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Exploring Users’ Perceptions and Senses of Solidarity in Taiwan’s National Health Insurance

Exploring Users’ Perceptions and Senses of Solidarity in Taiwan’s National Health Insurance Abstract Under the influence of concerns about sustainability, health system reforms have targeted institutional designs and have overlooked the role of socio-political factors like solidarity—a concept that is generally assumed to underpin the redistributive health system. The purpose of this research is to investigate users’ perceptions of the National Health Insurance (NHI) as a system, their senses of solidarity and their views on the sustainability of the system in Taiwan. Using the descriptive ethics approach, qualitative in-depth interviews were conducted with typical case sampling of 17 participants in the Taipei Metropolitan. The framework approach was used to analyze the interview transcripts. The research finds that despite great differences between users’ perceptions of the NHI, most users could share a notion of mutual relationship among each other. Three types of reasons are used to justify the obligations of mutual aid imposed by the NHI. These reasons are embedded within divergent conceptions of solidarity. The research also finds that government’s performance, the stability of decision-making and users’ personal experiences engaging with the system are important conditions for the users’ supportive attitude toward the system. Solidarity is a plausible concept in sustaining a non-Western social health insurance such as Taiwan’s NHI. Introduction Sustainability issues have haunted countries with publicly funded health systems for decades, particularly after the 2008 economic recession. Compounded with increasing service demands and dependency ratios due to aging populations and advancing new medical technologies, the financial pressure for these health systems has always been a key point of political debates (Saltman and Cahn, 2013; Reeves et al., 2015). Institutional reforms have been introduced in response, such as quasi-market competition mechanisms, prospective payment systems, recentralization of decision powers, enhancement of service capacity without increasing costs and budget-cutting mechanisms. Besides these institutional design approaches, another aspect of sustainability is to focus on the ethical underpinnings, on what values people uphold and are willing to commit to, through the health system. These two approaches are related to each other; however, the latter receives much less attention from health policy researchers and reformers. The Concept of Solidarity Theoretically, a redistributive welfare or publicly funded health system is legitimate when it is supported by the people who share a sense of solidarity. Because the welfare or health systems that scholars have discussed often already existed, from the ex post viewpoint, many simply assumed that a certain degree of solidarity is shared by the participants of these systems as if it is a social fact. The logic is that if the participants share a sense of solidarity, they could restrain and overcome their pure calculation of self-interest and act collectively to commit to the common goals that are shared by them, such as the pursuit of common interests, avoidance of common dangers and preservation of the ways of life (Jennings, 2007; Prainsack and Buyx, 2011; Dawson and Verweij, 2012). Historically, solidarity is the ethical underpinning of welfare systems and publicly funded health systems, providing the normative justification for why people as a political community should do something together for some common purposes (Houtepen and ter Meulen, 2000; Saltman and Dubois, 2004; Bump, 2015). In this sense, solidarity is a sociological descriptive concept that is used to explain the origins, presence and continuation of a public system. From a backward-looking perspective, the system originated from and was underpinned by a sense of solidarity shared by the participants. From a forward-looking perspective, if the system wants to continually maintain its legitimacy and sustainability in the future, it has to continue to be underpinned by this sense of solidarity as well. Solidarity is hence related to the ethical approach to address the sustainability issue. Nevertheless, this theoretical assumption made of publicly funded health systems, or more broadly of welfare systems, is not self-evident. Empirically, limited studies show that solidarity could contribute to the making and development of redistributive social policies (Tamir, 1993; Miller, 1995; Houtepen and ter Meulen, 2000; Brubaker, 2004; Miguel, 2004; Béland and Lecours, 2008; Singh, 2011, 2015;). Specifically, in regard to health systems, studies show that despite facing many external pressures, solidarity in European countries remains and holds the health systems together (Morone, 2000; Maarse and Paulus, 2003; Saltman and Bergman, 2005; Saltman, 2015). In this article, solidarity is conceptualized as a descriptive concept that describes a social phenomenon in which the members of a community are willing to share a sense of belonging, recognize a mutual relationship and are willing to pursue some common goals at some cost to their self-interests. These ends are often realized in the form of formal institutions that impose mandatory contributions (either through taxes or premiums) on the participants. This article defines these kinds of institutional arrangements more abstractly as an institutionalized mutual relationship. This descriptive concept of solidarity also has normative dimensions. First, there are some common goals recognized by the members of a community, and these goals are distinct from any particular individual’s personal goals. Second, there are some values or ethical reasons that are used to justify these common goals, and hence justify the mandates of the formal institutions. These values and reasons are the ones that this research intends to investigate. The Case of Taiwan The social and ethical overview of solidarity deduced from the Western experiences might be different from that of newly developed countries. For example, the welfare system in Taiwan was developed and expanded in the late twentieth century as a result of democratization. The National Health Insurance (NHI), as a part of the welfare system, is a single-payer universal health insurance that has been implemented in Taiwan since 1995 (Chiang, 1997; Cheng, 2015). Its development process was largely led by political elites and public health technocrats (Lu and Chiang, 2011). At the transition stage from authoritarian to democratic governance, the reform itself was welcomed by most people and became the campaign promise of major parties under intense political competition (Wong, 2004). Therefore, the establishment of the NHI appeared to be based on strong social consensus. However, because of the same mechanism, the core values of the system were seldom put on the table of public debate. Nation-wide surveys have shown that although Taiwanese people support and are satisfied with the system on the whole (National Health Insurance Administration, 2014), they hold conflicting judgments about the system's core values, such as the problems of inclusion criteria for the insured, the rationale behind priority setting and accountability (Chang et al., 2012). These differences in the normative judgments of the system make people wonder whether the legitimacy and sustainability of the NHI could be maintained during crises. Can such a health system like Taiwan’s be sustained by solidarity like its counterparts in the European countries, when facing the similar external pressures? The purpose of this article is, therefore, to provide a preliminary investigation of the features of solidarity in a non-Western society by exploring how the users perceive the NHI as a health system and how they make value judgments and choices within a system constrained by concerns about sustainability. This research adopts a descriptive ethics approach to understand what kinds of beliefs, values and attitudes people have. This approach provides data and information that may in turn be used to revise normative ethical theories (Sugarman et al., 2007). Before detecting the users’ senses of solidarity, it is necessary to clarify their perceptions of the NHI because these perceptions reveal what they think the NHI is and what they think the NHI should be. Suppose the users do not consider the NHI as an institutionalized mutual relationship with other users in respect to health-care needs. Then there would be no sense of solidarity among the users. Contrarily, it would be meaningful to discuss the users’ ethical reasons for the sense of solidarity if the users see themselves as connected with each other under the NHI. This article does not intend to propose a new definition or argument about the concept of solidarity in health care, but rather to empirically clarify the relationship between the ethical reasons of the system’s users and their senses of solidarity. Theoretically, this article contributes to the literature by providing empirical materials to enrich the discussion of the role of solidarity in public health ethics. It is also one of the few empirical works on Taiwan’s health sector solidarity. Practically, this article informs health policy makers and reformers of people’s ethical rationales for their views, providing a supplementary approach other than the institutional design to address the sustainability issue of the NHI in Taiwan. Methods Research Design As a newly developed democratic country in East Asia, Taiwan is one that adopted the social health insurance model from the West. However, with its very different cultural and historical context, the question of whether presumed solidarity still holds makes it a case worth studying. Qualitative methodology is the most appropriate approach to distinguish the nuances of the users’ value judgments and perspectives through their everyday experiences and engagement with the system. The research has two stages. The pilot stage, from April to May 2014, involved the refinement of the research question and the testing of the interview outline. Five participants were recruited from the internet or through direct contact in person and interviewed at this stage. The second stage was conducted between November 2014 and January 2015. Twelve participants were recruited from the internet. Both stages were conducted in the Taipei metropolitan area, which is the capital city and center of political and economic activities in Taiwan. The participants were recruited through typical case sampling. This sampling method could provide an illustrative profile of the target population through the selection of ‘average-like’ cases (Patton, 2002:236). In this research, a typical case is an average-like NHI user. According to the National Health Insurance Act, all legal residents who live, study or work in Taiwan are eligible to be and also required to be a user of the NHI. This is the target population of the research. Nevertheless, as a preliminary qualitative investigation, this research does not aim at generating findings that could represent the user population; rather, it seeks to provide an outline of the average-like NHI users. Therefore, quota sampling by age, gender, education and work status was used as a supplementary method of the selection criteria of typical cases. In the work status strata, the participants were recruited by sub-quotas of middle class, working class and working poor according to the Gilbert–Kahl model (Gilbert, 2011). These three classes were selected because they represent the largest proportion of the NHI contributors and beneficiaries. In the sense of the NHI, they are the average-like users in the Taipei metropolitan area. Data Collection Recruitment was mainly through a most widely used Bulletin Board System (BBS) in Taiwan—the PTT. The researcher posted recruitment notices on signboards in PTT and selected the respondents according to their fitness to the selection criteria for the purpose of typical case sampling. A total number of seventeen participants were recruited. They provided rich enough information for the purpose of this research. They were all NHI users living in the Taipei Metropolitan. Their ages ranged from 20 to 49, including eight females and nine males. Three of them had high school degrees, six had college degrees and eight had graduate degrees. Ten of them had a full-time job, six had a part-time job and one was unemployed (Table 1). Table 1. The summary of demographic characteristics of the 17 research participants Number Gender Age Education Work status 1 Male 20–29 College Full-time Student 2 Female 20–29 Graduate Full-time Market analyst 3 Male 30–39 Graduate Full-time Legal specialist 4 Female 30–39 Graduate Self-employed Used to be a contract elementary teacher 5 Female 30–39 Graduate Full-time Electronics manufacturing industry 6 Female 30–39 College Part-time Telephone interviewer 7 Male 30–39 College Full-time Railway employee 8 Male 40–49 High school Part-time Market vendor 9 Female 30–39 Graduate Part-time Online auction seller 10 Male 20–29 Graduate Full-time Civil servant 11 Female 30–39 College Full-time Technology industry, also serves as a part-time volunteer firefighter 12 Male 30–39 Graduate Unemployed Were seeking for jobs 13 Male 40–49 Graduate Part-time Contract English teacher 14 Male 30–39 College Full-time Customer service representative 15 Female 20–29 College Full-time Hospital administrative staff 16 Male 20–29 High school Full-time Software engineer 17 Female 40–49 High school Full-time Temp worker Number Gender Age Education Work status 1 Male 20–29 College Full-time Student 2 Female 20–29 Graduate Full-time Market analyst 3 Male 30–39 Graduate Full-time Legal specialist 4 Female 30–39 Graduate Self-employed Used to be a contract elementary teacher 5 Female 30–39 Graduate Full-time Electronics manufacturing industry 6 Female 30–39 College Part-time Telephone interviewer 7 Male 30–39 College Full-time Railway employee 8 Male 40–49 High school Part-time Market vendor 9 Female 30–39 Graduate Part-time Online auction seller 10 Male 20–29 Graduate Full-time Civil servant 11 Female 30–39 College Full-time Technology industry, also serves as a part-time volunteer firefighter 12 Male 30–39 Graduate Unemployed Were seeking for jobs 13 Male 40–49 Graduate Part-time Contract English teacher 14 Male 30–39 College Full-time Customer service representative 15 Female 20–29 College Full-time Hospital administrative staff 16 Male 20–29 High school Full-time Software engineer 17 Female 40–49 High school Full-time Temp worker Table 1. The summary of demographic characteristics of the 17 research participants Number Gender Age Education Work status 1 Male 20–29 College Full-time Student 2 Female 20–29 Graduate Full-time Market analyst 3 Male 30–39 Graduate Full-time Legal specialist 4 Female 30–39 Graduate Self-employed Used to be a contract elementary teacher 5 Female 30–39 Graduate Full-time Electronics manufacturing industry 6 Female 30–39 College Part-time Telephone interviewer 7 Male 30–39 College Full-time Railway employee 8 Male 40–49 High school Part-time Market vendor 9 Female 30–39 Graduate Part-time Online auction seller 10 Male 20–29 Graduate Full-time Civil servant 11 Female 30–39 College Full-time Technology industry, also serves as a part-time volunteer firefighter 12 Male 30–39 Graduate Unemployed Were seeking for jobs 13 Male 40–49 Graduate Part-time Contract English teacher 14 Male 30–39 College Full-time Customer service representative 15 Female 20–29 College Full-time Hospital administrative staff 16 Male 20–29 High school Full-time Software engineer 17 Female 40–49 High school Full-time Temp worker Number Gender Age Education Work status 1 Male 20–29 College Full-time Student 2 Female 20–29 Graduate Full-time Market analyst 3 Male 30–39 Graduate Full-time Legal specialist 4 Female 30–39 Graduate Self-employed Used to be a contract elementary teacher 5 Female 30–39 Graduate Full-time Electronics manufacturing industry 6 Female 30–39 College Part-time Telephone interviewer 7 Male 30–39 College Full-time Railway employee 8 Male 40–49 High school Part-time Market vendor 9 Female 30–39 Graduate Part-time Online auction seller 10 Male 20–29 Graduate Full-time Civil servant 11 Female 30–39 College Full-time Technology industry, also serves as a part-time volunteer firefighter 12 Male 30–39 Graduate Unemployed Were seeking for jobs 13 Male 40–49 Graduate Part-time Contract English teacher 14 Male 30–39 College Full-time Customer service representative 15 Female 20–29 College Full-time Hospital administrative staff 16 Male 20–29 High school Full-time Software engineer 17 Female 40–49 High school Full-time Temp worker Semi-structured face-to-face in-depth interviews with participants were conducted by the author. The length of interviews ranged from 60 to 90 minutes. Throughout the interview process, the interviewer used real cases of controversies surrounding NHI reported by the mass media as well as hypothetical scenarios to probe into the participants’ value judgments on the system and their reasons, motivations and justifications for their judgments. Counterfactual scenarios were applied to test the consistency and self-reliability of the participants’ responses (Walsh, 2007). To minimize bias and provide a comfortable interview environment, the interviewer would express his neutral stance on all NHI issues and invite the participants to feel free to express their opinion. The place of interview was determined by the interviewee, depending on their preferred location and environment. In most cases, it was a café or a quiet restaurant near the interviewee’s workplace or home. If the interviewee did not have a specific request, the author offered to conduct the interview in the research institute building in which he worked. The informed consent forms were signed after the interviewer explained to the participants the potential risks, the benefits and the rights of the participant before the interview began (research ethics approval was obtained from the National Taiwan University Hospital, Number 201410070RINC). The author took notes of the interviewees’ emotions and expressions during the interviews. With the interviewees’ permission, all the interviews were recorded and transcribed. When the transcripts are quoted in the article, any descriptive information regarding the interviewees is as minimal as possible to avoid any possible identification. The participants received a US$10 honorarium. Data Analysis The framework approach was used to analyze the interview transcripts. In comparison with other qualitative analysis methods, this deductive method is suitable for applied policy research that contains pre-set goals (Pope et al., 2000; Ritchie and Spencer, 2002). Before the interviews began, the interview outline included five themes that draw on prior issues of interest: (i) the interviewee’s attitude toward the NHI, (ii) their views about the legitimacy of mandatory inclusion of the insured, (iii) their attitude to the inclusion criteria of the insured, (iv) the conditions upon which the interviewee would be willing to compromise their own welfare to maintain the system’s sustainability and (v) interviewee’s experiences in any forms of public participation. After the interviews, the author immersed himself in the transcripts and notes and coded them systematically. A comprehensive code structure (Bradley et al., 2007) that lays out the relationships between all the codes and the analytic categories of interest, including users’ perceptions of the NHI as a system and their value judgments, was then generated from the coded transcripts. Finally, the typologies of main themes were mapped out in a table. The results section of this article is presented according to these themes. The transcripts and notes were coded and analyzed in Mandarin, and the quotations presented in this article were translated into English by the author. The report of numbers in qualitative inquiry is under debate (Pope et al., 2000; Sandelowski, 2001; Maxwell, 2010). In this article, considering its exploratory purpose, relative terms such as most, some and few are used to substitute for the actual numbers of interviewees who provided certain responses in each theme to depict findings with relative at the same time avoiding misleading inference of statistical representation. The author’s self-disclosure is important for readers to evaluate the author’s credibility (Patton, 1999). Before engaging in the research, the author was a frontline clerk in the governmental agency that runs the NHI. This experience was advantageous to the inquiry because the author could grasp the details of everyday functionings as well as the holistic view of the system. The disadvantage was that the author might be too sympathetic or attached to the system. However, this disadvantage motivated the author to explore and analyze NHI users’ perceptions and judgments as unbiasedly as possible to inform future policy-making and reforms. Results Users’ Perceptions of NHI as a System The interviewees’ attitude toward the NHI could be divided into two broad categories: empirical perceptions (What is the NHI?) and normative judgments (What should the NHI do?). Empirical perceptions In terms of ‘what the NHI is’, the interviewees perceived the NHI as a part of the not-for-profit welfare system that belongs to the formal institutions of the government, an actuarial insurance scheme that is similar to a for-profit private insurance, or somewhere between or a combination of the two. Only one interviewee saw the NHI as a form of public assistance, which is close to charity. First, most of the interviewees saw the NHI as a part of the not-for-profit welfare system. The term ‘welfare system’ used here is a broad one. It refers not only to the means-tested subsidy programs and social assistance but also to the whole formal institutional arrangements that are funded by public money to pursue common goals, and the NHI is a part of these arrangements. It, however, does not include the charity or philanthropy sector, which is informal and is funded by private money. Therefore, it is confusing and unsatisfactory to this group that the government officials have often said in the mass media that the financial balance of the NHI is under threat, or that the NHI is about to enter bankruptcy, particularly when the government prioritizes spending on such things as New Year Eve’s fireworks. They felt that it does not make sense to use the kind of language that is often used by for-profit businesses to describe the NHI. The NHI is called ‘insurance’ just for the purpose of describing its mechanism of fund collection, but since it is a part of the welfare system, and the government is responsible for the system’s function. In contrast, a minority of interviewees saw the NHI as an insurance system that is similar to private insurance, in which the insured’s premium contribution is calculated according to the actuarial rate. Therefore, the NHI should seek its own internal financial balance (just like other private insurance companies) and reflect the risks to the insured’s premium by setting different actuarial rates for different participants, rather than setting community rates (as many of the social health insurances in other countries do). The only difference is that in the NHI the insurer is the government, which they also expected to behave like a private insurance company in terms of business-level efficiency and independence from other governmental agencies. Between these two different perceptions of the system, the pure not-for-profit welfare system and the pure actuarial insurance, some interviewees saw the NHI as insurance inside the welfare system. Therefore, it is reasonable for the NHI to maintain its own financial balance and be under the threat of bankruptcy, but speaking overall the government still has more responsibility to support the system financially. Normative judgments In terms of ‘what NHI should be’ most interviewees saw that the NHI should be a means to maintain a mutual relationship between the users. Others saw the NHI as a practice of benevolent rule. A few of the interviewees considered the NHI as an illegitimate system that should be abolished. First, most of the interviewees agreed that the NHI reflects the social values of fairness, justice and social mutual aid in preventing social inequality due to illness. Fairness and justice (in Mandarin these two words have similar meanings and could be and are often used interchangeably or combined, e.g. fair-justice [gong ping zheng yi, ) were the words mentioned the most frequently, which shows that many interviewees could identify a mutual relationship with other NHI users, even if these users were not directly related to them. An equal relationship between the users of the system could be imagined in the sense that they share the financial risks of illness. The interviewees also agreed upon the value of the NHI in preventing social inequality. The main reason is that they could not accept the condition that in society some individuals or families would fall into poverty because of illness. This reason is related to the interviewees’ understanding of the essence of health services. For them, in many other aspects, such as talents, heritage or merit, inequality may be tolerated, but in health it is not. Hence, it is imperative for the state to ameliorate this kind of inequality: One of the reasons for the state to provide medical services is to reduce economic inequality. Yeah, then the poor would be able to afford a basic level of service, so that, well, I mean, in a minimal sense they should have the right to survive in the society. (M, age 30s, unemployed) Second, some interviewees saw the value of the NHI as the government’s ‘benevolent rule’, [de zheng, ]. Because the government, or the rulers that control the government, are enlightened and virtuous, they implement the NHI to care for people’s health needs, to ‘create well-being’ [zao fu, ] for people. Note that in this judgment, the government, the state and the rulers are considered as a unity that have a higher authority among the ruled; hence, it could make better judgments on what well-being is and what is good for the ruled. It has nothing to do with the attitude of individual government officials. In this judgment, the relationship between government and users is unilateral. In addition, because the benefits from the NHI are created by the government, the users do not identify a mutual relationship with other fellow users. Third, for those interviewees who did not recognize the legitimacy of the NHI, the system has no value at all and is a misallocation of public resources. One reason is that the government is inefficient in terms of funding for health services, and many resources are wasted. Another reason is that the NHI policy is so unstable that the interviewees felt they had been cheated by the government many times, and hence they did not trust the system any longer. One interviewee even expressed the extreme eugenicist opinion that those who could not afford basic health services might not be proper members of the society, and hence it is unnecessary to allocate public resources to them. In sum, despite the NHI users’ pluralistic perceptions and judgments toward the system, from most of them a notion of mutual relationship among the user community could be observed. What is the reasoning behind these perceptions and judgments? How do they relate to a sense of solidarity? Three Types of Reasons that Justify the NHI and the Senses of Solidarity Three types of reasons about the obligations of mutual aid brought by the NHI are found among interviewees: ex post facto, self-interest and community-interestreasons (Table 2). These reasons are crucial for interviewees to justify the state’s intervention in health issues and the legitimacy of the system. Note that these three types are not mutually exclusive. An interviewee may hold more than one reason and give them different weights. Table 2. The summary of the three types of reasons provided by the research participants to justify the National Health Insurance in Taiwan Types of reason Ex post facto Self-interest Community-interest (The simpler version) Relationship with other users as a whole Unclear Social cooperation based on self-interest Communal life with some shared common values Relationship with other individual users Unclear Unclear Members of the system Members of the system Equal moral status with shared egalitarian values Justifications of the state’s intervention Habituation and benevolence Beneficial, good deal, instrumental value of insurance, convenience and easier access to reimbursement’ Mutual aid, normal functioning of modern society and living together Mutual aid, universal necessity of health services, reciprocal mutual aid and contingent common risks Senses of solidarity Implicit recognition None or weak sense Less than strong sense Strong sense Types of reason Ex post facto Self-interest Community-interest (The simpler version) Relationship with other users as a whole Unclear Social cooperation based on self-interest Communal life with some shared common values Relationship with other individual users Unclear Unclear Members of the system Members of the system Equal moral status with shared egalitarian values Justifications of the state’s intervention Habituation and benevolence Beneficial, good deal, instrumental value of insurance, convenience and easier access to reimbursement’ Mutual aid, normal functioning of modern society and living together Mutual aid, universal necessity of health services, reciprocal mutual aid and contingent common risks Senses of solidarity Implicit recognition None or weak sense Less than strong sense Strong sense Table 2. The summary of the three types of reasons provided by the research participants to justify the National Health Insurance in Taiwan Types of reason Ex post facto Self-interest Community-interest (The simpler version) Relationship with other users as a whole Unclear Social cooperation based on self-interest Communal life with some shared common values Relationship with other individual users Unclear Unclear Members of the system Members of the system Equal moral status with shared egalitarian values Justifications of the state’s intervention Habituation and benevolence Beneficial, good deal, instrumental value of insurance, convenience and easier access to reimbursement’ Mutual aid, normal functioning of modern society and living together Mutual aid, universal necessity of health services, reciprocal mutual aid and contingent common risks Senses of solidarity Implicit recognition None or weak sense Less than strong sense Strong sense Types of reason Ex post facto Self-interest Community-interest (The simpler version) Relationship with other users as a whole Unclear Social cooperation based on self-interest Communal life with some shared common values Relationship with other individual users Unclear Unclear Members of the system Members of the system Equal moral status with shared egalitarian values Justifications of the state’s intervention Habituation and benevolence Beneficial, good deal, instrumental value of insurance, convenience and easier access to reimbursement’ Mutual aid, normal functioning of modern society and living together Mutual aid, universal necessity of health services, reciprocal mutual aid and contingent common risks Senses of solidarity Implicit recognition None or weak sense Less than strong sense Strong sense Ex post facto reasons Interviewees providing ex post facto reasons justified the state’s intervention in terms of habituation. The interactions between users, the insurer and health-care providers under the NHI throughout all these years have made the system become a way of life: I felt that I am getting used to it … it is what it is. If I need care services, I would use it. If I don’t, the premium I paid is just like benevolence to others, helping them when they are in need. Like Dāna [charitable giving] as those Buddhists say. (M, age 40s, contract English teacher) This reason implies that if the users do not resist the system, it is obvious that the system has some good qualities or is not too bad to be tolerated. Therefore it is natural to recognize its legitimacy. This account might be considered as an implicit recognition of solidarity that is generated by the practices of the system and users’ interaction with it throughout the years it has been implemented. Self-interest reasons Interviewees providing self-interest reasons justified the state’s intervention on the ground that the mandatory arrangement is beneficial to them. They either thought that the NHI is a ‘good deal’ made with the government, or that for the sake of convenience the NHI is better operated by the government. Interviewees’ experiences of engaging with the system would also affect their perceived health risks, which would then affect their evaluation toward the system. The ‘good deal’ logic is similar to the actuarial logic of private insurance. The interviewees saw that in the future they might encounter risk events, and the cost of these events is expected to be larger than the cost of their NHI premium. Therefore, it is a ‘good deal’ to purchase this social health insurance plan from the state. You see, no matter to what degree you raise the premium rate [of the NHI], at most 10% or 20%, it is still relatively small [in comparison to purchase private insurance or pay out-of-pocket] in the long run. Although I didn’t use many NHI services in recent years, I think it is acceptable to raise the premium rate [to maintain the financial balance of the NHI]. It’s better than letting the NHI go bankruptcy and you paying for all services by yourself. (M, age 20s, software engineer) By providing this reason, the interviewees saw themselves as having a unilateral relationship with the insurer. The calculation of benefits is based on individual perceived health risks. The state’s intervention could be justified as long as it is beneficial. On the other hand, if the burden imposed by the state is larger than the cost of their perceived health risks, the system would totally lose its legitimacy. Among the interviewees providing this type of reason, some of them mentioned the ‘convenience’ and ‘easier access to reimbursement’ of an insurance run by the government. They thought that in comparison with private insurance, the NHI has lower administrative costs and the burden of overseeing reimbursement is laid on health-care providers rather than beneficiaries, making it much easier to get through the process to pay for the services. It is difficult to observe any sense of solidarity among this type of interviewee. The interviews show that individual perceived health risks would be mediated by interviewees’ personal experiences of catastrophic health events and intensity of their interaction with the NHI. If the interviewees or their significant others had been through these experiences, they tended to evaluate the system as more beneficial. Here the line between calculation of self-interest and community-interests becomes vaguer, because these experiences make the users have a stronger recognition of the system’s values: In the process of caring, you were very tired, and you could not save the patient’s life. And the bills with many zeros behind would come at any time. You didn’t know what to do. So, people might complain [about the NHI], complain about the premiums of one thousand, two thousand (NT) dollars every month […], but you will know [the value of the NHI] when you see the medical bills. (F, age 30s, electronics manufacturing industry) Nevertheless, whether this kind of recognition could be regarded as recognition of the common value of mutual aid remains unclear. Community-interest reasons Interviewees providing this type of reason agreed that mutual aid itself has moral significance that justifies the state’s intervention. The notion of mutual aid implicitly assumes some forms of community identity, because to share mutual aid with a group of people, there must be a community. In our NHI case, the extent to which interviewees could identify relationships with other users forms the community. The reasons provided by the interviewees under this third type include universal necessity of health services, reciprocal mutual aid and moral obligations among users. First, some interviewees appealed to the universal necessity of health services. Just like public education, they thought that public provision of health services is required, for the longevity and quality of life and that the ability to afford health services should not be determined by one’s ability to pay. It is a matter of fairness. For the interviewees who provided this reason, their justification for the NHI has gone beyond calculation of self-interest and moved toward the consideration of community-interests. Their unit of evaluation is not only individual but also communal. The government has the responsibility: In terms of medical services, I think everyone should have adequate services when they are in need. I think it is pretty dangerous if the government does not provide this kind of assistance. In that circumstance, the rich could obtain the best services. I feel that it is quite unfair. […] The protection from the state should not be limited to infrastructure or anything; it should also include the maintenance of people’s lives. (F, age 20s, market Analyst) Because we all live in the same society, the advantaged could help the disadvantaged to achieve mutual aid. Well, as a way of life. Not just taking care of your own business. (F, age 20s, hospital administrative staff) Second, most interviewees invoked the notion of reciprocal mutual aid. This is not a strict norm of reciprocity, but rather an expectation that I am willing to help the others because I believe that sometime in the future someone would help me when I am in need. By providing this reason, the interviewees recognized the fact that people will likely need help at sometime, and based on this recognition, they also believed that people should share the responsibility to face these risks; hence, the state’s intervention is justified. However, it is unclear why the fact that people recognize these risks automatically leads to the normative judgment that they should share the responsibility. Some interviewees thought that it is because of the contingent nature of the distribution of these risks, and those who bear fewer risks are just luckier than the others. Therefore, it is reasonable for them to share the burden of these common risks. With this understanding of their relationship with other users, a sense of equal moral status could be found among the interviewees. They shared an egalitarian value that it is an obligation for every user of the NHI to help each other, and no one could opt out: You say you don't want to join the NHI, Labor Insurance, or National Pension. Well, then, are you going to say you don’t want to pay taxes, am I right? I never go to a public park, why do I have to pay the tax? I never drive a car, why do I have to pay the air pollution tax? I just don’t have to pay any tax at all. Yet you cannot do that, because you live in this society. (F, age 30s, electronics manufacturing industry) Community-interest reasons—a simpler version A simpler version of the community-interest reason is connected to the interviewees’ expectations for the normal functioning of modern society. Although similar to the community-interest reasons mentioned above, this simpler version is not embedded within the normative values of universal necessity, reciprocal mutual aid or moral obligations. The mere fact that people are living together in a society leads to the normative judgment that people should take care of each other’s health needs. Some interviewees also emphasized the role of cultural tradition. One interviewee said that, to him, the NHI is like an institutionalized version of the traditional virtue of mutual aid, expressing a strong sense of humanness [ren qing wei, ], a mixture of friendliness and hospitality, being considered as one of the traditional virtues]. However, in this simpler version, it is unclear whether these interviewees perceived a sense of equal moral status with the other users. In sum, the interviewees with this third type of reasons could more or less recognize that the NHI is a mutual aid institution based on the membership of the community. Its logic is reallocating resources from the many to the few who are in need to share the common risks. This logic is different from the unilateral relationship between the rich and the poor in charity-based arrangements. It could be concluded that between the NHI users there exist some senses of solidarity, which connects the individual user with the others. Summary The three types of reasons and the divergent senses of solidarity are summarized in Table 2. Those providing the community-interest reasons have a strong sense of solidarity. They are willing to share the obligations of care between the other NHI users and make commitments to the values upheld by the system. If necessary, they would withhold the maximization of their self-interest to maintain the public system. In practical terms, this means that in the case where the NHI fund starts having financial deficits, the users might be willing to accept and support a reform proposal that will harm their self-interest, such as increasing the premium rates or the co-payment but will sustain the service package covered by the NHI. (However, this acceptance is not without certain preconditions. Please see the next section.) Those providing the simpler version of community-interest reasons have a less strong sense of solidarity. While their perceived relationship with other individual users remains unclear, they are also willing to share the obligations of care for the purpose of mutual aid. For those who provide the ex post facto reasons, implicit solidarity is recognized as long as they are willing to participate in the system without questioning its legitimacy or calculating the benefits and costs of their participation. Those who provide self-interest reasons seem to have no sense of solidarity at all. They are willing to support the system as long as it is beneficial to them. However, if they could calculate their benefits in a longer term, they might be willing to withhold their maximization of self-interest in the short term to receive larger benefits in the future. For instance, suppose a reform proposal that increases the premium is proposed to fill the deficit gap of the NHI fund. This proposal will harm the user’s benefits (losing more money on paying a larger premium every month). However, suppose the user encounters an unexpected car accident or is diagnosed with lung cancer at some point after the reform. Then the sustained NHI at that time point will pay for most of the expensive treatment (such as an ICU bed) for the user. To maximize her benefits in the long term, the user might accept and support the proposal in the first place. If this is the case, then they might be categorized as having a weak sense of solidarity in that at least they are willing to participate in social cooperation in the public provision of health services. Now that the perceptions and judgments toward the NHI and the contents of solidarity have been presented, in the next section, the conditions under which the interviewees would be willing to withhold the maximization of their self-interest and to support the sustainability of the NHI when necessary will be presented. Conditions for the Users’ Supportive Attitude Due to reports in the mass media, a majority of the interviewees recognized the fact that the NHI has encountered several financial crises during its 23-year implementation and needs the public’s support to maintain its financial sustainability. With this understanding in mind, most users are willing to accept the reform projects proposed by the government, such as raising premium rates and limiting the adoption of new drugs and treatments into the service package covered by the NHI. However, this acceptance comes along with certain conditions, including the government’s performance, the users’ personal experience and the stability of NHI-related decision-making. Government’s performance The most mentioned condition is the government’s performance, which contains three dimensions: transparency, effectiveness and coherence. When the interviewees spoke of transparency, in most cases, they specifically referred to financial transparency. Many interviewees thought that the government, as the insurer of the NHI, does not provide adequate information about the expenditure of the NHI for people to evaluate whether the premiums they contributed were spent properly. In other cases, they thought that although the government does provide the information, it does not do so in an understandable manner. There are merely blocks of data filled with professional jargon uploaded on the website. Without transparent information disclosure, they were not willing to accept the reform proposals: In the future, ideally I would think it is OK [to raise the premium rates]. But sometimes I feel that it’s like a passive action. I paid the premium and fulfilled my obligation, but I hope that it has a more transparent financial report, so that everyone could know how exactly the NHI fund was spent. (M, age 30s, unemployed) To the interviewees, effectiveness means the proper use of the NHI fund for proper ends. Many interviewees had the perception, either from their personal experiences or from the mass media, that under the current situation the fund has been wasted in many places. To them this is a serious issue. If the government could not solve the problem (or at least show that it is attempting to solve the problem) and enhance the effectiveness of resource allocation, they would not be willing to support any reform proposal: It should be the government’s responsibility to supervise. If the government had done it well, if there were less waste of medical resources. […] Like what we said, many people keep asking for prescriptions and drugs while they are not sick at all. In this case you say you want to raise the premium? I would be very reluctant to pay. (F, age 40s, temp worker) The last dimension of the government’s performance is coherence. To the interviewees, coherence means that they tended to see the whole public service system as a unity, and the performance of the NHI cannot be evaluated separately from that unity. In other words, not only the performance of the NHI but also of the public services system is considered as the basis for their support to the NHI. They thought it is unreasonable that on the one hand the NHI is about to go bankrupt, while on the other hand the government is still spending a huge amount on unnecessary luxuries, such as fireworks in the New Year's Eve celebration (this example was emphasized by two interviewees). Personal experience The second condition is personal experience. If one had been through the experience of having a great need for medical services, one would have a stronger sense of self-restraint about one’s personal usage of NHI resources. For example, an interviewee said that she asks the doctor not to give her drugs that she does not need. In this specific case, the doctor said that she would not need to take any drug, but as backup the doctor still wanted to prescribe some drugs to her. These people feel the significance of spending on medical services and are concerned about the crowding effect of resource allocation. If they unnecessarily used the resources, some people might suffer from the lack of resources. The government has the responsibility to make proper arrangements to reduce unnecessary use and to transfer resources to under-served regions. Stability of decision-making The third condition is the stability of NHI-related decision-making. Short-term reform proposals seem to be more untrustworthy to the users, because they are concerned about the increasing burdens in the future. As one interviewee mentioned: I am OK with raising premium rates. However, the game rules should be as clear as possible, so that the rate won’t have to be raised every one or two years, or [that the reform proposal will not] be withdrawn easily because of the pressure from public opinions. […] Otherwise, they proposed the Second Generation Reform [that raised the premium rates] this year, what about next time? Would there be the Third, the Fourth, the Fifth Generation, and so on so forth? People would be afraid [of the uncertain future burden]. (F, age 30s, electronics manufacturing industry) Discussion The analysis of the three types of reasons justifying the NHI indicates that most of the interviewees had some senses of solidarity in mind, among which the strong sense of solidarity would be the cornerstone of a sustainable NHI system. This sense would actively support future reforms and uphold the core values of the system. The weak sense of solidarity is a necessary condition for maintaining the system’s normal functioning. However, its relationship with the sustainability of the system remains unclear. There is a bourgeoning discussion on the role of solidarity in bioethics and public health ethics (Beauchamp, 1985; Dawson and Verweij, 2012; Jennings, 2007, 2016; Prainsack and Buyx, 2011, 2015; Krishnamurthy, 2013). Both the weak and the strong senses of solidarity in the NHI found in this research are analogous with the notions of rational solidarity and constitutive solidarity distinguished by Dawson and Verweij (Dawson and Verweij, 2012). The rational category conforms to the weak sense of solidarity, and the constitutive category conforms to the strong sense of solidarity. In rational solidarity, people are willing to cooperate for their long-term interests, such as facing common risks and tentatively put aside their short-term interests. Constitutive solidarity ‘describes a set of norms about how we behave towards each other in social groups’ (Dawson and Verweij, 2012). For particular individuals, such as those who are young and have lower health risks, it might be irrational to recognize the values of a publicly funded health system, ‘but still reasonable given people’s identification with a community, way of life and set of values’ (Dawson and Verweij, 2012). Some of the commitments required by constitutive solidarity could be demanding for individuals, asking them not only to consider the common goals but even to put their self-interest at risk. Dawson and Verweij suggest that this constitutive solidarity is also required for comprehensive health care plans, of which the NHI in Taiwan is an exact case. This implication also conforms with Dan E. Beauchamp’s earlier argument that the goal of public health is not merely to instrumentally maximize aggregative welfare; rather, it includes ‘the commitment of the whole people to face the threat of death and disease in solidarity’ for the common good (Beauchamp, 1985). However, this research is subject to Dawson and Verweij’s criticism of Prainsack and Buyx for adopting an approach that understands solidarity as a more descriptive than normative concept. The research findings suggest that Prainsack and Buyx’s definition of solidarity, ‘shared practice reflecting a collective commitment to carry “costs” (financial, social, emotional or otherwise) to assist others’ (Prainsack and Buyx, 2011), could be found in those who have a strong sense of solidarity in the NHI. However, this descriptive solidarity does not provide any normative guidance to what role solidarity should play in a health system. The value of solidarity here is, hence, instrumental. The strong sense of solidarity as a means to sustain the NHI would have its value, only if people consider either the sustainability of the institution of the NHI or the sustainability of its core values as a right thing to pursue collectively. Nevertheless, one could still argue that, Prainsack and Buyx’s definition of the descriptive concept of solidarity has a normative dimension, which is the recognition of a mutual relationship among the users of the system. In this sense, solidarity requires the users to see each other as equal moral agents, at least with respect to health needs. If this is the case, a further issue for future research to analyze is what the boundary of the user community is and how it is defined, namely, the question of ‘solidarity with whom’? (Prainsack and Buyx, 2017:183). There is still the issue of applying the concept of solidarity in different cultural and historical contexts. Generally speaking, the origins of solidarity in the West might be seen in the legacies of civic republicanism, Judeo–Christian traditions, labor movements and the national sentiments formed in the post-WWII reconstruction era (Saltman and Dubois, 2004; Bump, 2015). In an East Asian society like Taiwan, which is largely based on Confucian social ethics (Eikemo and Bambra, 2008; Zhang, 2010), what does it mean to have a weak or strong sense of solidarity? Such a question requires further research, but, nevertheless, it might be the case that because of the 23-year practices of the NHI, people have gradually realized the long-term benefits brought by the system. They have formed a weak sense of solidarity. Furthermore, people might gradually recognize and uphold the core values of the system and form a strong sense of solidarity, which would later in turn support the system’s sustainability. One could also arguably infer that this strong sense of solidarity might open a chance to bind the community together in Taiwan’s political context of conflicting national identities (Corcuff, 2002; Brown, 2004; Cole, 2016). As some case studies have shown, the welfare institutions could forge solidarity among people (McEwen, 2002; Béland and Lecours, 2005; Law and Mooney, 2012) and even be considered as a part of the nation-building project (Kymlicka, 2007). As Krishnamurthy argues, social institutions could forge the sense of solidarity among fellow citizens, motivating them to ‘make sacrifices that justice demands’ and eventually forming a more just society (Krishnamurthy, 2013). From the research findings, the practices of the NHI in Taiwan might be the case, in that the NHI forges users’ strong sense of solidarity and motivates them to make sustainable choices, as the users recognize that the NHI and its core values are the essential components of a just society. However, note that the solidarity Krishnamurthy refers to here is ‘political’ solidarity, which largely differs from the general concept of solidarity, because it clearly limits the boundary of solidarity within a ‘state and among fellow citizens’ (Krishnamurthy, 2013). This, again, calls for future investigations of the meanings and implications of the boundary of health sector solidarity within and between borders and around the globe (Schwartz, 2007; West-Oram and Buyx, 2017). On this note, the concept of solidarity is shown to be plausible and meaningful both in terms of the sustainability of the NHI system itself and the sustainability of the whole political community. The mutually reinforced relationship between the practices of the NHI and senses of solidarity in the NHI is beyond the scope of this research. As has been suggested, solidarity in the health sector is dynamic (Saltman, 2015), depending on the users’ or citizens’ perceptions and recognition of the core values of the system. Limitations Because of the exploratory nature of this research, it has several limitations. First, although typical case sampling was used, the geographical and linguistic barriers limit the generalizability of findings to the population living in the northern region of Taiwan and the Mandarin-speaking population. The other barrier is that the researcher cannot access interviewees who are in very high or low social economic status. Despite these limitations, the sampled interviewees could represent the average-like population that is influenced by the NHI system, as the research was designed to target. Second, the descriptive ethics approach could at best detect the interviewees’ perceptions and judgments at the time when the interviews were conducted but could not measure what choices the interviewees will make when they actually encounter real life situations. Third, due to the time limit, two important issues related to solidarity are not covered in the interview. One is intergenerational solidarity, which is an urgent issue in sustainability of public systems considering the aging population and stagnated economy (Houtepen and ter Meulen, 2000). The other is national identity, which is a particular concern in Taiwan as well as other regions with multicultural social bases or with secession or independence movements. Conclusions Through this exploratory investigation, three types of reasons used to justify the obligations of mutual aid imposed by the state through the NHI are distinguished. They are embedded within different senses of solidarity and have different relationships with the sustainability of health system. The concept of solidarity that originated from the traditional welfare states has been shown to be an applicable analytic concept as well as empirical phenomena in Taiwan and potentially in other newly developed countries. Health policy makers and reformers could adopt measures to maintain the government’s performance and stability of decision-making and build an environment that could make users have more engagement with the NHI, to cultivate users’ sense of solidarity and meet the conditions for their supportive attitude toward the system when the NHI encounters next crisis. Future research on solidarity could be built on the framework of three senses of solidarity from this research to further distinguish the causal directions between solidarity and sustainable health systems in East Asian societies. In an age of economic recession and austerity (Reeves et al., 2015), solidarity has its strength to be addressed in the debates of public health arrangements of the developed countries, for publicly funded health systems are not merely the protection of some rights that are derived from universal normative principles; rather, it is a realization of serious and genuine commitments that are made by the community members, recognizing that they share the same membership and mutual obligations of care (Jennings, 2016). From this point, we could reconsider Beauchamp’s insight: ‘Health is social … The way we provide or arrange for public’s health … helps reshape society and especially the body politics’ (Beauchamp, 1996: 25). Acknowledgements The author gratefully acknowledges the contribution made by all research participants. The article is derived from the author’s master thesis at National Taiwan University. 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Available online at www.phe.oxfordjournals.org This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Public Health Ethics Oxford University Press

Exploring Users’ Perceptions and Senses of Solidarity in Taiwan’s National Health Insurance

Public Health Ethics , Volume 12 (1) – Apr 1, 2019

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Oxford University Press
Copyright
© The Author(s) 2018. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org
ISSN
1754-9973
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1754-9981
DOI
10.1093/phe/phy021
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Abstract

Abstract Under the influence of concerns about sustainability, health system reforms have targeted institutional designs and have overlooked the role of socio-political factors like solidarity—a concept that is generally assumed to underpin the redistributive health system. The purpose of this research is to investigate users’ perceptions of the National Health Insurance (NHI) as a system, their senses of solidarity and their views on the sustainability of the system in Taiwan. Using the descriptive ethics approach, qualitative in-depth interviews were conducted with typical case sampling of 17 participants in the Taipei Metropolitan. The framework approach was used to analyze the interview transcripts. The research finds that despite great differences between users’ perceptions of the NHI, most users could share a notion of mutual relationship among each other. Three types of reasons are used to justify the obligations of mutual aid imposed by the NHI. These reasons are embedded within divergent conceptions of solidarity. The research also finds that government’s performance, the stability of decision-making and users’ personal experiences engaging with the system are important conditions for the users’ supportive attitude toward the system. Solidarity is a plausible concept in sustaining a non-Western social health insurance such as Taiwan’s NHI. Introduction Sustainability issues have haunted countries with publicly funded health systems for decades, particularly after the 2008 economic recession. Compounded with increasing service demands and dependency ratios due to aging populations and advancing new medical technologies, the financial pressure for these health systems has always been a key point of political debates (Saltman and Cahn, 2013; Reeves et al., 2015). Institutional reforms have been introduced in response, such as quasi-market competition mechanisms, prospective payment systems, recentralization of decision powers, enhancement of service capacity without increasing costs and budget-cutting mechanisms. Besides these institutional design approaches, another aspect of sustainability is to focus on the ethical underpinnings, on what values people uphold and are willing to commit to, through the health system. These two approaches are related to each other; however, the latter receives much less attention from health policy researchers and reformers. The Concept of Solidarity Theoretically, a redistributive welfare or publicly funded health system is legitimate when it is supported by the people who share a sense of solidarity. Because the welfare or health systems that scholars have discussed often already existed, from the ex post viewpoint, many simply assumed that a certain degree of solidarity is shared by the participants of these systems as if it is a social fact. The logic is that if the participants share a sense of solidarity, they could restrain and overcome their pure calculation of self-interest and act collectively to commit to the common goals that are shared by them, such as the pursuit of common interests, avoidance of common dangers and preservation of the ways of life (Jennings, 2007; Prainsack and Buyx, 2011; Dawson and Verweij, 2012). Historically, solidarity is the ethical underpinning of welfare systems and publicly funded health systems, providing the normative justification for why people as a political community should do something together for some common purposes (Houtepen and ter Meulen, 2000; Saltman and Dubois, 2004; Bump, 2015). In this sense, solidarity is a sociological descriptive concept that is used to explain the origins, presence and continuation of a public system. From a backward-looking perspective, the system originated from and was underpinned by a sense of solidarity shared by the participants. From a forward-looking perspective, if the system wants to continually maintain its legitimacy and sustainability in the future, it has to continue to be underpinned by this sense of solidarity as well. Solidarity is hence related to the ethical approach to address the sustainability issue. Nevertheless, this theoretical assumption made of publicly funded health systems, or more broadly of welfare systems, is not self-evident. Empirically, limited studies show that solidarity could contribute to the making and development of redistributive social policies (Tamir, 1993; Miller, 1995; Houtepen and ter Meulen, 2000; Brubaker, 2004; Miguel, 2004; Béland and Lecours, 2008; Singh, 2011, 2015;). Specifically, in regard to health systems, studies show that despite facing many external pressures, solidarity in European countries remains and holds the health systems together (Morone, 2000; Maarse and Paulus, 2003; Saltman and Bergman, 2005; Saltman, 2015). In this article, solidarity is conceptualized as a descriptive concept that describes a social phenomenon in which the members of a community are willing to share a sense of belonging, recognize a mutual relationship and are willing to pursue some common goals at some cost to their self-interests. These ends are often realized in the form of formal institutions that impose mandatory contributions (either through taxes or premiums) on the participants. This article defines these kinds of institutional arrangements more abstractly as an institutionalized mutual relationship. This descriptive concept of solidarity also has normative dimensions. First, there are some common goals recognized by the members of a community, and these goals are distinct from any particular individual’s personal goals. Second, there are some values or ethical reasons that are used to justify these common goals, and hence justify the mandates of the formal institutions. These values and reasons are the ones that this research intends to investigate. The Case of Taiwan The social and ethical overview of solidarity deduced from the Western experiences might be different from that of newly developed countries. For example, the welfare system in Taiwan was developed and expanded in the late twentieth century as a result of democratization. The National Health Insurance (NHI), as a part of the welfare system, is a single-payer universal health insurance that has been implemented in Taiwan since 1995 (Chiang, 1997; Cheng, 2015). Its development process was largely led by political elites and public health technocrats (Lu and Chiang, 2011). At the transition stage from authoritarian to democratic governance, the reform itself was welcomed by most people and became the campaign promise of major parties under intense political competition (Wong, 2004). Therefore, the establishment of the NHI appeared to be based on strong social consensus. However, because of the same mechanism, the core values of the system were seldom put on the table of public debate. Nation-wide surveys have shown that although Taiwanese people support and are satisfied with the system on the whole (National Health Insurance Administration, 2014), they hold conflicting judgments about the system's core values, such as the problems of inclusion criteria for the insured, the rationale behind priority setting and accountability (Chang et al., 2012). These differences in the normative judgments of the system make people wonder whether the legitimacy and sustainability of the NHI could be maintained during crises. Can such a health system like Taiwan’s be sustained by solidarity like its counterparts in the European countries, when facing the similar external pressures? The purpose of this article is, therefore, to provide a preliminary investigation of the features of solidarity in a non-Western society by exploring how the users perceive the NHI as a health system and how they make value judgments and choices within a system constrained by concerns about sustainability. This research adopts a descriptive ethics approach to understand what kinds of beliefs, values and attitudes people have. This approach provides data and information that may in turn be used to revise normative ethical theories (Sugarman et al., 2007). Before detecting the users’ senses of solidarity, it is necessary to clarify their perceptions of the NHI because these perceptions reveal what they think the NHI is and what they think the NHI should be. Suppose the users do not consider the NHI as an institutionalized mutual relationship with other users in respect to health-care needs. Then there would be no sense of solidarity among the users. Contrarily, it would be meaningful to discuss the users’ ethical reasons for the sense of solidarity if the users see themselves as connected with each other under the NHI. This article does not intend to propose a new definition or argument about the concept of solidarity in health care, but rather to empirically clarify the relationship between the ethical reasons of the system’s users and their senses of solidarity. Theoretically, this article contributes to the literature by providing empirical materials to enrich the discussion of the role of solidarity in public health ethics. It is also one of the few empirical works on Taiwan’s health sector solidarity. Practically, this article informs health policy makers and reformers of people’s ethical rationales for their views, providing a supplementary approach other than the institutional design to address the sustainability issue of the NHI in Taiwan. Methods Research Design As a newly developed democratic country in East Asia, Taiwan is one that adopted the social health insurance model from the West. However, with its very different cultural and historical context, the question of whether presumed solidarity still holds makes it a case worth studying. Qualitative methodology is the most appropriate approach to distinguish the nuances of the users’ value judgments and perspectives through their everyday experiences and engagement with the system. The research has two stages. The pilot stage, from April to May 2014, involved the refinement of the research question and the testing of the interview outline. Five participants were recruited from the internet or through direct contact in person and interviewed at this stage. The second stage was conducted between November 2014 and January 2015. Twelve participants were recruited from the internet. Both stages were conducted in the Taipei metropolitan area, which is the capital city and center of political and economic activities in Taiwan. The participants were recruited through typical case sampling. This sampling method could provide an illustrative profile of the target population through the selection of ‘average-like’ cases (Patton, 2002:236). In this research, a typical case is an average-like NHI user. According to the National Health Insurance Act, all legal residents who live, study or work in Taiwan are eligible to be and also required to be a user of the NHI. This is the target population of the research. Nevertheless, as a preliminary qualitative investigation, this research does not aim at generating findings that could represent the user population; rather, it seeks to provide an outline of the average-like NHI users. Therefore, quota sampling by age, gender, education and work status was used as a supplementary method of the selection criteria of typical cases. In the work status strata, the participants were recruited by sub-quotas of middle class, working class and working poor according to the Gilbert–Kahl model (Gilbert, 2011). These three classes were selected because they represent the largest proportion of the NHI contributors and beneficiaries. In the sense of the NHI, they are the average-like users in the Taipei metropolitan area. Data Collection Recruitment was mainly through a most widely used Bulletin Board System (BBS) in Taiwan—the PTT. The researcher posted recruitment notices on signboards in PTT and selected the respondents according to their fitness to the selection criteria for the purpose of typical case sampling. A total number of seventeen participants were recruited. They provided rich enough information for the purpose of this research. They were all NHI users living in the Taipei Metropolitan. Their ages ranged from 20 to 49, including eight females and nine males. Three of them had high school degrees, six had college degrees and eight had graduate degrees. Ten of them had a full-time job, six had a part-time job and one was unemployed (Table 1). Table 1. The summary of demographic characteristics of the 17 research participants Number Gender Age Education Work status 1 Male 20–29 College Full-time Student 2 Female 20–29 Graduate Full-time Market analyst 3 Male 30–39 Graduate Full-time Legal specialist 4 Female 30–39 Graduate Self-employed Used to be a contract elementary teacher 5 Female 30–39 Graduate Full-time Electronics manufacturing industry 6 Female 30–39 College Part-time Telephone interviewer 7 Male 30–39 College Full-time Railway employee 8 Male 40–49 High school Part-time Market vendor 9 Female 30–39 Graduate Part-time Online auction seller 10 Male 20–29 Graduate Full-time Civil servant 11 Female 30–39 College Full-time Technology industry, also serves as a part-time volunteer firefighter 12 Male 30–39 Graduate Unemployed Were seeking for jobs 13 Male 40–49 Graduate Part-time Contract English teacher 14 Male 30–39 College Full-time Customer service representative 15 Female 20–29 College Full-time Hospital administrative staff 16 Male 20–29 High school Full-time Software engineer 17 Female 40–49 High school Full-time Temp worker Number Gender Age Education Work status 1 Male 20–29 College Full-time Student 2 Female 20–29 Graduate Full-time Market analyst 3 Male 30–39 Graduate Full-time Legal specialist 4 Female 30–39 Graduate Self-employed Used to be a contract elementary teacher 5 Female 30–39 Graduate Full-time Electronics manufacturing industry 6 Female 30–39 College Part-time Telephone interviewer 7 Male 30–39 College Full-time Railway employee 8 Male 40–49 High school Part-time Market vendor 9 Female 30–39 Graduate Part-time Online auction seller 10 Male 20–29 Graduate Full-time Civil servant 11 Female 30–39 College Full-time Technology industry, also serves as a part-time volunteer firefighter 12 Male 30–39 Graduate Unemployed Were seeking for jobs 13 Male 40–49 Graduate Part-time Contract English teacher 14 Male 30–39 College Full-time Customer service representative 15 Female 20–29 College Full-time Hospital administrative staff 16 Male 20–29 High school Full-time Software engineer 17 Female 40–49 High school Full-time Temp worker Table 1. The summary of demographic characteristics of the 17 research participants Number Gender Age Education Work status 1 Male 20–29 College Full-time Student 2 Female 20–29 Graduate Full-time Market analyst 3 Male 30–39 Graduate Full-time Legal specialist 4 Female 30–39 Graduate Self-employed Used to be a contract elementary teacher 5 Female 30–39 Graduate Full-time Electronics manufacturing industry 6 Female 30–39 College Part-time Telephone interviewer 7 Male 30–39 College Full-time Railway employee 8 Male 40–49 High school Part-time Market vendor 9 Female 30–39 Graduate Part-time Online auction seller 10 Male 20–29 Graduate Full-time Civil servant 11 Female 30–39 College Full-time Technology industry, also serves as a part-time volunteer firefighter 12 Male 30–39 Graduate Unemployed Were seeking for jobs 13 Male 40–49 Graduate Part-time Contract English teacher 14 Male 30–39 College Full-time Customer service representative 15 Female 20–29 College Full-time Hospital administrative staff 16 Male 20–29 High school Full-time Software engineer 17 Female 40–49 High school Full-time Temp worker Number Gender Age Education Work status 1 Male 20–29 College Full-time Student 2 Female 20–29 Graduate Full-time Market analyst 3 Male 30–39 Graduate Full-time Legal specialist 4 Female 30–39 Graduate Self-employed Used to be a contract elementary teacher 5 Female 30–39 Graduate Full-time Electronics manufacturing industry 6 Female 30–39 College Part-time Telephone interviewer 7 Male 30–39 College Full-time Railway employee 8 Male 40–49 High school Part-time Market vendor 9 Female 30–39 Graduate Part-time Online auction seller 10 Male 20–29 Graduate Full-time Civil servant 11 Female 30–39 College Full-time Technology industry, also serves as a part-time volunteer firefighter 12 Male 30–39 Graduate Unemployed Were seeking for jobs 13 Male 40–49 Graduate Part-time Contract English teacher 14 Male 30–39 College Full-time Customer service representative 15 Female 20–29 College Full-time Hospital administrative staff 16 Male 20–29 High school Full-time Software engineer 17 Female 40–49 High school Full-time Temp worker Semi-structured face-to-face in-depth interviews with participants were conducted by the author. The length of interviews ranged from 60 to 90 minutes. Throughout the interview process, the interviewer used real cases of controversies surrounding NHI reported by the mass media as well as hypothetical scenarios to probe into the participants’ value judgments on the system and their reasons, motivations and justifications for their judgments. Counterfactual scenarios were applied to test the consistency and self-reliability of the participants’ responses (Walsh, 2007). To minimize bias and provide a comfortable interview environment, the interviewer would express his neutral stance on all NHI issues and invite the participants to feel free to express their opinion. The place of interview was determined by the interviewee, depending on their preferred location and environment. In most cases, it was a café or a quiet restaurant near the interviewee’s workplace or home. If the interviewee did not have a specific request, the author offered to conduct the interview in the research institute building in which he worked. The informed consent forms were signed after the interviewer explained to the participants the potential risks, the benefits and the rights of the participant before the interview began (research ethics approval was obtained from the National Taiwan University Hospital, Number 201410070RINC). The author took notes of the interviewees’ emotions and expressions during the interviews. With the interviewees’ permission, all the interviews were recorded and transcribed. When the transcripts are quoted in the article, any descriptive information regarding the interviewees is as minimal as possible to avoid any possible identification. The participants received a US$10 honorarium. Data Analysis The framework approach was used to analyze the interview transcripts. In comparison with other qualitative analysis methods, this deductive method is suitable for applied policy research that contains pre-set goals (Pope et al., 2000; Ritchie and Spencer, 2002). Before the interviews began, the interview outline included five themes that draw on prior issues of interest: (i) the interviewee’s attitude toward the NHI, (ii) their views about the legitimacy of mandatory inclusion of the insured, (iii) their attitude to the inclusion criteria of the insured, (iv) the conditions upon which the interviewee would be willing to compromise their own welfare to maintain the system’s sustainability and (v) interviewee’s experiences in any forms of public participation. After the interviews, the author immersed himself in the transcripts and notes and coded them systematically. A comprehensive code structure (Bradley et al., 2007) that lays out the relationships between all the codes and the analytic categories of interest, including users’ perceptions of the NHI as a system and their value judgments, was then generated from the coded transcripts. Finally, the typologies of main themes were mapped out in a table. The results section of this article is presented according to these themes. The transcripts and notes were coded and analyzed in Mandarin, and the quotations presented in this article were translated into English by the author. The report of numbers in qualitative inquiry is under debate (Pope et al., 2000; Sandelowski, 2001; Maxwell, 2010). In this article, considering its exploratory purpose, relative terms such as most, some and few are used to substitute for the actual numbers of interviewees who provided certain responses in each theme to depict findings with relative at the same time avoiding misleading inference of statistical representation. The author’s self-disclosure is important for readers to evaluate the author’s credibility (Patton, 1999). Before engaging in the research, the author was a frontline clerk in the governmental agency that runs the NHI. This experience was advantageous to the inquiry because the author could grasp the details of everyday functionings as well as the holistic view of the system. The disadvantage was that the author might be too sympathetic or attached to the system. However, this disadvantage motivated the author to explore and analyze NHI users’ perceptions and judgments as unbiasedly as possible to inform future policy-making and reforms. Results Users’ Perceptions of NHI as a System The interviewees’ attitude toward the NHI could be divided into two broad categories: empirical perceptions (What is the NHI?) and normative judgments (What should the NHI do?). Empirical perceptions In terms of ‘what the NHI is’, the interviewees perceived the NHI as a part of the not-for-profit welfare system that belongs to the formal institutions of the government, an actuarial insurance scheme that is similar to a for-profit private insurance, or somewhere between or a combination of the two. Only one interviewee saw the NHI as a form of public assistance, which is close to charity. First, most of the interviewees saw the NHI as a part of the not-for-profit welfare system. The term ‘welfare system’ used here is a broad one. It refers not only to the means-tested subsidy programs and social assistance but also to the whole formal institutional arrangements that are funded by public money to pursue common goals, and the NHI is a part of these arrangements. It, however, does not include the charity or philanthropy sector, which is informal and is funded by private money. Therefore, it is confusing and unsatisfactory to this group that the government officials have often said in the mass media that the financial balance of the NHI is under threat, or that the NHI is about to enter bankruptcy, particularly when the government prioritizes spending on such things as New Year Eve’s fireworks. They felt that it does not make sense to use the kind of language that is often used by for-profit businesses to describe the NHI. The NHI is called ‘insurance’ just for the purpose of describing its mechanism of fund collection, but since it is a part of the welfare system, and the government is responsible for the system’s function. In contrast, a minority of interviewees saw the NHI as an insurance system that is similar to private insurance, in which the insured’s premium contribution is calculated according to the actuarial rate. Therefore, the NHI should seek its own internal financial balance (just like other private insurance companies) and reflect the risks to the insured’s premium by setting different actuarial rates for different participants, rather than setting community rates (as many of the social health insurances in other countries do). The only difference is that in the NHI the insurer is the government, which they also expected to behave like a private insurance company in terms of business-level efficiency and independence from other governmental agencies. Between these two different perceptions of the system, the pure not-for-profit welfare system and the pure actuarial insurance, some interviewees saw the NHI as insurance inside the welfare system. Therefore, it is reasonable for the NHI to maintain its own financial balance and be under the threat of bankruptcy, but speaking overall the government still has more responsibility to support the system financially. Normative judgments In terms of ‘what NHI should be’ most interviewees saw that the NHI should be a means to maintain a mutual relationship between the users. Others saw the NHI as a practice of benevolent rule. A few of the interviewees considered the NHI as an illegitimate system that should be abolished. First, most of the interviewees agreed that the NHI reflects the social values of fairness, justice and social mutual aid in preventing social inequality due to illness. Fairness and justice (in Mandarin these two words have similar meanings and could be and are often used interchangeably or combined, e.g. fair-justice [gong ping zheng yi, ) were the words mentioned the most frequently, which shows that many interviewees could identify a mutual relationship with other NHI users, even if these users were not directly related to them. An equal relationship between the users of the system could be imagined in the sense that they share the financial risks of illness. The interviewees also agreed upon the value of the NHI in preventing social inequality. The main reason is that they could not accept the condition that in society some individuals or families would fall into poverty because of illness. This reason is related to the interviewees’ understanding of the essence of health services. For them, in many other aspects, such as talents, heritage or merit, inequality may be tolerated, but in health it is not. Hence, it is imperative for the state to ameliorate this kind of inequality: One of the reasons for the state to provide medical services is to reduce economic inequality. Yeah, then the poor would be able to afford a basic level of service, so that, well, I mean, in a minimal sense they should have the right to survive in the society. (M, age 30s, unemployed) Second, some interviewees saw the value of the NHI as the government’s ‘benevolent rule’, [de zheng, ]. Because the government, or the rulers that control the government, are enlightened and virtuous, they implement the NHI to care for people’s health needs, to ‘create well-being’ [zao fu, ] for people. Note that in this judgment, the government, the state and the rulers are considered as a unity that have a higher authority among the ruled; hence, it could make better judgments on what well-being is and what is good for the ruled. It has nothing to do with the attitude of individual government officials. In this judgment, the relationship between government and users is unilateral. In addition, because the benefits from the NHI are created by the government, the users do not identify a mutual relationship with other fellow users. Third, for those interviewees who did not recognize the legitimacy of the NHI, the system has no value at all and is a misallocation of public resources. One reason is that the government is inefficient in terms of funding for health services, and many resources are wasted. Another reason is that the NHI policy is so unstable that the interviewees felt they had been cheated by the government many times, and hence they did not trust the system any longer. One interviewee even expressed the extreme eugenicist opinion that those who could not afford basic health services might not be proper members of the society, and hence it is unnecessary to allocate public resources to them. In sum, despite the NHI users’ pluralistic perceptions and judgments toward the system, from most of them a notion of mutual relationship among the user community could be observed. What is the reasoning behind these perceptions and judgments? How do they relate to a sense of solidarity? Three Types of Reasons that Justify the NHI and the Senses of Solidarity Three types of reasons about the obligations of mutual aid brought by the NHI are found among interviewees: ex post facto, self-interest and community-interestreasons (Table 2). These reasons are crucial for interviewees to justify the state’s intervention in health issues and the legitimacy of the system. Note that these three types are not mutually exclusive. An interviewee may hold more than one reason and give them different weights. Table 2. The summary of the three types of reasons provided by the research participants to justify the National Health Insurance in Taiwan Types of reason Ex post facto Self-interest Community-interest (The simpler version) Relationship with other users as a whole Unclear Social cooperation based on self-interest Communal life with some shared common values Relationship with other individual users Unclear Unclear Members of the system Members of the system Equal moral status with shared egalitarian values Justifications of the state’s intervention Habituation and benevolence Beneficial, good deal, instrumental value of insurance, convenience and easier access to reimbursement’ Mutual aid, normal functioning of modern society and living together Mutual aid, universal necessity of health services, reciprocal mutual aid and contingent common risks Senses of solidarity Implicit recognition None or weak sense Less than strong sense Strong sense Types of reason Ex post facto Self-interest Community-interest (The simpler version) Relationship with other users as a whole Unclear Social cooperation based on self-interest Communal life with some shared common values Relationship with other individual users Unclear Unclear Members of the system Members of the system Equal moral status with shared egalitarian values Justifications of the state’s intervention Habituation and benevolence Beneficial, good deal, instrumental value of insurance, convenience and easier access to reimbursement’ Mutual aid, normal functioning of modern society and living together Mutual aid, universal necessity of health services, reciprocal mutual aid and contingent common risks Senses of solidarity Implicit recognition None or weak sense Less than strong sense Strong sense Table 2. The summary of the three types of reasons provided by the research participants to justify the National Health Insurance in Taiwan Types of reason Ex post facto Self-interest Community-interest (The simpler version) Relationship with other users as a whole Unclear Social cooperation based on self-interest Communal life with some shared common values Relationship with other individual users Unclear Unclear Members of the system Members of the system Equal moral status with shared egalitarian values Justifications of the state’s intervention Habituation and benevolence Beneficial, good deal, instrumental value of insurance, convenience and easier access to reimbursement’ Mutual aid, normal functioning of modern society and living together Mutual aid, universal necessity of health services, reciprocal mutual aid and contingent common risks Senses of solidarity Implicit recognition None or weak sense Less than strong sense Strong sense Types of reason Ex post facto Self-interest Community-interest (The simpler version) Relationship with other users as a whole Unclear Social cooperation based on self-interest Communal life with some shared common values Relationship with other individual users Unclear Unclear Members of the system Members of the system Equal moral status with shared egalitarian values Justifications of the state’s intervention Habituation and benevolence Beneficial, good deal, instrumental value of insurance, convenience and easier access to reimbursement’ Mutual aid, normal functioning of modern society and living together Mutual aid, universal necessity of health services, reciprocal mutual aid and contingent common risks Senses of solidarity Implicit recognition None or weak sense Less than strong sense Strong sense Ex post facto reasons Interviewees providing ex post facto reasons justified the state’s intervention in terms of habituation. The interactions between users, the insurer and health-care providers under the NHI throughout all these years have made the system become a way of life: I felt that I am getting used to it … it is what it is. If I need care services, I would use it. If I don’t, the premium I paid is just like benevolence to others, helping them when they are in need. Like Dāna [charitable giving] as those Buddhists say. (M, age 40s, contract English teacher) This reason implies that if the users do not resist the system, it is obvious that the system has some good qualities or is not too bad to be tolerated. Therefore it is natural to recognize its legitimacy. This account might be considered as an implicit recognition of solidarity that is generated by the practices of the system and users’ interaction with it throughout the years it has been implemented. Self-interest reasons Interviewees providing self-interest reasons justified the state’s intervention on the ground that the mandatory arrangement is beneficial to them. They either thought that the NHI is a ‘good deal’ made with the government, or that for the sake of convenience the NHI is better operated by the government. Interviewees’ experiences of engaging with the system would also affect their perceived health risks, which would then affect their evaluation toward the system. The ‘good deal’ logic is similar to the actuarial logic of private insurance. The interviewees saw that in the future they might encounter risk events, and the cost of these events is expected to be larger than the cost of their NHI premium. Therefore, it is a ‘good deal’ to purchase this social health insurance plan from the state. You see, no matter to what degree you raise the premium rate [of the NHI], at most 10% or 20%, it is still relatively small [in comparison to purchase private insurance or pay out-of-pocket] in the long run. Although I didn’t use many NHI services in recent years, I think it is acceptable to raise the premium rate [to maintain the financial balance of the NHI]. It’s better than letting the NHI go bankruptcy and you paying for all services by yourself. (M, age 20s, software engineer) By providing this reason, the interviewees saw themselves as having a unilateral relationship with the insurer. The calculation of benefits is based on individual perceived health risks. The state’s intervention could be justified as long as it is beneficial. On the other hand, if the burden imposed by the state is larger than the cost of their perceived health risks, the system would totally lose its legitimacy. Among the interviewees providing this type of reason, some of them mentioned the ‘convenience’ and ‘easier access to reimbursement’ of an insurance run by the government. They thought that in comparison with private insurance, the NHI has lower administrative costs and the burden of overseeing reimbursement is laid on health-care providers rather than beneficiaries, making it much easier to get through the process to pay for the services. It is difficult to observe any sense of solidarity among this type of interviewee. The interviews show that individual perceived health risks would be mediated by interviewees’ personal experiences of catastrophic health events and intensity of their interaction with the NHI. If the interviewees or their significant others had been through these experiences, they tended to evaluate the system as more beneficial. Here the line between calculation of self-interest and community-interests becomes vaguer, because these experiences make the users have a stronger recognition of the system’s values: In the process of caring, you were very tired, and you could not save the patient’s life. And the bills with many zeros behind would come at any time. You didn’t know what to do. So, people might complain [about the NHI], complain about the premiums of one thousand, two thousand (NT) dollars every month […], but you will know [the value of the NHI] when you see the medical bills. (F, age 30s, electronics manufacturing industry) Nevertheless, whether this kind of recognition could be regarded as recognition of the common value of mutual aid remains unclear. Community-interest reasons Interviewees providing this type of reason agreed that mutual aid itself has moral significance that justifies the state’s intervention. The notion of mutual aid implicitly assumes some forms of community identity, because to share mutual aid with a group of people, there must be a community. In our NHI case, the extent to which interviewees could identify relationships with other users forms the community. The reasons provided by the interviewees under this third type include universal necessity of health services, reciprocal mutual aid and moral obligations among users. First, some interviewees appealed to the universal necessity of health services. Just like public education, they thought that public provision of health services is required, for the longevity and quality of life and that the ability to afford health services should not be determined by one’s ability to pay. It is a matter of fairness. For the interviewees who provided this reason, their justification for the NHI has gone beyond calculation of self-interest and moved toward the consideration of community-interests. Their unit of evaluation is not only individual but also communal. The government has the responsibility: In terms of medical services, I think everyone should have adequate services when they are in need. I think it is pretty dangerous if the government does not provide this kind of assistance. In that circumstance, the rich could obtain the best services. I feel that it is quite unfair. […] The protection from the state should not be limited to infrastructure or anything; it should also include the maintenance of people’s lives. (F, age 20s, market Analyst) Because we all live in the same society, the advantaged could help the disadvantaged to achieve mutual aid. Well, as a way of life. Not just taking care of your own business. (F, age 20s, hospital administrative staff) Second, most interviewees invoked the notion of reciprocal mutual aid. This is not a strict norm of reciprocity, but rather an expectation that I am willing to help the others because I believe that sometime in the future someone would help me when I am in need. By providing this reason, the interviewees recognized the fact that people will likely need help at sometime, and based on this recognition, they also believed that people should share the responsibility to face these risks; hence, the state’s intervention is justified. However, it is unclear why the fact that people recognize these risks automatically leads to the normative judgment that they should share the responsibility. Some interviewees thought that it is because of the contingent nature of the distribution of these risks, and those who bear fewer risks are just luckier than the others. Therefore, it is reasonable for them to share the burden of these common risks. With this understanding of their relationship with other users, a sense of equal moral status could be found among the interviewees. They shared an egalitarian value that it is an obligation for every user of the NHI to help each other, and no one could opt out: You say you don't want to join the NHI, Labor Insurance, or National Pension. Well, then, are you going to say you don’t want to pay taxes, am I right? I never go to a public park, why do I have to pay the tax? I never drive a car, why do I have to pay the air pollution tax? I just don’t have to pay any tax at all. Yet you cannot do that, because you live in this society. (F, age 30s, electronics manufacturing industry) Community-interest reasons—a simpler version A simpler version of the community-interest reason is connected to the interviewees’ expectations for the normal functioning of modern society. Although similar to the community-interest reasons mentioned above, this simpler version is not embedded within the normative values of universal necessity, reciprocal mutual aid or moral obligations. The mere fact that people are living together in a society leads to the normative judgment that people should take care of each other’s health needs. Some interviewees also emphasized the role of cultural tradition. One interviewee said that, to him, the NHI is like an institutionalized version of the traditional virtue of mutual aid, expressing a strong sense of humanness [ren qing wei, ], a mixture of friendliness and hospitality, being considered as one of the traditional virtues]. However, in this simpler version, it is unclear whether these interviewees perceived a sense of equal moral status with the other users. In sum, the interviewees with this third type of reasons could more or less recognize that the NHI is a mutual aid institution based on the membership of the community. Its logic is reallocating resources from the many to the few who are in need to share the common risks. This logic is different from the unilateral relationship between the rich and the poor in charity-based arrangements. It could be concluded that between the NHI users there exist some senses of solidarity, which connects the individual user with the others. Summary The three types of reasons and the divergent senses of solidarity are summarized in Table 2. Those providing the community-interest reasons have a strong sense of solidarity. They are willing to share the obligations of care between the other NHI users and make commitments to the values upheld by the system. If necessary, they would withhold the maximization of their self-interest to maintain the public system. In practical terms, this means that in the case where the NHI fund starts having financial deficits, the users might be willing to accept and support a reform proposal that will harm their self-interest, such as increasing the premium rates or the co-payment but will sustain the service package covered by the NHI. (However, this acceptance is not without certain preconditions. Please see the next section.) Those providing the simpler version of community-interest reasons have a less strong sense of solidarity. While their perceived relationship with other individual users remains unclear, they are also willing to share the obligations of care for the purpose of mutual aid. For those who provide the ex post facto reasons, implicit solidarity is recognized as long as they are willing to participate in the system without questioning its legitimacy or calculating the benefits and costs of their participation. Those who provide self-interest reasons seem to have no sense of solidarity at all. They are willing to support the system as long as it is beneficial to them. However, if they could calculate their benefits in a longer term, they might be willing to withhold their maximization of self-interest in the short term to receive larger benefits in the future. For instance, suppose a reform proposal that increases the premium is proposed to fill the deficit gap of the NHI fund. This proposal will harm the user’s benefits (losing more money on paying a larger premium every month). However, suppose the user encounters an unexpected car accident or is diagnosed with lung cancer at some point after the reform. Then the sustained NHI at that time point will pay for most of the expensive treatment (such as an ICU bed) for the user. To maximize her benefits in the long term, the user might accept and support the proposal in the first place. If this is the case, then they might be categorized as having a weak sense of solidarity in that at least they are willing to participate in social cooperation in the public provision of health services. Now that the perceptions and judgments toward the NHI and the contents of solidarity have been presented, in the next section, the conditions under which the interviewees would be willing to withhold the maximization of their self-interest and to support the sustainability of the NHI when necessary will be presented. Conditions for the Users’ Supportive Attitude Due to reports in the mass media, a majority of the interviewees recognized the fact that the NHI has encountered several financial crises during its 23-year implementation and needs the public’s support to maintain its financial sustainability. With this understanding in mind, most users are willing to accept the reform projects proposed by the government, such as raising premium rates and limiting the adoption of new drugs and treatments into the service package covered by the NHI. However, this acceptance comes along with certain conditions, including the government’s performance, the users’ personal experience and the stability of NHI-related decision-making. Government’s performance The most mentioned condition is the government’s performance, which contains three dimensions: transparency, effectiveness and coherence. When the interviewees spoke of transparency, in most cases, they specifically referred to financial transparency. Many interviewees thought that the government, as the insurer of the NHI, does not provide adequate information about the expenditure of the NHI for people to evaluate whether the premiums they contributed were spent properly. In other cases, they thought that although the government does provide the information, it does not do so in an understandable manner. There are merely blocks of data filled with professional jargon uploaded on the website. Without transparent information disclosure, they were not willing to accept the reform proposals: In the future, ideally I would think it is OK [to raise the premium rates]. But sometimes I feel that it’s like a passive action. I paid the premium and fulfilled my obligation, but I hope that it has a more transparent financial report, so that everyone could know how exactly the NHI fund was spent. (M, age 30s, unemployed) To the interviewees, effectiveness means the proper use of the NHI fund for proper ends. Many interviewees had the perception, either from their personal experiences or from the mass media, that under the current situation the fund has been wasted in many places. To them this is a serious issue. If the government could not solve the problem (or at least show that it is attempting to solve the problem) and enhance the effectiveness of resource allocation, they would not be willing to support any reform proposal: It should be the government’s responsibility to supervise. If the government had done it well, if there were less waste of medical resources. […] Like what we said, many people keep asking for prescriptions and drugs while they are not sick at all. In this case you say you want to raise the premium? I would be very reluctant to pay. (F, age 40s, temp worker) The last dimension of the government’s performance is coherence. To the interviewees, coherence means that they tended to see the whole public service system as a unity, and the performance of the NHI cannot be evaluated separately from that unity. In other words, not only the performance of the NHI but also of the public services system is considered as the basis for their support to the NHI. They thought it is unreasonable that on the one hand the NHI is about to go bankrupt, while on the other hand the government is still spending a huge amount on unnecessary luxuries, such as fireworks in the New Year's Eve celebration (this example was emphasized by two interviewees). Personal experience The second condition is personal experience. If one had been through the experience of having a great need for medical services, one would have a stronger sense of self-restraint about one’s personal usage of NHI resources. For example, an interviewee said that she asks the doctor not to give her drugs that she does not need. In this specific case, the doctor said that she would not need to take any drug, but as backup the doctor still wanted to prescribe some drugs to her. These people feel the significance of spending on medical services and are concerned about the crowding effect of resource allocation. If they unnecessarily used the resources, some people might suffer from the lack of resources. The government has the responsibility to make proper arrangements to reduce unnecessary use and to transfer resources to under-served regions. Stability of decision-making The third condition is the stability of NHI-related decision-making. Short-term reform proposals seem to be more untrustworthy to the users, because they are concerned about the increasing burdens in the future. As one interviewee mentioned: I am OK with raising premium rates. However, the game rules should be as clear as possible, so that the rate won’t have to be raised every one or two years, or [that the reform proposal will not] be withdrawn easily because of the pressure from public opinions. […] Otherwise, they proposed the Second Generation Reform [that raised the premium rates] this year, what about next time? Would there be the Third, the Fourth, the Fifth Generation, and so on so forth? People would be afraid [of the uncertain future burden]. (F, age 30s, electronics manufacturing industry) Discussion The analysis of the three types of reasons justifying the NHI indicates that most of the interviewees had some senses of solidarity in mind, among which the strong sense of solidarity would be the cornerstone of a sustainable NHI system. This sense would actively support future reforms and uphold the core values of the system. The weak sense of solidarity is a necessary condition for maintaining the system’s normal functioning. However, its relationship with the sustainability of the system remains unclear. There is a bourgeoning discussion on the role of solidarity in bioethics and public health ethics (Beauchamp, 1985; Dawson and Verweij, 2012; Jennings, 2007, 2016; Prainsack and Buyx, 2011, 2015; Krishnamurthy, 2013). Both the weak and the strong senses of solidarity in the NHI found in this research are analogous with the notions of rational solidarity and constitutive solidarity distinguished by Dawson and Verweij (Dawson and Verweij, 2012). The rational category conforms to the weak sense of solidarity, and the constitutive category conforms to the strong sense of solidarity. In rational solidarity, people are willing to cooperate for their long-term interests, such as facing common risks and tentatively put aside their short-term interests. Constitutive solidarity ‘describes a set of norms about how we behave towards each other in social groups’ (Dawson and Verweij, 2012). For particular individuals, such as those who are young and have lower health risks, it might be irrational to recognize the values of a publicly funded health system, ‘but still reasonable given people’s identification with a community, way of life and set of values’ (Dawson and Verweij, 2012). Some of the commitments required by constitutive solidarity could be demanding for individuals, asking them not only to consider the common goals but even to put their self-interest at risk. Dawson and Verweij suggest that this constitutive solidarity is also required for comprehensive health care plans, of which the NHI in Taiwan is an exact case. This implication also conforms with Dan E. Beauchamp’s earlier argument that the goal of public health is not merely to instrumentally maximize aggregative welfare; rather, it includes ‘the commitment of the whole people to face the threat of death and disease in solidarity’ for the common good (Beauchamp, 1985). However, this research is subject to Dawson and Verweij’s criticism of Prainsack and Buyx for adopting an approach that understands solidarity as a more descriptive than normative concept. The research findings suggest that Prainsack and Buyx’s definition of solidarity, ‘shared practice reflecting a collective commitment to carry “costs” (financial, social, emotional or otherwise) to assist others’ (Prainsack and Buyx, 2011), could be found in those who have a strong sense of solidarity in the NHI. However, this descriptive solidarity does not provide any normative guidance to what role solidarity should play in a health system. The value of solidarity here is, hence, instrumental. The strong sense of solidarity as a means to sustain the NHI would have its value, only if people consider either the sustainability of the institution of the NHI or the sustainability of its core values as a right thing to pursue collectively. Nevertheless, one could still argue that, Prainsack and Buyx’s definition of the descriptive concept of solidarity has a normative dimension, which is the recognition of a mutual relationship among the users of the system. In this sense, solidarity requires the users to see each other as equal moral agents, at least with respect to health needs. If this is the case, a further issue for future research to analyze is what the boundary of the user community is and how it is defined, namely, the question of ‘solidarity with whom’? (Prainsack and Buyx, 2017:183). There is still the issue of applying the concept of solidarity in different cultural and historical contexts. Generally speaking, the origins of solidarity in the West might be seen in the legacies of civic republicanism, Judeo–Christian traditions, labor movements and the national sentiments formed in the post-WWII reconstruction era (Saltman and Dubois, 2004; Bump, 2015). In an East Asian society like Taiwan, which is largely based on Confucian social ethics (Eikemo and Bambra, 2008; Zhang, 2010), what does it mean to have a weak or strong sense of solidarity? Such a question requires further research, but, nevertheless, it might be the case that because of the 23-year practices of the NHI, people have gradually realized the long-term benefits brought by the system. They have formed a weak sense of solidarity. Furthermore, people might gradually recognize and uphold the core values of the system and form a strong sense of solidarity, which would later in turn support the system’s sustainability. One could also arguably infer that this strong sense of solidarity might open a chance to bind the community together in Taiwan’s political context of conflicting national identities (Corcuff, 2002; Brown, 2004; Cole, 2016). As some case studies have shown, the welfare institutions could forge solidarity among people (McEwen, 2002; Béland and Lecours, 2005; Law and Mooney, 2012) and even be considered as a part of the nation-building project (Kymlicka, 2007). As Krishnamurthy argues, social institutions could forge the sense of solidarity among fellow citizens, motivating them to ‘make sacrifices that justice demands’ and eventually forming a more just society (Krishnamurthy, 2013). From the research findings, the practices of the NHI in Taiwan might be the case, in that the NHI forges users’ strong sense of solidarity and motivates them to make sustainable choices, as the users recognize that the NHI and its core values are the essential components of a just society. However, note that the solidarity Krishnamurthy refers to here is ‘political’ solidarity, which largely differs from the general concept of solidarity, because it clearly limits the boundary of solidarity within a ‘state and among fellow citizens’ (Krishnamurthy, 2013). This, again, calls for future investigations of the meanings and implications of the boundary of health sector solidarity within and between borders and around the globe (Schwartz, 2007; West-Oram and Buyx, 2017). On this note, the concept of solidarity is shown to be plausible and meaningful both in terms of the sustainability of the NHI system itself and the sustainability of the whole political community. The mutually reinforced relationship between the practices of the NHI and senses of solidarity in the NHI is beyond the scope of this research. As has been suggested, solidarity in the health sector is dynamic (Saltman, 2015), depending on the users’ or citizens’ perceptions and recognition of the core values of the system. Limitations Because of the exploratory nature of this research, it has several limitations. First, although typical case sampling was used, the geographical and linguistic barriers limit the generalizability of findings to the population living in the northern region of Taiwan and the Mandarin-speaking population. The other barrier is that the researcher cannot access interviewees who are in very high or low social economic status. Despite these limitations, the sampled interviewees could represent the average-like population that is influenced by the NHI system, as the research was designed to target. Second, the descriptive ethics approach could at best detect the interviewees’ perceptions and judgments at the time when the interviews were conducted but could not measure what choices the interviewees will make when they actually encounter real life situations. Third, due to the time limit, two important issues related to solidarity are not covered in the interview. One is intergenerational solidarity, which is an urgent issue in sustainability of public systems considering the aging population and stagnated economy (Houtepen and ter Meulen, 2000). The other is national identity, which is a particular concern in Taiwan as well as other regions with multicultural social bases or with secession or independence movements. Conclusions Through this exploratory investigation, three types of reasons used to justify the obligations of mutual aid imposed by the state through the NHI are distinguished. They are embedded within different senses of solidarity and have different relationships with the sustainability of health system. The concept of solidarity that originated from the traditional welfare states has been shown to be an applicable analytic concept as well as empirical phenomena in Taiwan and potentially in other newly developed countries. Health policy makers and reformers could adopt measures to maintain the government’s performance and stability of decision-making and build an environment that could make users have more engagement with the NHI, to cultivate users’ sense of solidarity and meet the conditions for their supportive attitude toward the system when the NHI encounters next crisis. Future research on solidarity could be built on the framework of three senses of solidarity from this research to further distinguish the causal directions between solidarity and sustainable health systems in East Asian societies. In an age of economic recession and austerity (Reeves et al., 2015), solidarity has its strength to be addressed in the debates of public health arrangements of the developed countries, for publicly funded health systems are not merely the protection of some rights that are derived from universal normative principles; rather, it is a realization of serious and genuine commitments that are made by the community members, recognizing that they share the same membership and mutual obligations of care (Jennings, 2016). From this point, we could reconsider Beauchamp’s insight: ‘Health is social … The way we provide or arrange for public’s health … helps reshape society and especially the body politics’ (Beauchamp, 1996: 25). Acknowledgements The author gratefully acknowledges the contribution made by all research participants. The article is derived from the author’s master thesis at National Taiwan University. 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Available online at www.phe.oxfordjournals.org This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

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Public Health EthicsOxford University Press

Published: Apr 1, 2019

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