years, returns with coronavirus.” Taiwan News, 14 Apr. 2020, https://www.taiwannews.com.tw/en/news/3915729

[2] 2020-2021 Handbook of Taiwan’s National Health Insurance, by the National Health Insurance Administration, Ministry of Health and Welfare

[3] Such moral intuition is inspired by Elizabeth S. Anderson’s negative critique of luck egalitarianism in her phenomenon work ‘What is the Point of Equality?

“保養” by 【J】 is licensed under CC BY 2.0

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At Yale-NUS College, we are thinking about ideals of equality and democracy, and how they relate to practice, in Singapore and in the wider world.

This website showcases our reflections.

Articles were originally submitted as course papers for Professor Sandra Field’s classes Contemporary Egalitarianism and Democratic Theory.

The Equality&Democracy project has been made possible through the support of a Teaching Innovation Grant from the Yale-NUS Centre for Teaching and Learning: ‘Applying Political Philosophy to Real World Cases’.

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