【Column Article】“Learning from Japan’s Ministry of Health Reform: Ensuring the Sustainability of Taiwan’s National Health Insurance”
By Prof. Lee Po-Chang, Chair Professor, College of Public Health, Taipei Medical University
Japan’s Yomiuri Shimbun reported on its October 26 front page under the headline:
“In-Depth Debate on Medical Costs for the Elderly: Expanding the 30% Co-Payment Group—Direction to Be Finalized by Year-End.”
The Ministry of Health, Labour and Welfare (MHLW) is planning to expand the scope of seniors aged 70 and above who must pay 30% of medical expenses out of pocket. Those whose income levels are comparable to the working-age population will be required to pay 30% when receiving care, with full implementation planned by 2028.
The rationale: escalating medical costs and worsening population aging require a fairer distribution of healthcare burdens between generations.
Currently in Japan, seniors aged 75 and above pay 10% out of pocket, while high-income earners in that group pay 20–30%. For those aged 70–74, the standard rate is 20%, rising to 30% for high-income earners. The MHLW argues that some older adults have incomes comparable to those still working and are financially capable of paying more. Expanding the definition of “working-equivalent income earners” to include more people paying 30% is therefore seen as a necessary reform for long-term sustainability.
This reflects a shared dilemma among advanced welfare nations: population aging, longer lifespans, and technological advancement are driving healthcare costs ever higher. If all expenses continue to be borne by the younger generation, the system will eventually collapse. Japan’s medical insurance spending already accounts for 11% of its GDP, and the proportion of older adults with significant income and assets continues to grow. If they keep enjoying low-cost care, the fairness and credibility of the system will erode.
“Those with greater means should bear greater responsibility”—this is the essence of social fairness. Japan chose partial self-payment rather than higher taxes to sustain its system without expanding the tax burden, creating a social consensus: old age does not mean exemption, and higher income should entail higher contribution.
In contrast, since Taiwan launched its National Health Insurance in 1995, it has achieved “universal coverage,” but after thirty years, the concept of user payment is virtually nonexistent. Citizens enjoy high-tech medical services for a minimal registration fee. Attempts by the NHI Administration to adjust co-payment policies have repeatedly been derailed by populist resistance, undermining the system’s financial prudence and risk-sharing mechanisms.
During my tenure as NHI Director-General, I strongly advocated for co-payment reform—requiring those who use costly medical services to bear a fair share of expenses, thereby protecting resources for the truly vulnerable. Premier Su Tseng-chang at the time fully supported this “user-pays” direction. Although the global budget system has succeeded in controlling expenditure, it has also fostered zero-sum competition among hospitals and excessive outpatient visits. Without a reasonable co-payment mechanism, waste becomes a systemic illness.
Japan’s reform philosophy offers valuable lessons for Taiwan: true social justice means asking those with the ability to contribute more, so that those in need do not have to give up treatment due to financial hardship.
Partial self-payment is not punishment—it is education. It does not weaken welfare—it safeguards sustainability.
Taiwan has long been trapped in the misconception that “opposing reform protects livelihoods,” treating fairness-oriented reforms as additional burdens. In reality, “user-pays” is the key to sustaining the NHI and ensuring intergenerational justice. Japan’s willingness to address the politically sensitive issue of elderly cost-sharing stems from its understanding that without adjustments today, the younger generation will be unable to shoulder tomorrow’s burden.
Health insurance reform is not merely a technical matter—it is a moral and value-based choice. Japan is now moving along a path that balances fairness with sustainability. When society recognizes that “reasonable co-payment” is a shared responsibility, the NHI can regain public trust and continue to protect everyone’s health.
Going forward, Taiwan can begin with three key steps:
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Establish an income-linked, tiered co-payment system with a ceiling, to protect patients with severe illnesses and low-income groups.
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Apply differential rates for high-cost imaging, medical materials, and new drugs, introducing “necessity and value” assessments to curb overuse.
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Enhance risk protection by exempting rare disease and catastrophic illness patients from co-payments and providing prior notification, ensuring that reform is both empathetic and precise.
Policy reform requires courage and communication, supported by data and principles. As long as the goal remains clear—those who can afford more should pay more, and those in need must not be left behind—Taiwan’s National Health Insurance can continue for another thirty years as one of the nation’s proudest public assets.
Original source:https://talk.ltn.com.tw/article/paper/1729703
