From authoritarianism to statism: The politics of national health insurance in Taiwan

In 1995 the Taiwanese state installed a national health insurance program in the context of democratic transition. This program replaced several occupation-based schemes by bringing all citizens together in a single plan under the centralized control of the state. The single plan adopts inequitable financing methods that divide citizens into special categories.;This study explores the sociopolitical processes behind the construction of the distinctive institutional forms of the national health insurance program. Tracing the long-term historical transformation to explained how and why a statist plan was created to replace the old insurance programs, this study adopts a historical institutionalist perspective, focusing on how the characters of polity and state-society relations, and their transformation over time, shaped the institutional development of health insurance; and how state policies and actions shaped the institutional features of health insurance that structure human choices, whose behavioral consequences became determinants of political responses.;Part I of this study investigates the sociopolitical construction of crisis in the old insurance systems. It is argued that authoritarian patterns of governance created institutional vulnerability that led to crisis. The authoritarian elites actively devised health insurance programs to attract supports from selective social groupings, and single-handedly set the rules governing the insurance systems. Institutional features of the insurance systems shaped by state policies, however, induced many kinds of self-seeking behaviors that could not be effectively monitored by state power. Such self-seeking behaviors generated negative consequences that contributed to system crisis.;Part II explores the construction and consequences of the statist plan as the solution to the crisis in the old system. Formulating the plan during democratic transition was restricted in bureaucratic-technocratic sphere without wider societal participation. The newly expanded representative arenas did not establish effective mechanisms of expressing interests and values in collective terms, and failed to address greater concerns for equality. The capacities of societal actors to participate in governing the collective institutions were still weak, and state dominance prevailed. But state power was expanded without building administrative capacities of reliable enforcement. Self-seeking behaviors still persisted in the national health insurance program centered on ethical obligations.