The majority of the public has been caught by surprise by the fact that the actual changes made in the second-generation NHI have not been as sweeping as had been hoped.

On the eve of the vote, the ruling KMT party suddenly changed tack, abandoning the total-household-income-based pre-mium calculation method it had long advocated, and returning to the method based on the six categories and 14 subcategories of individuals in the first-generation NHI system (but adding a 15th subcategory for "convicted criminals"), with monthly premium payments calculated on salaries. However, six forms of supplemental income have been added, including interest and dividends, thus putting premium rates on a double-track system.

The Bureau of National Health Insurance (BNHI) estimates that once the new law goes into force, 83% of the populace will see a drop in premiums, while the remaining high-income earners will see an increase in theirs. This adjustment will keep the NHI financially balanced for the next five years.

The law just passed is quite different from the version proposed at first by Yaung Chih-liang. During the process, Yaung -stated frankly that he was frustrated.

However, the final decision was made practically overnight. After all the debating came to a sudden end, startled and regretful voices immediately arose, because giving up on the idealistic yet vaguely defined "household income" premium calculation method and returning to the old way of doing things was a disappointment.

In reality, given the consensus of broadening the premium base to save the NHI, most people were mentally prepared to pay higher premiums. But they didn't see why this should depend on wage earners who had little to spare, while capital gains were not included in the calculation.

The greatest quarrel regarding the first version of the second-generation NHI bill was over so-called "virtual income." Neither the NHI Civic Surveillance Alliance (CSA) nor the "blue" or "green" camps were able to accept certain ideas. They expressed bewilderment that premiums for those with no income (homemakers, the unemployed, etc.) were to be calculated based on an income of NT$17,280 (a figure equal to the minimum wage, and used in the calculation of pensions under the National Pension Insurance), while pensions from public employment would not be included in the income calculation. As such, the DOH's version was sent back to the Executive Yuan for revision, becoming a product of compromise.

There is no such thing as absolute fairness. From whatever perspective one evaluates it, applying the monthly-salary-based premium calculation method is detrimental to most households, while a household-income-based calculation will likewise be disadvantageous to one-person households who have not reported as supporting dependents. However, from the standpoint of the overall welfare of society, the concept of single individuals helping other households nurture the future of society looks to be altruistic in a narrow sense, but is actually self-interested in a broad sense. Plus this policy is not unique to the second-generation NHI: isn't the government's offer of a child-raising allowance to encourage childbirth a different approach to the same end?

As to vagueness and the fact that the premium base is insufficient to achieve a state of fairness, the new law is ultimately still an abandonment of the ideals. However, the design of the supplemental premium includes a 2% add-on premium rate for income such as dividends, interest, rent, hourly fees, TV entertainer's wages, and payments for writers' work, for bonuses that are over four times the value of the monthly premium, and for consulting fees and travel allowances. Those affected more by these changes include employees in high-tech industries and high-end sales, with low base pay but high bonuses, as well as high-income earners such as models, entertainers, architects, and accountants. The DOH estimates that this will boost the premium base by about NT$1,040.7 billion, meaning that a 2% levy should increase premium income by NT$20 billion. But NHI Civic Surveillance Alliance spokesperson Eva Teng believes that lowering premium rates while making up for it in other areas will result in no improvements, and the NHI may face insolvency by 2021.

The "unsatisfactory but acceptable" second-generation NHI in fact includes significant improvements, thanks to its reforms in information disclosure, safeguarding the healthcare rights of the disadvantaged, broadening public participation and supervision, and reducing healthcare waste.

The new law better protects the public's healthcare rights. In the past, impoverished people have had their NHI cards cancelled for not paying their premiums, preventing them from receiving needed medical attention. This will not happen again. To deal with those unable to make their premium payments, the BNHI must make investigations and find social resources to help them. As for people living overseas who do not pay premiums, the new system imposes a six-month waiting period upon returning to Taiwan before they can rejoin the NHI system, thereby minimizing wasted resources caused by people returning from overseas just to take immediate advantage of the system.

Next, regarding the co-payments that are of such great concern to the populace, the revamped NHI will provide partial funding for medical devices, but exclude new drugs whose efficacy is unclear, to prevent doctors from persuading people to undergo unnecessary treatments requiring out-of-pocket payment.

Third, the revised NHI includes numerous new regulations for healthcare providers. For example, hospitals must comply with regulations on ratios of NHI-insured beds, and every day they must publish the usage status of such beds. A hospital without enough NHI-insured beds will be fined, thus effectively fixing the problem of not being able to find a single NHI-insured bed. And when doctors prescribe medicine, they will be required to provide written prescriptions, to prevent doctors from profiting- off differences in drug prices, and to boost public safety and healthcare quality with respect to medication.

Lastly, for greater transparency of health insurance information, health-care providers will have to disclose their finances, and the BNHI will periodically publish information on their care quality and legal compliance.

Furthermore, the new law requires the government to fund at least 36% of the NHI's budget (compared to 34-35% in the old system), to ensure the basic financial stability of the scheme.

The new NHI is expected to come into force next year, and the nearly NT$60 billion in losses from before its implementation will be gradually amortized by the central government. It looks to be a fresh start, but one cannot help lament the missed chance for bold and sweeping reforms.

An editorial in the United Daily News describes government timidity in its reform efforts thus: "Obviously it's like old clothing that no longer fits a grown body: after years of making alterations, at last the decision has been made to make a new garment, but in the end they had no courage to put it on."

The road from capitalist thinking toward that of a welfare state is a long one. Though the NHI revision for now solves the NHI's inability to make ends meet, building a lasting system requires stronger communication with the public.

Though expressing regret over the new law, the Taiwan Healthcare Reform Foundation affirms that the second-generation NHI has made efforts in the move toward greater fairness: "Though it's not a big enough step, a step forward is always better than lingering in the same place.