Taiwanese pro-democracy protestors clashing with the military police at a World Human Rights Day gathering on December 10, 1979 (Photo: taiwan’s National Repository of Cultural Heritage)
Taiwanese pro-democracy protestors clashing with the military police at a World Human Rights Day gathering on December 10, 1979 (Photo: taiwan’s National Repository of Cultural Heritage)
" "To find your way in the fog, follow the tracks of the oxcart ahead of you." "
It’s about 4 p.m. Maine-time when my wife Hanji and I pop out of bed, wide awake though seriously jet-lagged, having arrived late the night before after a 21-hour flight from Portland to Taipei, Taiwan. It’s still dark, but the city is already roaring to life, with the whoosh of its state-of-the-art public rail system and the growl of hundreds of scooters zipping by our window. We begin planning our day. First we’ll take a couple of the city’s public bicycles down to the morning market for a light meal of Chinese egg pancakes. Then it’s on to serious business.

For Hanji it’s a full health exam, lab tests and a teeth cleaning. For me, it’s time to stock up on my asthma medication. For many years, I thought I had outgrown the condition, but in recent years, the wheezing and the frightening morning tightness in my chest has returned. Up until six years ago, my medications cost around $10 for the insurance co-pay, but they’ve since jumped to about $60 for one and $200 for a monthly dose of the other, due to a 2005 U.S. Food and Drug Administration decision to ban asthma inhalers containing chlorofluorocarbons (CFCs), which are known to contribute to the depletion of the ozone layer (albeit very minutely). 

As Mother Jones magazine reported in 2011, a consortium of seven pharmaceutical companies spent over half-a-billion dollars to lobby the FDA to ban generic CFC-based inhalers for “environmental reasons,” despite concerns from scientists and consumer advocates that the move would be of negligible benefit to the environment and that the new patented hydrochlorofluorocarbon (HFC) inhaler replacements actually emit greenhouse gases known to cause climate change. In the end, the cheaper generic CFC inhalers were banned, patents on new brand-name HFC inhalers were enforced, and the drug companies made out like bandits.

It’s the kind of Machiavellian behavior we’ve come to expect from a dysfunctional political system that allows corporations to exploit well-meaning laws to increase their bottom lines. It’s also an indictment of our broken health care system that puts profit over public health. But it’s a small price to pay for the luxury of breathing. 

Meanwhile, back in Taipei, Hanji’s total bill for the teeth cleaning, exams, lab tests and medicine is a fraction of what we’d pay out of pocket in the U.S. And I’m walking away with several months’ worth of inhalers for just $5 and $15 a pop. And that’s paying out-of-pocket without using health insurance. 

We’ve done this semi-annual routine for the past several years, despite the fact that we actually do have health insurance back in the U.S. But even though we pay over $3,000 per year for the premiums, it doesn’t cover the cost of my asthma medications and it has a $3,000 deductible. Back home we spend hours on the phone arguing with our provider over incorrectly coded bills, and we’ve had three bills discharged so far due to mistakes it’s made. Then there are the battles with the insurance company while we await the judgments of shadowy “managed care” tribunals to decide whether our plan will cover various medical procedures. 

We’ve realized that it’s actually cheaper and less stressful to simply see Taiwanese doctors for routine medical issues and medicines while we’re visiting Hanji’s family rather than deal with the massive tangled bureaucracy of the American health care system. And the irony is that Taiwan’s health insurance system is run by the biggest bureaucracy of them all — the government. 

When we lived in Taiwan several years ago, health care was always something we took for granted, like electricity or running water. In Taiwan there is no patchwork of private and public health insurance providers or maddeningly complex, Rube Goldberg-like insurance schemes that force consumers to choose among private subsidized plans with varying levels of coverage. I paid a $27-per-month premium for my National Health Insurance (NHI) card, which allowed me to choose from hundreds of hospitals and private neighborhood clinics. Taiwanese don’t generally wait weeks and months for an appointment. They just walk in and wait for the doctor to see them. Many clinics are open seven days a week, 12 hours a day in order to compete with the other ones down the block. The total bill for services is standardized and bundled with the cost of medicine — US $8 at a clinic and $14 at the hospital. 

NHI not only covers the cost of prescription drugs, but also dental services, diagnoses and treatment, consultations and operations, lab tests, anesthesia, inpatient and ambulatory care, traditional Chinese medicinal therapies, acupuncture, home nurse visits, chronic mental illness care, maternity services, physical rehabilitation and pretty much every other necessary health care service. Preventive care, including annual checkups, are free. People suffering from catastrophic illnesses, veterans and their dependents, children under the age of three, women giving birth and people living in remote rural areas are all exempt from making out-of-pocket co-payments. 

Employees and employers pay premiums for NHI coverage on a sliding scale through payroll taxes, which are supplemented by the out-of-pocket co-pays along with some direct government funding. Ninety-three percent of the hospitals and clinics are contracted with the NHI, which includes not only health care providers, but also pharmacies, nursing homes, psychiatric community rehabilitation centers, midwife clinics, labs, and physical therapy clinics, among others.

Unlike in the market-driven health care system in the US, where private insurers have limited bargaining power, particularly where larger medical providers hold near monopolies over health care services, Taiwan’s NHI Administration is able to control costs because it is the single payer for health services and drugs, with the full bargaining power of the entire island of 23 million people. All Taiwanese are required to pay into the government-run insurance plan.

Despite attempts to bring down costs through the Affordable Care Act, the United States still spends about $2.8 trillion per year on health care, which works out to about $8,500 per person and 17.5 percent of the country’s gross domestic product (GDP). In contrast, Taiwan’s per-capita annual health expenditures are US $2,546, accounting for just 6.2 percent of its GDP on health care. It also has a 2-percent administrative overhead, compared to the U.S., where about 12 percent of private insurance premiums go to administration. Every year, Taiwan’s Department of Health negotiates with physicians and hospitals to set the Global Budget, which helps keep the cost of the NHI down. While Census and Commonwealth Fund figures indicate that there are still 48 million uninsured and 31.7 million underinsured Americans, 99 percent of residents in Taiwan receive full coverage under the NHI.

Later on in our first day in Taiwan, I catch up with old buddy Jeff Curran. In our 20s we played in a punk rock band, but now with a wife and two kids, he’s moved on from his hard-rocking days to being a respectable 38-year-old family man. 

“I love almost everything about [the health care system],” he says. “I don’t worry about cost at all when it comes to my family getting sick. If my kids get sick or hurt, I just take them in to see somebody, and I never even think of how much it’s going to cost. It’s by far my favorite thing about Taiwan, and it is by far the biggest thing I’ll miss.”

Last year, Jeff had to have an endoscopy and oral surgery. And one day he and his wife Tracy rushed their daughter to the hospital after she burned her hands. All three visits: 8 bucks, 8 bucks, 8 bucks. But next month, Jeff and Tracy are moving back to his hometown, Seattle, where he’ll have to start all over again after living abroad for 15 years. The one thing that has caused the family the most worry about their transition, he says, is health care.

“I’ve been reassured that my family will be okay at the beginning because we’re poor and will be covered by Medicaid, but eventually, once we start earning money, I really have no idea,” he says. “It’s at the forefront of every thought and conversation I have about moving back. My goal is to find a job that offers health benefits for me and my family. In fact, I will take any job that offers that.”

While 80 percent of Taiwanese express satisfaction with the NHI, last year 72 percent of Americans told the polling firm Gallup that the U.S. health care system either had “big problems” or was in “crisis.” Unlike many American politicians who view health care as a privilege, for over 20 years Taiwanese lawmakers have formed a virtual consensus around the NHI mission that health care is a human right for everyone — “rich or poor, young or old, healthy or infirm.” But it took decades of intense struggle to get there. 

Taiwan’s Political Revolution

On a Sunday morning, we meet up with Lee Ying-yuan, a longtime politician and member of the leading Democratic Progressive Party (DPP), at a McDonald’s near his office at the Executive Yuan. 

A former dissident when the country was under martial law, Lee has served as a legislator, the Minister of the Council of Labor Affairs, Secretary General under the Prime Minister, Secretary-General of the DPP, and was most recently appointed to head the Environmental Protection Agency by newly elected DPP President Tsai Ing-wen. He’s also a childhood friend of my late father-in-law Chang Chen-hsiang. In the 1970s and ’80s, Lee and Hanji’s father were ardent supporters of the pro-democracy movement, which called for direct elections after several decades of one-party rule under the repressive dictatorship of the Chinese Nationalist Party, known as the Kuomintang (KMT). 

Following its defeat at the hands of Communist Mao Tse-dong’s Red Army in 1949, KMT leader General Chiang Kai-shek and his followers fled mainland China to establish the exiled Republic of China (ROC) government. With strong backing from the U.S., the capitalist ROC soon became a bulwark against the Communist Mainland during the tense years of the Cold War. 

But the KMT also had a dismal human rights record, most notably in its violent crackdown of a 1947 populist uprising that resulted in the deaths of between 10,000 and 30,000 Taiwanese civilians. A period known as the “White Terror” followed in which thousands of dissidents were executed or imprisoned. But during that time, Taiwan also developed rapidly from a poor agricultural economy to a thriving high-tech manufacturing hub due to the KMT’s state-led, interventionist economic policies. 

But after the U.S. began normalizing relations with China during the 1970s, it terminated official diplomatic ties with Taiwan and the country was expelled from the U.N. in order to appease the Mainland government, which to this day lays claim to the island. With an improving economy and marginalization of the KMT government on the global scene, overseas-educated students and academics like Lee began pushing not only for direct elections and an end to human rights abuses, but also for a range of environmental and labor protections. 

“At that time there were all kinds of injustices among laborers and farmers,” said Lee, who grew up in a farming village in southern Taiwan. “All kinds of social movements converged because it was time for the workers to change the system.”

Political parties were still illegal, so members of the dissident coalition called themselves the Tangwei (“outside-the-KMT). 

“Later the KMT felt that the movement became so powerful and forceful … so they designed an incident,” said Lee.

The “Kaohsiung Incident” occurred on December 10, 1979, when a peaceful pro-democracy demonstration turned violent as police marched in to break it up, injuring 90 demonstrators and later arresting and imprisoning dozens of its leaders. Imprisoned activist Lin Yi-hsiung, whose mother and twin 7-year-old daughters were murdered by an unknown assassin after his wife called Amnesty International, would later recall his treatment by the interrogators.

“If the investigators were not satisfied with an answer, they would keep hitting me until I couldn’t bear it any longer,” he wrote in a statement published by the International Committee for Human Rights in Taiwan in 1981. “I shall never forget the verbal intimidation, and what some of the investigators said to me: ‘If you don’t talk and give us the evidence, we will beat you. If you get beaten to death, we will just say that you committed suicide out of fear or guilt. If you don’t talk we will knock all your teeth out.’”

But the Kaohsiung Incident marked a watershed moment in Taiwan’s primarily peaceful transition from an authoritarian regime to a democracy, as the aggressive crackdown only strengthened the public’s resolve for freedom. Finally, in 1986, the KMT granted permission to the leaders of the Tangwei to officially launch the Democratic Progressive Party, which was founded on the liberal principles of social justice outlined in a platform developed by the Tangwei. 

Lee, who holds a master’s degree in health policy and management from Harvard and a Ph.D. in health economics from the University of North Carolina, said Tangwei members were particularly adamant that universal health care be a priority for the new party.  

“After the Kaohsiung Incident, the Tangwei developed 10 planks, including to directly elect the president, elect the legislature and the last one was to implement national insurance,” said Lee. “So we had this social issue connected with the political reform.” 

One year later, martial law was lifted. Nevertheless, Lee and other overseas dissidents would continue to be blacklisted for their involvement in pro-Taiwan indepedence organizations as the KMT insisted Taiwan and China should one day be unified. After living in the US for several years in exile, Lee illegally returned to Taiwan in 1990 and went into hiding, traveling with just a razor, a toothbrush and toothpaste, and often disguising himself to elude intelligence agents. He was eventually arrested in 1991 and spent nine months in prison, famously writing at the time: “To all dissidents worldwide, it’s easier to be put in prison than be insulted for your beliefs...I found myself composed and considered life in prison bearable as it was the result of staying true to my beliefs," 

The Revolution Bears Fruit

By the early ’90s, after the KMT began ceding to political pressure and fully opened up Taiwan to free elections, many former dissidents began returning from exile and were elected to the Legislative Yuan and the National Assembly, a now-defunct martial law-era body previously in charge of electing the president. 

Hanji’s father returned from South Africa and was elected to the National Assembly, while voters sent Lee to the Legislative Yuan in 1995. But by then, National Healthcare was already in its implementation phase. Unlike the Republicans, who at that time were scuttling the Clinton administration’s proposed health care reform plan, the conservative KMT knew it had to act or face political consequences.

“Our base was the underprivileged, the workers, the farmers and those with low income,” said Lee. “We laid the foundations little by little and finally it became so popular with the general public that the KMT could not reject this kind of policy. That’s why they began to introduce the national insurance bill in the Legislature.”

But doctors and health care providers vigorously fought the measure, and when the bill was brought before the Legislative Yuan at midnight on the last night of the session, Lee said that doctors were burning “ghost money” for the gods, anxiously praying it would die. 

“The doctors were always opposed to this act because they were deprived of their freedom of practice,” he said. “In a national single-payer system, the government has the final say whether or not to apply this medicine or procedure. So they felt that they could not apply their knowledge freely.”

Following the Oxcart 

Former KMT President Lee-Teng-hui’s administration faced a considerable challenge in developing such an ambitious program, but it was determined to have it in place before the 1996 elections. 

At that time, Taiwan had a patchwork system of private health care providers, with some insurance plans covering government employees, farmers, fishermen and laborers. But nearly half the population was forced to pay out-of-pocket for medical services. As journalist T.R. Reid writes in his book “The Healing of America,” the government set up a planning commission years earlier to study other health care systems around the world.  

“The first thing we realized was that a little island of 23 million people didn’t know how to run a national health care system,” former Bureau of National Health Insurance CEO Chang Hong-jen told Reid. “Well there’s a Chinese saying, ‘To find your way in the fog, follow the tracks of the oxcart ahead of you.’ So we decided the intelligent way through the fog was to look to other industrialized countries. The basic plan was to figure out which nations had found a smart path to universal health care coverage, and follow those tracks.”

The government hired Professor William Hsiao, a health care economist at the Harvard School of Public Health, who looked at health care systems in Japan, the U.S., Canada, Germany, the U.K. and France. As Reid noted, Hsiao rejected the free-market U.S. system because it didn’t cover everybody. He also passed on the multi-payer “Bismarck model” insurance used in Germany, France and Japan because it would have been more difficult to control health care costs. Hsiao preferred the U.K.’s totally nationalized health system if Taiwan was starting over from scratch, but it wouldn’t work for the country’s private hospitals and providers. Taiwan finally settled on a “Medicare for All” plan and on March 1, 1995, comprehensive health care coverage was delivered to 11 million uninsured people.

“This created a flood of new demand for medical services,” wrote Reid. “The market responded with a flood of new supply: clinics, hospitals, dentists, optometrists, labs, hostels and acupuncture sprang up everywhere.” 

But like all health care systems around the world, the Taiwanese NHI faces significant challenges. According to the government’s own data, patients give the system low grades for its quality of care and the short length of doctor’s visits compared to other industrialized countries. Taiwan also has a shortage of doctors and nurses in a variety of fields for a number of reasons including low reimbursements. Emergency rooms and clinics are also often overcrowded in part due to a cultural belief that people should see a doctor for every little sniffle or cough. The NHI also permits patients to bypass primary care doctors to seek specialists without referrals, which critics argue leads to unnecessary tests and procedures. 

As the population has aged and the demand for services has increased over the past 20 years, the NHI has also become financially strained at times. At one point, the government even began borrowing from banks to keep the system solvent. However, a few years ago the NHIA responded by broadening its revenue base and increasing premiums. As a result of rate changes and other recent reforms, NHIA now reports a US $6 billion surplus and is expected to be solvent until 2017. And as Princeton University health expert Tsung-Mei Cheng notes in an analysis published by the Brookings Institution, according to its per-capita GDP, Taiwan is as rich as Germany, Canada and Denmark — all of which spend far more on health care. It can afford to spend more to improve the system.

And even with all of its problems, 80 percent of Taiwanese still apparently love their “socialist” health care system. Addressing the 2015 Global Health Forum in Taipei last November, former KMT President Ma Ying-jeou praised the NHI, which he credited with extending average life expectancy from 74.5 years in 1995 to nearly 80 in 2014.

“The NHI is characterized by high efficiency, low premiums and quality services,” Ma said. “It has been hailed as a world-leading program in terms of affordability, convenience, flexibility, patient satisfaction and universal coverage.”

The American Millennial Revolution?

Meanwhile, back in the U.S., Americans are facing their own democratic crisis. With a yawning gap between the rich and the poor and big money controlling the levers of power, many voters are no longer willing to tolerate an establishment political class that is not responsive to their needs. It’s in this political climate that voters will likely face a choice this November between the moderate status-quo centrist  Hillary Clinton and the right-wing authoritarian strongman Donald Trump. For the time being, it appears that Democratic Socialist Bernie Sanders’ “political revolution” for social and economic justice has become a dream deferred. 

Lee Ying-yuan, who describes himself as an “anyone-but-Trump” guy, believes Americans should embrace modest incremental changes to the system rather than wholesale social democratic reforms. As he noted, Taiwan and the United States have very different cultural histories, which makes progressive change in America much more difficult. 

“Your ancestors came to the United States because they were pursuing individual freedom and economic autonomy,” he said. “And you had abundant resources. Anyone who was courageous enough, who worked diligently enough could make a living. If you couldn’t make a living in the East, you moved to the West. Political reform has to rely on the past for each society and each state. We introduced single-payer all at once, but you have Medicare and Medicaid, so multi-payers have been your system. Therefore, I think you can only try to refine it, to incrementally amend it. It’s more feasible, particularly in a society that has this respect for individual freedom.” 

And the U.S. also has a long history of racial oppression and class tensions that have heavily influenced national politics. Since the formation of the modern welfare state, American conservatives have often used race and class as a tactic to mobilize opposition to social welfare policies, arguing that they would benefit “less deserving” people. With the country experiencing a rapid demographic transition along with heightened anxieties about its economic future, the two political parties are increasingly resembling two warring tribes based not as much on political philosophy as on cultural, ethnic and racial identity. On one side, the multicultural Democratic Party pushes for more inclusion of marginalized groups of people, while on the other side, the predominantly white middle-class Party of Trump is focused on arming themselves, blocking foreign immigration and battling the adherents of “political correctness.” 

However, evidence shows that the mood of the country may be gradually changing for the better. Several surveys in recent years indicate that millennials, who make up the most diverse generation in American history, are much more racially tolerant and less religious than their parents and grandparents. And America has also come a long way from the hyper-individualist pioneer days and even the Cold War era, when the cry of “socialism” was enough to kill every attempt to pass universal health care since Harry Truman. 

While conservatives continue to spout the S-word like an epithet, the younger generation, many of whom weren’t even born when the Berlin Wall came down, doesn’t appear to hold the same fears and prejudices. In poll after poll — from Gallup and Pew to YouGov and the Harvard Institute of Politics  — between a third and nearly half of young Americans surveyed have expressed favorable views of “socialism.” 

And like the young Taiwanese student dissidents who studied the principles of democracy and human rights abroad, more and more millennials are also traveling the world to discover that they actually don’t have the same rights as their foreign counterparts in the wealthy industrialized world when it comes to basic necessities like health care and education. For many struggling young Americans, who are now more globally connected than any generation in history, abstract notions like “American exceptionalism” and “freedom” don’t really mean much when you can’t afford to see a doctor. 

In March, Republican pollster Frank Luntz expressed alarm about the “Snapchat Generation” after viewing the results of his survey of 1,000 first- and second-time voters ages 18 to 26. Fifty-eight percent said they believed “socialism” was the most compassionate political system, while just 33 percent picked capitalism (the other 9 percent picked “communism”). Sixty-six percent said that corporate America “embodies everything that is wrong with America,” and the group ranked income inequality as the most pressing issue facing the nation. 

Fifty-eight percent said that “America isn’t any better or worse than most other countries,” and a stunning 88 percent said they are at least somewhat “optimistic” about their own future, with 54 percent reporting that they are “extremely” or “very” optimistic. Whether all this means that Americans may finally be ready to “follow the oxcart” of other wealthy countries remains to be seen. But perhaps a revolution of consciousness has already begun. Certainly, Medicare, Medicaid and Social Security stand as a testament that it’s happened before.

“Make no mistake,” wrote Luntz, “this is the stuff of serious sea change for America.”