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Thursday, October 12, 2017

this American's experience with universal health care

One thing I have come to appreciate so much about Taiwan is its universal health care system. The definition of universal health care is a health care system that provides health care and financial protection to all citizens of a particular country.

Due to debates going on in America, I feel like it is my duty to offer my personal experience with universal health care to balance out the voices of those Americans who try to make inflammatory statements about it despite the fact they have never experienced it themselves-- or, as is likely, actually been to a country that has it. 

First, let me hit you with this truth bomb in the form of a map:
The countries in gray do not have universal healthcare, the countries in blue do, and the countries in green are beginning to implement it. In regards to this issue, America has more in common with Africa and the Middle East than it does with the nations we like to compare ourselves to in Europe, Oceania, or Asia.

[Bonus points for you if you can find Taiwan on this map. Hint: it's blue.] 

Below is an abstract from the U.S. National Library of Medicine. You can the whole study here
Taiwan adopted a national health insurance system in 1995. It is a government administered insurance-based national healthcare system. Although, like the UK, Taiwan has a single payer system for healthcare, there are several differences between the two systems. The characteristics of the Taiwanese system include good accessibility, comprehensive population coverage, short waiting times, relatively low costs and a national health insurance databank for planning, monitoring and evaluating health services. The weaknesses include variable quality of care, a weak gatekeeper role and increasing financial pressures.
I think this the first thing Americans talk about when debating the possibility of NHI in America, so I will be as transparent as possible.

[Note: Taiwan's universal health care is paid for through premiums, which are largely based on payroll taxes and then supplemented with co-pays, out-of-pocket payments, and government funding.]

Since the largest contributor to NHI is payroll taxes, let's look at one of my pay stubs: 
I make 115,119 New Taiwanese Dollars (NTD) monthly, which is the equivalent of $3,837 USD. As you can see at the bottom of my pay stub in the column labeled "Health Insurance Deduction", I lose 1,296 NTD monthly to NHI, which is the equivalent of $43 USD. In one year, from my salary and guaranteed bonuses, I earn $55,636 USD. In the course of that same year, I pay $516 USD to NHI, which is a whopping one percent of my income. I will reiterate: I am sacrificing one percent of my income in payroll taxes to fund Taiwan's NHI.

The copay at every single clinic or hospital is the same: 150 NTD, which is $5 USD. Often when I go to the doctor, this is the only fee I pay. This is true when I pop by our neighborhood clinic for flu or ear infection treatment, or when I was pregnant and would get an ultrasound at every appointment along with a urine test, or when I had to see a GI specialist about a polyp in my gallbladder. Please understand what I am saying: the fee for seeing the doctor and any medication is 150 NTD.

The only times this has not been true for me were when I had my elective c-section and when I went to the ER for said polyp as well as when I was 36 weeks pregnant and experiencing complications. My elective c-section and my 6 day/5 night stay in the hospital cost me 30,000 NTD, which is $1,000 USD, because it was not covered by insurance. My two trips to the ER, one of which included an x-ray, an ultrasound, a urine test, a blood test, the consultation of two doctors, and two prescriptions, both cost me 600 NTD each, which is $20 USD.

I understand that this is only true for Taiwan's universal health care system, and apparently there is "increasing financial pressure", at least according to the U.S. National Library of Medicine, but I am clearly being charged a negligible amount of money to receive quality, comprehensive health care.

This is the second thing Americans rage about when talking about instituting NHI in America: wait times to get appointments to see doctors. Once again, it is my endeavor to be as transparent as possible, so let's break this down as clearly as possible.

Yesterday, Sean mentioned that he wanted to see a dermatologist to get a few moles and freckles checked out. Within three minutes of him mentioning that, I had already booked him an appointment online for today for him to see a dermatologist. How? I will walk you step by step through the process.

Everyone, meet Mackay Memorial Hospital.
Mackay Memorial Hospital, Hsinchu City
[Note: In order for you to understand the process, you will need to open a tab with this website.]

This hospital is a five to ten minute drive from our apartment depending on traffic. In Taiwan, hospitals are a collection of doctors' offices as well as emergency services. For example, I went to Mackay to see my OBGYN throughout my pregnancy. It is also where I delivered Ruby. It is also where we take Ruby to see her pediatrician. It is also where she was hospitalized in the baby unit when she was one month old for her severe GERD. It is also where I went to the ER due to extreme stomach pain about one month ago. It is also where I consulted with a GI specialist and underwent testing for different abdominal conditions. It is also where Sean visited a dermatologist to get tested for skin cancer. It is also where he had physical therapy for back pain from a tennis injury. It is also where he had a series of rabies shots after he was bitten by a monkey in Bali, but that is a whole story in and of itself.

Do you get the picture-- need something done? It's simple: go to this one place where you can have anything and everything done.

There are two other hospitals just like Mackay in Hsinchu City alone, but we go to Mackay because it has the best reputation in Hsinchu City and we know it well. However, at any point in time, I can see any doctor at the other two hospitals in Hsinchu City, or, if I wanted, I could see any doctor on the island. For example, we took Ruby to a children's hospital in Linkou, a suburb of Taipei, just for a second opinion about her GERD medications and their dosages from a pediatric GERD specialist who was recommended to us by one of Sean's student's parents.

You may be wondering how it is so easy to make an appointment at any of these hospitals, and I will show you. Let's pretend that I am making an appointment for Ruby to see her pediatrician later today because she woke up with a fever. After going to Mackay Memorial Hospital's homepage, I follow these steps:

Step 1: Translate the webpage to English
Step 2: Click on "Network Registration"
Step 3: Translate the webpage to English
Step 4: Click on "Network Registration"
Step 5: Translate the webpage to English
Step 6: Click on the department I want, which in this scenario is department #30 Pediatric
Step 7: Translate the webpage to English
Step 8: Find Ruby's pediatrician #4543 Li Sijia (whom we adore by the way) on the desired day of the week at the desired time, which is either the morning, afternoon, or evening
Step 9: Find the date; appointments can be booked three to four weeks in advance.
Step 10: Enter your medical ID # and date of birth

And that's that. You did it. Congratulations. That is exactly how I made Sean an appointment in less than three minutes yesterday so he could see a dermatologist today.

[Note: Each hospital in Taiwan has a similar online registration system.]

Using Mackay's website, you can also cancel appointments or double check the date and time of standing appointments.

Here are some things you should know:

First, if a pediatrician has a full schedule, you will not be able to choose that date on Step 9. In that case, you could choose a different doctor who has an opening on the same date. In the entire 5+ years I have lived here, I have never had a problem seeing a doctor when I needed to. Further, every single time I have needed to take Ruby in without advanced warning, I have always been able to take her to see her pediatrician. I never had to make an appointment with a different one. I am sure if we stayed here for another five years, it may happen once, but really, who cares? If I need to, I can see a doctor that day.

Second, if you miss more than two appointments in one month without cancelling first, you will not be allowed to make anymore appointments that month. However, that is just for that one specific hospital. You could always make an appointment at a different hospital. However, as it takes less than one minute to cancel an appointment online, I don't know why anyone wouldn't just do that.

Third, all Taiwanese citizens and alien residents (which we are) have an NHI card. Your NHI number is the medical ID for Step #10. Every single clinic and hospital has a machine that can read the chip, and it contains your medical history. It looks like this:
When we first came to Taiwan, we obviously needed to apply for our NHI cards. I got one instantaneously because I was employed. Sean had to wait six months before he could be covered under NHI because he was not working, and therefore not paying into the system (albeit I was paying for him with my NHI dependent payroll deduction). However, he could still visit a doctor at any time. Instead of entering his medical ID # for Step #10, he entered his passport #.

In fact, every single one of you reading this blog post could make an appointment at Mackay Memorial Hospital now that I have shown you how to do it (but please don't, okay?).

The entire process of going to a doctor appointment in Taiwan is very, very different from the process in America. Once you have completed Step #10 for making an appointment to see a doctor, you will be given an online confirmation with the following information:
The conformation for Sean's appointment, which has been poorly translated into English by Google
  • the date of your appointment
  • your doctor's name 
  • the hours of your doctor's clinic (morning clinics are from 9am-12pm, afternoon clinics are from 1pm-4pm, and evening clinics are from 5pm-8pm)
  • the floor of the hospital your doctor's clinic is found on
  • the room in the clinic in which you will meet with your doctor 
  • your patient number
The most important pieces of information to take note of are the clinic hours and your patient number. For example, I made an appointment for Sean to see a dermatologist (Dr. Lin Shang/#4222) during a morning clinic, which runs from 9am-12pm, and his patient number was 41. The number system is much like the one at the DMV where you pull a number and wait your turn. Today, that meant that Sean was the 41st patient the doctor met with during the morning clinic, and he had to wait for the 40 people before him to meet with the doctor before it was his turn. 

Your most obvious question should be: How do I know what time to go to the hospital if I don't have a specific time to meet with the doctor? When we first moved to Taiwan, we just guessed when to go, and we spent a lot of time in waiting rooms. However, after a few months, we learned that there is a feature on Mackay's website (and every other hospital's website) that allows you to check which number the doctor is on for those particular clinic hours, so today, Sean headed to the hospital when the doctor was on patient 37, and he waited less than five minutes to see the doctor. 

Another obvious question should be: What happens if I miss my number? When I was pregnant, I made all of my check ups during evening clinics, which occur from 5pm-8pm, so Sean could be there. However, those are peak rush hour traffic times. Sometimes, we would get to the clinic and the doctor would be on a number after my patient number, meaning I wasn't there when it was my turn to see the OBGYN. How does the hospital deal with that? You knock on the doctor's door to let the nurse know you are there late, and then you have to wait two more numbers before they will squeeze you in for your turn.

The exception to this system is getting a procedure or scan done. For example, when Ruby was admitted to the hospital when she was one month old, her doctors discovered that she has an ovarian cyst. Their recommendation is that we monitor it every three months to check its size. In September, she had her first follow up scan. We were given a specific appointment to have the echo done, so we knew exactly when to go to the hospital. The same was true for my ultrasound scan to check my abdomen.

I think a lot of Americans worry that their quality of health care will suffer if universal health care is instituted. In this regard, I can only speak of my personal experience. Never once have I felt rushed in and out of a doctor's office.

Ruby's pediatrician regularly spends at least 15-20 minutes with us for her well baby check ups, and when Ruby was ill with severe GERD in the first few months of her life, her pediatrician routinely spent 30-45 minutes with us to talk about how to manage her symptoms. Further, she has also called specialists while we were in the office to see if there was anything else we could be doing.

During my high risk pregnancy, my OBGYN was meticulous in looking over my blood pressure charts and examining my other varied symptoms of preeclampsia. He did everything in his power to help up make it from my diagnosis at week 26 to 38 weeks so I had the best chance of delivering a healthy baby. He even came to the hospital in the middle of the night to double check on me when I was 36 weeks pregnant and experiencing complications, so all I can say is I never feel like I sacrifice quality for cost here.

One unique aspect of visiting a doctor in Taiwan is that during the appointment, he or she will use the patient's health card to pull up medical records on a computer and update the records in real time. All medications and previous tests & visits are available to peruse with the click of a button. I find it to be very helpful (and time saving) not having to explain things to new doctors. For example, last month, I went to the ER due to extreme stomach pain. While there, I had an ultrasound, x-ray, blood tests, and a urine test. After being sent home with some medication, I made an appointment with a GI specialist at the recommendation of the ER doctor. When I met with the GI specialist, he could examine the results of the ultrasound, x-ray, and labs. He was also able to schedule an appointment for me to get a more thorough echo just three days later during which he found the cause of my pain: a polyp in my gallbladder.

Overall, I have no concerns about the quality of treatment I receive or the timeline in which I receive it.

Each hospital has its own pharmacy. If a doctor prescribes you medication, he or she will electronically send it to the pharmacy in the middle of your appointment, so while you are still meeting with the doctor, the pharmacy technicians are already filling your prescriptions.

Once you are done meeting with the doctor, you will receive an invoice and prescription, and you will take them to the cashier. At the cashier, you will pay the co-pay, and they will stamp your prescription. Then, you go to the pharmacy (in the hospital) and show them the receipt. Then, they will walk you through anything you need to know about how to take the medication or possible side effects.

I have never been given a medication that was not covered by my $5 USD co-pay.

I strongly suggest you read this literature about Taiwan's universal health care, but I will review its salient points.

  • NHI is compulsory in Taiwan, so every single citizens, which includes me, has it. 
  • Taiwanese people sacrifice 1-2% of their annual income in order to contribute to NHI. 
  • Anyone living below the poverty line receives NHI for free without contributing any payroll tax. 
  • Doctors are well trained and go through the same schooling as American doctors, and they are still paid well and earn on average $110,000+ USD annually. Considering the GDP is $22,000 USD, doctors are certainly still in Taiwan's upper class. 
  • Since instituting NHI in 1995, the life expectancy for both men and women in Taiwan has increased, and the discrepancy between the health of the rich, middle class, and poor has narrowed significantly. 
  • The system is convenient and there are no "waiting lists" to see doctors or have procedures
  • There are literally no limitations about which doctor or hospital patients can seek care from or at

Moving forward, it will be very hard for us to go back to America's health care system and not cast harsh judgment, and I already know what some people will say: if I think Taiwan is so much better than America, why don't we just stay?

Here is my response: is it such a terrible thing for me to wish my own country to be a more humane, people-centered place instead of a corrupt, profit-centered place? I mean, really, come on you guys: refusal to cover preexisting conditions and health care bills that cause bankruptcy? Is it really such a terrible thing that I wish we could be our neighbor's keeper like the people of Taiwan are, and all contribute to one pot that helps every single person?

Is it really such a terrible thing to take an honest look around and think: we can be better and do better, so let's?

If you think it really is such a terrible thing, well, then, I guess I am really not all that surprised because 67 percent of the population seems to agree with you, which is really something I just cannot wrap my mind around, which is precisely why we are getting our permanent citizenship in Taiwan just in case we feel we need to return. 

After all is said and done, what do you think?
Do you want America to at least try to be better in this regard?
Do you want to see universal health care in the states?

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