The dispute surrounding the debts owed by local governments to the Bureau of National Health Insurance reveals the chaos in Taiwan's system of government. Naturally, the insurance bureau can make loud demands in accordance with the National Health Insurance Lawasking local governments to pay the premiums they owe. However, local governments are sitting back and relaxing as if they have every reason to owe the money, claiming that "the central government should implement the laws it enacts."

Next comes the lack of mechanisms for coordination or integration between levels of government and the resulting fragmentation and conflict. Those in top positions have not demonstrated the authority and dexterity of good administrators, while local politicians seem to attach little importance to the big picture, their vision being limited to winning votes.

If the debt problem is not resolved, the insurance bureau will face a liquidity crisis in a few months. Because such crises are caused by man-made factors, they hardly constitute a legitimate reason for raising premiums, even if the bureau's financial reserves fall below the minimum level -- equivalent to one month's benefits -- stipulated by law.

Things need not have come to this. If we look at examples from other advanced countries, there are two principles for averting such disputes. Either make power compatible with responsibility at all levels of government, or establish a unified system of administrative rules.

To "make power compatible with responsibility" means to clearly designate the responsibility for healthcare. If the central government is to assume this responsibility, then the legislation, implementation and financial matters should all be shouldered by the central government. If the local governments are to take this responsibility, then the related policy-making and implementation, including funding, should be handled at the local level.

Even though the central government provides financial support within its budget limits, in principle it does not interfere directly in the content of the programs proposed by local governments or the conditions they set for implementation. The local governments can set financial and administrative priorities at their own discretion and adjust the content and standards of benefits in order to balance their finances. The US Medicaid program and the medical and health-insurance programs run by the provinces of Canada are examples of this kind of system.

Japan provides an example of a unified administrative system. In its medical-insurance program for the elderly, the central government enacts unified laws but the sources of funding are rather complex. They include money pooled from the health-insurance schemes that the elderly person originally adopted, the person's own out-of-pocket payments and payments from the central government and various levels of local governments according to a set formula.

It is worth noting that the levels of Japan's local governments are far more complex than those of Taiwan, but after many years of implementation, Japan's system now has unified rules and does not lead to chaos.

The key to solving the debt problem once and for all is to amend the National Health Insurance Law so as to establish the principle of "the central government taking responsibility for the laws it enacts." However, with politicians refusing to make compromises for the sake of the country, there is no knowing whether the amendment will be successful.

Establishing unified administrative rules will be easier said than done, given that old grudges between the different political parties remain unresolved. Also, because it is difficult to pass judgment on such disputes from ethical or theoretical perspectives, even an interpretation of the Constitution by the Council of Grand Justices may not result in a clear decision.

One possible solution is to simply follow the current track. The insurance bureau, which has the right to pursue the debts owed by local governments in accordance with the National Health Insurance Law, may use tougher measures to pressure these governments to respond. If the local governments do not respond, the bureau may apply for deductions from the central government subsidies for the local governments. This will force a confrontation between the central and local governments. A compromise and a reasonable solution may then arise from these tensions.

The health insurance bureau's trump card is the high public support for and reliance on the National Health Insurance program. No politician would dare commit the great crime of causing the program's collapse. By leaving behind its underdog mentality and making the dispute bigger, the National Health Insurance Bureau may have the best chance of solving the problem.

Associate professor at the department of social welfare at National Chung Cheng University.

Translated by Francis Huang

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