39 MARTINDALE CENTER FOR THE STUDY OF PRIVATE ENTERPRISE funding model that would tax 90% of total governmental revenue (Cheng, 2015). The combination of income-based and supplementary premiums creates an equitable, affordable approach, but the low rates raise concerns about meeting the rising needs of the aging population. Many Taiwanese supplement their NHI coverage with private insurance to access a broader range of services. Although the exact number of people with private insurance is difficult to ascertain, estimates range from 53% to 71.1% (Gusmano, 2023; Tsuei, 2024). This trend reflects the demand for comprehensive health-care options and an intensifying reliance on private insurance to improve coverage. The NHI requires copayments for medical, dental, and prescription drug services. The NHI does not use a gatekeeper method or require referrals, but patients who visit medical centers or hospitals without a referral face higher copayments than those who follow the referral network (NHI Administration, 2024). Copayments vary depending on the type of medical institution (clinic, district hospital, regional hospital, or medical center). For example, dental care and traditional Chinese medicine copayments are capped at NT$50, while clinic copayments start at NT$50 and can rise to NT$420 without a referral (NHI Administration, 2024). Emergency care copayments are means-tested, with subsidies available based on family income or disability status. Medication copayments depend on drug prices and the prescribing institution. The graduated copayment structure aims to reduce overuse, encourage clinics as the first point of contact, and maintain accessibility (NHI Administration, 2024). In addition to outpatient copayments, there is coinsurance for inpatient stays, which is 10% for acute beds (under 30 days) and 5% for chronic beds, with caps to limit excessive costs (Gusmano, 2023). Taiwan boasts exceptionally low health expenditure as a percentage of GDP, approximately 6.6% compared to the OECD average of 9.7% in 2021 (Cheng, 2024; Gusmano, 2023). To sustain low premium rates and control expenditure, Taiwan has implemented measures to limit health-care spending to a specified amount. The NHI Administration uses a global budget cap to guarantee health-care spending does not exceed a predetermined percentage of GDP, retaining tight control over NHI funding (Yip et al., 2019). In recent years, total health expenditure has remained capped at around 6% of GDP, with minimal expansion since 2017, when it was 6.1% (Gusmano, 2023). The growth rate of health expenditure was relatively low in 2023, at 3.3%, consistent with previous years (NHI Administration, 2024). While these figures highlight the system’s efficiency, they may inadequately convey the burden posed by the rapidly aging population requiring frequent and costly care. Recent political discussions have included the possibility of raising the annual health expenditure from 6.6%, but no action has yet been taken (Cheng, 2024). If the expenditure cap is reached, the NHI Administration may implement cost-control measures, such as limiting reimbursements or reducing services, which might strain providers and threaten the quality of care. Although Taiwan’s health spending is lower than that of many other countries, reevaluation of the rigid expenditure limits can ensure sustainably meeting the surging needs of an aging society. Health-care utilization in Taiwan has steadily risen, reflecting a parallel call for more medical services. Between 1998 and 2019, the intensity of both outpatient and inpatient services has climbed significantly. The average annual outpatient visits per person went from 13.8 to 16.2, and inpatient admissions rose from 11.1 to 14.6 per 100 people (Tsuei, 2024). Taiwan’s rate of 12.1 physician visits per year significantly exceeds the OECD average of 6.8 (Gusmano, 2023). This high level raises concerns about the quality of care; given the need for health-care professionals, greater demands place pressure on the workforce and likely contribute to burnout and difficulty with retention. Long-term care policy Taiwan has primarily managed its aging population by establishing long-term care systems separate from the NHI. The Long-term Care Plan (LTC) 1.0 was established in 2007 as the first effort in creating a formal long-term care approach, with home- and community-based services developed by local governments and primarily targeting adults ages 65+ with disabilities (Chen & Fu, 2020). Problems associated with LTC 1.0 included a lack of sustainable funding, underutilization, and a narrow scope of services (Yeh, 2020). To tackle these issues, LTC 2.0 was implemented in 2017 to procure sustainable funding through the central government budget and taxes on tobacco, alcohol, and estates (Yeh, 2020). LTC 2.0’s enhanced efforts regarding the aging population include outreach and widely expanding the range of services. LTC 2.0 lowered the age of inclusion for people with disabilities and increased total services covered, adding dementia care, Indigenous community services, support services for caregivers, multiservice centers for daycare and respite care, a community-based integration frame-
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