vox--2020-01-13--A new virus may be the cause of China’s mysterious pneumonia outbreak

The mysterious outbreak in China causing dozens of people to fall sick with pneumonia appears to be the result of a new coronavirus , a member of the same family of viruses as SARS .
On January 9 , a report on the state broadcaster China Central Television said 15 of the people who had become ill tested positive for the new virus .
In one patient , Chinese investigators conducted whole genome sequencing , confirming the “ typical coronavirus appearance , ” Xu Jianguo , a member of the Chinese Academy of Engineering who led the assessment , told @ @ @ @ @ @ @ scientists in China shared the genetic sequence of the new virus and the World Health Organization applauded China ’ s efforts .
“ WHO is reassured of the quality of the ongoing investigations and the response measures implemented in Wuhan , and the commitment to share information regularly , ” the agency said in a statement .
This was a contrast to the SARS outbreak of 2003 , when China was heavily criticized for withholding information about the outbreak for too long .
The new outbreak was first reported on December 31 in @ @ @ @ @ @ @ million and the capital of Hubei , one of China ’ s most populous provinces , according to Wuhan ’ s municipal health commission .
The outbreak has been linked to a food market — Huanan Seafood Wholesale Market — where vendors peddle seafood as well as animals , such as birds and rabbits .
This could mean the new disease spread to humans from one of the animals there .
To date , authorities in Wuhan reported 41 patients with the novel coronavirus infection — “ mainly business staff and purchasers ” @ @ @ @ @ @ @ 41 , seven are severely ill and two have been discharged from hospital .
One patient — a 61-year-old man with underlying health problems , including chronic liver disease — died on January 9 .
The man went into hospital with respiratory failure and severe pneumonia .
He had bought food from the Huanan market regularly and tested positive for the new virus .
Coronaviruses attack the respiratory system and can target the cells deep within the lungs .
“ There are tons of coronaviruses , ” said Vincent Munster , an emerging @ @ @ @ @ @ @ of Allergy and Infectious Diseases .
Most infect mammals and birds .
Two of the six that are known to infect humans , SARS and MERS , can cause severe pneumonia and even death .
The rest lead to milder symptoms , like a common cold .
In the case of SARS , the virus was discovered in China in 2003 after it jumped from civet cats — a food delicacy in China — to humans .
It went on to spread to two dozen countries and eventually killed 774 people and infected @ @ @ @ @ @ @ outbreak , there are some reassuring signs .
“ According to Chinese authorities , the virus in question can cause severe illness in some patients and does not transmit readily between people , ” the WHO said in an earlier statement .
So far , the main symptoms reported are fever followed by difficulty breathing , the WHO said .
In chest X-rays , patients appear to have lesions in both lungs .
While seven of the 41 cases in Wuhan are serious , the death toll stands at one , according to @ @ @ @ @ @ @ any measures for travelers and advising against travel or trade restrictions on China , even on the cusp of China ’ s Lunar New Year holiday , during which hundreds of millions of people are expected to travel , according to the South China Morning Post .
But it ’ s still early days .
Researchers will need to confirm that this new virus is without a doubt the driver of the outbreak , said Marion Koopmans , who studies emerging infectious diseases as director of the department of virology at Erasmus Medical @ @ @ @ @ @ @ then need to figure out what type of illness the virus causes in the confirmed cases .
“ If [ the new virus ] is indeed the likely cause , and seeded at the market , a key question is how transmissible this is , ” Koopmans said .
Viruses that spill over from animals may not be very transmissible “ if they sit deep in the lungs and are not shed easily , ” she added .
That would mean , Munster said , “ the epidemic potential of this virus might @ @ @ @ @ @ @ also need to find out which animal is spreading the virus to humans — the “ natural reservoir ” of the virus — and how the virus made the jump , and then make sure that animal is contained .
Right now , the WHO says there ’ s “ no clear evidence ” of human-to-human transmission of the virus .
But it ’ s possible it ’ s occurring in this outbreak , despite the reports .
As David Hui , an expert in emerging infections at the Chinese University of Hong @ @ @ @ @ @ @ , the minimum incubation period for some viral infections — 15 days — hadn ’ t even passed since the outbreak was first reported .
This means more of the contacts of the known cases may fall sick in the coming days .
For now , the market that ’ s been linked to the outbreak has been closed for disinfection , and health officials are following 739 close contacts of the patients , including 419 medical staff , to see if they develop symptoms .
Health officials in Wuhan say there have @ @ @ @ @ @ @ .

The US will start screening at three airports for passengers with the mysterious, new virus originating in Wuhan, China that’s caused three deaths and nearly 200 people to fall sick with pneumonia.
On Friday, the Centers for Disease Control and Prevention (CDC) and the Department of Homeland Security’s Customs and Border Protection announced the new measure, which will begin on January 17. Travelers from Wuhan to three US airports — San Francisco (SFO), New York (JFK), and Los Angeles (LAX) airports — will be screened for symptoms, such as cough and fever.
“I expect that we’re going to see more cases, and I think it’s highly plausible that there will be at least a case in the United States,” said Nancy Messonnier, director of CDC’s National Center for Immunization and Respiratory Diseases in a press briefing Friday.
Following the move, Wuhan’s health authorities reported a spike in illness — 136 additional cases over the weekend, as well as a third death. And already, cases have popped up in travelers from Wuhan to Japan, Thailand, and Korea — as well as two major Chinese cities, Beijing and Shenzhen.
The big question the growing caseload and these travelers raise — arguably the most important question about this outbreak — is whether the virus is spreading from person to person.
So far, a leading theory has been that the virus, called 2019-nCoV, spread directly to people from animals at a Wuhan food market, which has been linked to some of the cases in the outbreak. If that’s true, and 2019-nCoV isn’t yet spreading from person to person, the outbreak should burn out quickly. (Once the animal shedding the virus is identified and contained, cases should stop turning up.)
But evidence is piling up to suggest the virus may already be spreading among humans. Several of the travelers never visited the market. Wuhan officials have also reported evidence of viral spread within one family: a husband who worked at the market got sick, followed by his wife, who hadn’t visited the market. Just the fact that travelers with the virus are showing up in other countries hints at at least some person-to-person spread, Neil Ferguson, an infectious diseases epidemiologist at Imperial College London, told the BBC.
If that’s the case, “the scope of this outbreak expands massively,” said Peter Daszak, the president of EcoHealth Alliance, a US global health research organization working in China. In the worst case, the virus could already be moving more broadly in China — and maybe further. That risk appears to be heightened as millions start to travel this week for China’s Lunar New Year on January 25th.
At least four people have traveled with the virus outside of China
Because health authorities are dealing with a new virus, the picture of this outbreak — and its seriousness — is shifting rapidly, and will continue to do so in the coming days.
The outbreak was only declared on December 31. By January 9, the state broadcaster China Central Television reported that 15 of the people who had become ill tested positive for the new virus. By January 11, scientists in China shared the genetic sequence of the new virus, and the WHO applauded China’s efforts.
“WHO is reassured of the quality of the ongoing investigations and the response measures implemented in Wuhan, and the commitment to share information regularly,” the agency said in a statement.
This was also a contrast to the SARS outbreak of 2003, when China was heavily criticized for withholding information about the outbreak for too long.
But other aspects of the outbreak bear a startling resemblance to SARS, which also involved a then-new virus when it was discovered in 2003. The virus jumped from civet cats — a food delicacy in China — to humans, and went on to spread to two dozen countries. It eventually killed 774 people and infected more than 8,000.
For now, the current outbreak has centered on the the Huanan South China Seafood Market in Wuhan, the capital of Hubei, one of China’s most populous provinces. Health officials in Wuhan originally reported that the patients with the virus so far were “mainly business staff and purchasers” at the Huanan South China Seafood Market, where vendors peddle seafood as well as animals such as birds and rabbits. This pointed to the possibility that the new virus had spread to humans from one of the animals there.
But the recent spike in cases, along with the growing number of travelers detected with the virus, mean something else may be going on.
On Monday, South Korea reported its first case of the virus — and the fourth example of international spread — in a 35-year-old woman who traveled from Wuhan. She never visited markets or had contact with animals, WHO reported.
Before that, a Chinese man in his 30s was diagnosed with the virus upon returning to Tokyo, where he lives. He’d also visited Wuhan, the mainland Chinese city of 19 million that’s currently the center of the outbreak, according to Japan’s Ministry of Health.
The other two cases were identified in Thailand. The first involved a 61-year-old Chinese woman, who had traveled to Bangkok from Wuhan. She came down with a fever on January 5, days before Chinese officials announced their finding that the outbreak is likely caused by a new coronavirus, of the same family of viruses as SARS. The second, also a Chinese woman, aged 74, arrived in Thailand on January 13, and had no relation to the first visitor who fell ill.
These developments caused the WHO to acknowledge on January 18th that “there is evidence of limited human-to-human transmission.”
Three patient deaths mark this virus “a significant concern”
As of January 19, authorities in China have reported 198 patients with the coronavirus infection. Among them, 170 are still in the hospital, 126 have mild illness, and 44 are in severe or critical condition. Three patients have died. All cases involve adults aged 25 to 89, and about half are male.
The leading hypothesis is that the disease is the result of the new coronavirus, 2019-nCoV. Coronaviruses attack the respiratory system and can target the cells deep within the lungs. “There are tons of coronaviruses,” said Vincent Munster, an emerging viral diseases researcher at the National Institute of Allergy and Infectious Diseases.
Most infect mammals, including bats. Two of the six that are known to infect humans, SARS and MERS, can cause severe pneumonia and even death. The rest lead to milder symptoms, like a common cold.
In the current outbreak, the main symptoms reported are fever followed by difficulty breathing, the WHO said. In chest X-rays, patients appear to have lesions in both lungs. But a preliminary genetic analysis of the 2019-nCoV virus, by Daszak’s EcoHealth Alliance, found it’s closely related to SARS. It, along with the three deaths, “marks this virus as a significant concern,” said Daszak.
Big questions remain
Researchers will need to confirm that this new virus is without a doubt the driver of the outbreak, said Marion Koopmans, who studies emerging infectious diseases as director of the virology department at Erasmus Medical Center in Rotterdam. They’ll then need to figure out the full spectrum of illness the virus causes in the confirmed cases.
“If [the new virus] is indeed the likely cause, and seeded at the market, a key question is how transmissible this is,” Koopmans said. Viruses that spill over from animals may not be very transmissible “if they sit deep in the lungs and are not shed easily,” she added. That would mean, Munster said, “the epidemic potential of this virus might still be limited.”
But, again, the Japan, Thailand, and Korea cases — along with the potential family spread in Wuhan — suggest the possibility for human-to-human viral transmission.
Health officials would also need to find out which animal is spreading the virus to humans — the “natural reservoir” of the virus — and how the virus made the jump, and then make sure that animal is contained.
“We don’t know where the virus came from,” Daszak said. “We don’t know the geographic origin of the wildlife reservoir. And it’s now known to be lethal.”
At the moment, the WHO is not recommending any measures for travelers, nor is it advising against travel or trade restrictions on China, even on the cusp of China’s Lunar New Year holiday, during which hundreds of millions of people are expected to travel. (A new study found the top travel destinations out of Wuhan are Asian megacities, including Bangkok, Hong Kong, Tokyo, and Taipei.)
The CDC in the US has stated that “the risk from 2019-nCoV to the American public is deemed to be low.” They’ve said the new airport screening is a precautionary measure. The market that’s been linked to the outbreak has been closed for disinfection, and health investigators are have tracked at least 800 close contacts of the patients.
With the first cases turning up outside of China, the WHO said it was considering organizing an emergency committee meeting. If such a meeting is called, a panel of independent experts would discuss whether the outbreak is dire enough to constitute a “public health emergency of international concern,” a rare designation the WHO gives to diseases that pose a global threat.


Everybody Covered

You hear it all the time : American health care spends more money and produces worse outcomes than many other developed countries ’ systems .
But why ?
What have other countries done to achieve universal health care , to cover everybody , that the United States has not ?
And what are the consequences of those choices ?
To answer these questions , Vox reporters traveled the world last fall to see other health systems in action , talking with doctors , patients , and government officials to get the full and often complex picture .
Everybody Covered takes @ @ @ @ @ @ @ in Taiwan , a private-public hybrid in Australia , supercharged Obamacare in the Netherlands , the vaunted National Health Service of Great Britain , and an innovative hospital budgeting scheme right here in Maryland .
Our project was made possible by a grant from The Commonwealth Fund .
Each system provides its own lessons about how to improve health care — not only in designing a better system but in the societal choices and shared sacrifices that must be made to attain universal health care .
No health care system is perfect .
@ @ @ @ @ @ @ peers have figured out a way to deliver truly universal coverage and quality care .
The United States has not .
America can and should do better .
Other countries can help show the way .
Here ’ s what ’ s coming in the Everybody Covered series .
Taiwan ’ s single-payer success story — and its lessons for America Taiwan overhauled its health care system 25 years ago , setting up a program as close to Sen. Bernie Sanders ’ s Medicare-for-all as exists in the real world .
But it @ @ @ @ @ @ @ challenge to keep the single-payer plan sustainable .
Difficult choices await the Taiwanese people , even as they ’ ve seen health care vastly improve .
The Aussies have developed a public-private hybrid : public insurance anybody is eligible for and private insurance for people who want more choices .
On balance , it works well : Everybody has coverage , people who can afford private insurance like having options , and Australian health care ranks among the best in the world .
But private insurance is facing a crisis , raising new @ @ @ @ @ @ @ system .
The Dutch have Obamacare for everybody : mandatory private insurance that bars denying coverage based on preexisting conditions , a model of managed competition .
By some metrics , they have built the best health care system in the world .
Access to providers is exemplary .
But costs to patients can be high compared to other countries , leading some critics to question how well the private market has worked in delivering more affordable care .
The Mid-Atlantic state has a payment system for hospitals unlike anything else in the @ @ @ @ @ @ @ capping payments to hospitals on a yearly basis , the state has strived to incentivize more efficient , higher-quality health care .
Some experts think cost containment , not coverage expansion , should be the next step for health care reform .
Should Maryland ’ s all-payer model go nationwide ?
Right now , the United States rations care in a simple , cruel way : If you can ’ t afford it , you can ’ t get it .
In national health care systems , decisions do need to be made @ @ @ @ @ @ @ the government is willing to pay , and what happens when the government can ’ t or won ’ t cover treatments people want .
The UK , in particular , offers a model for making these decisions in clear , transparent ways — but that very transparency is part of what makes it so politically controversial .
Look for Everybody Covered on the Vox Media Podcast Network starting January 21 .
Episodes coming soon to The Impact , The Weeds , The Ezra Klein Show , Reset , and Today , Explained @ @ @ @ @ @ @ a grant from The Commonwealth Fund .
All content is editorially independent and produced by our journalists .

You hear it all the time: American health care spends more money and produces worse outcomes than many other developed countries’ systems. But why? What have other countries done to achieve universal health care, to cover everybody, that the United States has not? And what are the consequences of those choices?
To answer these questions, Vox reporters traveled the world last fall to see other health systems in action, talking with doctors, patients, and government officials to get the full and often complex picture. Everybody Covered takes a closer look at a single-payer plan in Taiwan, a private-public hybrid in Australia, supercharged Obamacare in the Netherlands, the vaunted National Health Service of Great Britain, and an innovative hospital budgeting scheme right here in Maryland. Our project was made possible by a grant from The Commonwealth Fund.
Each system provides its own lessons about how to improve health care — not only in designing a better system but in the societal choices and shared sacrifices that must be made to attain universal health care.
No health care system is perfect. But most of America’s economic peers have figured out a way to deliver truly universal coverage and quality care. The United States has not.
America can and should do better. The rest of the world can help show the way. We found at least 9 things Americans can learn from other countries’ health systems.
To better understand how health care really works elsewhere, check out the stories and podcasts below.
Taiwan overhauled its health care system 25 years ago, setting up a program as close to Sen. Bernie Sanders’s Medicare-for-all as exists in the real world. But it has been, and remains, a challenge to keep the single-payer plan sustainable. Difficult choices await the Taiwanese people, even as they’ve seen health care vastly improve.
by Dylan Scott
The Aussies have developed a public-private hybrid: public insurance anybody is eligible for and private insurance for people who want more choices. On balance, it works well: Everybody has coverage, people who can afford private insurance like having options, and Australian health care ranks among the best in the world. But private insurance is facing a crisis, raising new questions about the viability of a two-tiered system.
by Dylan Scott
The Dutch have Obamacare for everybody: mandatory private insurance that bars denying coverage based on preexisting conditions, a model of managed competition. By some metrics, they have built the best health care system in the world. Access to providers is exemplary. But costs to patients can be high compared to other countries, leading some critics to question how well the private market has worked in delivering more affordable care.
by Dylan Scott
The Mid-Atlantic state has a payment system for hospitals unlike anything else in the United States: global budgets. By capping payments to hospitals on a yearly basis, the state has strived to incentivize more efficient, higher-quality health care. Some experts think cost containment, not coverage expansion, should be the next step for health care reform. Should Maryland’s all-payer model go nationwide?
by Tara Golshan
Right now, the United States rations care in a simple, cruel way: If you can’t afford it, you can’t get it. In national health care systems, decisions do need to be made about who gets what, how much the government is willing to pay, and what happens when the government can’t or won’t cover treatments people want. The UK, in particular, offers a model for making these decisions in clear, transparent ways — but that very transparency is part of what makes it so politically controversial.
by Ezra Klein
Everybody Covered on the Vox Media Podcast Network
CREDITS
Reporters: Dylan Scott, Tara Golshan, Ezra Klein
Photographers: Ashley Pon, Anne Moffat, Marlena Waldthausen, Andrew Mangum
Editors: Elbert Ventura, Libby Nelson, Laura McGann
Podcast producer/co-reporter: Byrd Pinkerton
Podcast editor: Amy Drozdowska
Podcast senior producer/host: Jillian Weinberger
Visuals editor: Kainaz Amaria
Graphics: Christina Animashaun, Zac Freeland
Copy editors: Tanya Pai, Tim Williams
Engagement: Lauren Katz
Fact checkers: Kayla Chen, Matt Giles
This series was made possible by a grant from The Commonwealth Fund. All content is editorially independent and produced by our journalists.


vox--2020-01-13--Taiwan’s single-payer success story — and its lessons for America

HUALIEN COUNTY , Taiwan — Thirty years ago , before she dyed her hair pink to cover up the white , Dr. Huei-wen Tien came to Xiulin , a township on the east coast of Taiwan severed from the island ’ s urban centers by a formidable mountain range .
She had agreed to serve for 10 years in an aboriginal community in exchange for her medical education .
Unconventional by nature — her motorcycle helmet says “ Punk ” — Tien says she wanted a challenge .
She found one here , where about 15,000 people , mostly of @ @ @ @ @ @ @ lush gorges of a national park that shares their name .
Diabetes , alcoholism and heart disease are common problems among the Taroko .
The indigenous people have endured displacement , forced assimilation , and discrimination over the centuries .
They are also poorer than the ethnically Han Chinese who make up most of Taiwan ’ s population .
But they never have to worry about one thing : their health care .
In Taiwan , everybody is covered .
The Taiwanese health care system is built on the belief that everyone deserves @ @ @ @ @ @ @ much as anywhere else .
The costs to patients are minimal .
And the government has set up special programs to deliver care to the people in Xiulin and their neighbors in Hualien County .
On a warm October afternoon , in a government health clinic in the foothills of the Zhongyang ( Central ) Mountain Range , Tien saw an older Taroko woman she ’ s treated for decades .
They have a comfortable rapport .
The doctor teased the patient for her high blood sugar , asked what she had for @ @ @ @ @ @ @ her diabetes medication that she skipped that morning .
( The woman said she was busy . )
Tien then inserted the woman ’ s national health insurance card into a chip reader to pull up her medical record on the computer .
The cards are ubiquitous in Taiwan , the signature of its single-payer health care system , carried by everyone from the woman in Xiulin to a venture biotech executive I met in Taipei .
In the 1990s , Taiwan did what has long been considered impossible in the US : @ @ @ @ @ @ @ a fractured and inequitable health care system and transformed it into something as close to Sen. Bernie Sanders ’ s vision of Medicare-for-all as anything in the world .
I came here last October to learn what it takes to set up and sustain such a system .
It ’ s one of several stops around the globe that Vox made this past fall , in an effort to learn how other countries tried to achieve universal and affordable health care .
Our project , Everybody Covered , was made possible by a @ @ @ @ @ @ @ ’ s clearly a need for lessons .
Compared to the rest of the developed world , America spends more money on health care and produces worse outcomes .
By one advanced metric — mortality for causes that should be avoidable with accessible , high-quality health care — the United States ranked last among the G7 countries in 2016 .
America ’ s infant mortality rate is almost double that of some of its peers .
Nearly one in 10 Americans lack insurance .
People go bankrupt over medical bills .
Yet Americans @ @ @ @ @ @ @ on health care per capita as the average comparable country .
No health care system is perfect .
But most of America ’ s economic peers have figured out a way to deliver truly universal coverage and quality care .
The United States has not .
“ Canada and virtually all European and Asian developed nations have reached , decades ago , a political consensus to treat health care as a social good , ” health care economist Uwe Reinhardt wrote in his book Priced Out shortly before his death in 2017 .
@ @ @ @ @ @ @ United States have never reached a politically dominant consensus on the issue.
” Taiwan made its choice in the 1990s and embraced single-payer .
It has required sacrifice : by doctors who believe they ’ re forced to see too many patients every day ; by patients with complex and costly conditions who can ’ t always access the latest treatments ; by citizens who have been asked from time to time , and will be asked again , to pay more for their health care than they did before .
The vast @ @ @ @ @ @ @ approve of their health care system .
They know it isn ’ t a utopia .
The country has made hard choices to keep this program sustainable , and it will need to do so again .
That is what it takes to realize the single-payer dream .
Taiwan took a broken system and built a new national health insurance program In the 1980s , Taiwan wasn ’ t yet a democracy , but the stirrings of popular rule could be felt .
At the time , about 40 percent of Taiwanese people @ @ @ @ @ @ @ everything , even their house , if they had a medical crisis .
Desperate to outflank reformers , the ruling government convened high-profile meetings to fix its health care system .
One guest at a 1989 conference was the German-born Reinhardt , a Princeton economist who was married to Taiwan-born scholar Tsung-Mei ( May ) Cheng .
Reinhardt , who later co-wrote the seminal paper “ It ’ s The Prices , Stupid ” about American health care and helped define the health policy debate in the US in the 2000s , was @ @ @ @ @ @ @ adopt .
He thought it over and talked about it with his wife for a couple of nights in their hotel room .
He finally delivered his answer : single-payer .
One national health insurance plan , run by the government , covering everybody .
In Reinhardt ’ s view , single-payer would be the most equitable and efficient program .
It was similar to systems already in place in Canada and the United Kingdom .
He came up with the metaphor of the “ single pipe ” — through which all the @ @ @ @ @ @ @ to convey the concept to public officials .
It was a convincing presentation .
As Cheng and her husband left to return to the United States , they didn ’ t know what would happen next .
“ We went back to Princeton , ” Cheng recalls , “ and six months later , we were told the government would accept your recommendation to go single-payer.
” The national government would eventually fast-track the implementation of the new system to 1995 , hoping to get the chaotic transition period over before the first @ @ @ @ @ @ @ plenty of skepticism leading up to it .
Industry , experts , and the public alike doubted the program would succeed .
Labor protesters threw paper money traditionally used in a funerary rite when the legislature passed the single-payer bill in 1994 .
A majority of people in Taiwan disapproved of the single-payer plan when it took effect .
But the program ’ s reputation quickly improved once people started to enjoy its benefits .
Approval has dipped ( when premiums were hiked in the 2000s ) and risen ( when the rural @ @ @ @ @ @ @ Xiulin was implemented ) over the years , but there has always been a solid baseline of support .
Today , approval of the national health insurance program hovers near its all-time high , over 80 percent .
The system endures 25 years after it was established .
Part of its appeal is its simplicity .
Everybody in Taiwan is insured through the National Health Insurance Administration ( NHIA ) .
They receive an ID card as proof of coverage , which also stores their medical records .
The Taiwanese program runs with @ @ @ @ @ @ @ its funding is spent on administration , according to a 2015 review by Cheng .
( Compare that to the US , where researchers have estimated that private insurers spend around 12 percent of overhead , and hospitals spend around 25 percent on administrative work . )
Experts say Taiwan ’ s advanced IT infrastructure deserves a good share of the credit .
The benefits are quite comprehensive : hospital care , primary care , prescription drugs , traditional Chinese medicine .
Patients must make copays when they visit the doctor or fill @ @ @ @ @ @ @ , but they are generally low , 360 NTD ( about $ 12 ) or less .
Lower-income patients are given an additional break on their cost-sharing obligations .
Higher-income patients can take out private insurance for certain things not covered by the single-payer program .
The system is mostly funded by payroll-based premiums , with contributions from workers and their employers , supplemented by more progressive income taxes and tobacco and lottery levies .
Premiums have been raised twice in the past 18 years to cover the growing cost of the program @ @ @ @ @ @ @ 2010 moved the payroll income tax rate from 4.55 percent to 5.17 , a 14 percent increase .
In the early 2000s , again at Reinhardt ’ s recommendation , Taiwan converted to global budgets to pay for health care as another cost-control measure .
This means that every year , government officials and private providers sit across a table and negotiate rates for services , with an annual cap set on the total payments to hospitals and doctors that the government will make .
Health spending has stayed flat in recent years @ @ @ @ @ @ @ it is growing at a slower rate in Taiwan than in the United States .
Taiwanese patients use a lot of health care , and it puts a strain on providers What it all adds up to is a system that patients seem broadly happy with — maybe too happy , according to doctors and economists I met .
“ I believe we are too kind to our patient [ s ] , ” says Shou-Hsia Cheng , a health economics professor at National Taiwan University ( NTU ) who has worked at @ @ @ @ @ @ @ , “ which is not a good thing , actually.
” Taiwanese people take advantage of their cheap , accessible health care .
The average number of physician visits per year ( 12.1 ) is nearly twice that of other developed economies .
There was a dramatic spike in use after single-payer was passed : A 1997 JAMA research paper led by Shou-Hsia Cheng found that physician visits among the newly insured doubled in the first year of the program compared to the year before .
That has had predictable downsides : Hospitals @ @ @ @ @ @ @ of health care providers to attend to everyone in need can be stretched pretty thin .
I visited the National Taiwan University Hospital , a red-brick building in the heart of Taipei from the Japanese colonial period , one weekday afternoon .
All of the clinic lobbies were full .
The registration desk , run take-a-number style , was bustling , beeps constantly pinging over the PA system as patients ’ numbers were called .
On another morning , inside a north-central Taipei primary care clinic , several patients were already sitting along @ @ @ @ @ @ @ receiving infrared therapy for chronic pain , just a few minutes after the doors opened .
The one doctor on site looked a bit frazzled as he showed me around before his clinic filled up any further .
The scenes bring to mind something I heard from trauma surgeon Li-Jian Chien , a member of the Taiwanese doctors union that formed in 2012 out of the frustrations felt in the medical profession .
In Taiwan , he says , “ the patient [ is ] in heaven ” — but “ the doctor @ @ @ @ @ @ @ the opposite of the United States , he elaborates , where high cost sharing leads people to skip necessary care for serious conditions .
Chien says national health insurance with negligible cost sharing has pushed doctors to the brink .
His friend and fellow physician Bing-Hong Lin exclaimed at one point during our interview : “ We are not the Avengers !
” Surveys conducted by the government show health care providers have rather mixed opinions on the single-payer system — a significant plurality , 43 percent , said they were “ neutral @ @ @ @ @ @ @ to the public ’ s sky-high favorability .
Chien says he sometimes sees the same patient dozens of times every year in the emergency department where he works , often for problems that aren ’ t emergencies .
The low costs mean patients have little incentive to avoid the ER .
“ Everyone wants to live forever , but it ’ s impossible , ” Chien says .
“ Some people abuse emergency , abuse health care.
” At the same time , because Taipei has a lot of traffic accidents , injured @ @ @ @ @ @ @ department ’ s doors all the time .
His attention is divided when it shouldn ’ t be .
Lin has started doing cosmetic medicine for adults on the side because he has become so frustrated by his pediatric practice .
It ’ s a more lucrative field , paid for privately by patients , with a less demanding workload .
His is not an uncommon choice , according to experts .
Lin still bitterly remembers being called back early from leave he had taken in 2005 to attend his father ’ s @ @ @ @ @ @ @ shortage at the hospital where he was doing his residency .
Taiwanese hospitals and clinics are understaffed compared to the rest of the world : There are about 1.7 doctors in Taiwan for every 1,000 patients , which is well below the average of 3.3 in other developed countries .
There are especially shortages of specialists in less urbanized parts of the country .
“ Taiwan ’ s low ratios would be considered inadequate by OECD standards , ” Tsung-Mei Cheng wrote in 2015 , “ especially in view of the high utilization @ @ @ @ @ @ @ The country does excel at keeping wait times short for services like cataract and hip replacement surgeries .
But providers are feeling the strain .
Taiwanese doctors work about 10 more hours a week on average than those in the United States .
A 2016 survey of hospital physicians found that working overtime was prevalent , and doctors who worked a lot of overtime were more likely to say they might leave the hospital where they worked .
Crowded facilities , like the NTU Hospital , are the norm .
Hospitals supplement their @ @ @ @ @ @ @ — food courts , parking , and so on — to keep themselves solvent .
The worry is that Taiwan ’ s national health insurance has given patients such a good deal on medical care that they are overwhelming the system .
Patients must make sacrifices , too , like when a drug is too expensive to cover The patients have their own grievances .
They ’ ve seen their premiums hiked and more taxes introduced over the past two decades , and they will probably be asked again soon to chip in @ @ @ @ @ @ @ are comprehensive for most people , Taiwan still doesn ’ t cover everything .
Costly treatments for rare conditions are sometimes excluded .
A new drug for spinal muscular atrophy — a genetic disorder that progressively breaks down the patient ’ s muscle tissue , resulting in early death — came on the market in the US in 2017 .
The first year of treatment costs $ 750,000 .
Yi Jie Li , a 25-year-old woman with spinal atrophy and an outspoken advocate who wrote the 2017 book 7,300 Days : The Most @ @ @ @ @ @ @ the NHIA pleading with it to cover the drug for the patients it could help .
The department replied in a letter , and the president of Taiwan called her on the phone .
They said they would do their best .
But the drug still isn ’ t covered .
New medicines sometimes debut in Taiwan a full five years after they came on the market in the United States .
For patients who need those medications , every day of waiting is a trial .
“ Now the medicine is there @ @ @ @ @ @ @ you can not use ” it .
In some rural parts of the country , medical understaffing means less access to specialists and pediatricians .
High use has frustrated doctors in the cities , but it ’ s patients who suffer if it ’ s hard for them to see a doctor or nurse .
Even though Taiwanese patients get a good deal on health care , they don ’ t come across as entitled .
Some of the patients I met , including those who have faced the gravest diagnoses , seem @ @ @ @ @ @ @ them to keep a single-payer system sustainable .
Gloria Lin was diagnosed with breast cancer shortly before national health insurance took effect ; today she is president of the Taiwanese Cancer Patient Association .
Her group plays a part in talks between government and providers about what will be covered ( and for how much ) .
She told me that of course she wants to see every new cancer drug covered by the government plan .
But she also understands why that ’ s impossible : The system would become too expensive @ @ @ @ @ @ @ it [ to go ] bankrupt , ” she says .
“ We have to work hand to hand together solve the problem .
… We have to be sensible for each other.
” National health insurance achieved what the Taiwanese government hoped it would .
Everybody can afford health care .
People are living longer , healthier lives .
But the ever-growing cost of providing health care to everybody makes it challenging for the program to remain financially sustainable .
The government keeps having to ask doctors , hospitals , and patients @ @ @ @ @ @ @ .
That ’ s not usually a political winner .
No elected official is running on a campaign of higher premiums and higher copays .
But it helps that national health insurance has proven so popular .
People want to make it work because single-payer has clearly improved Taiwanese lives .
One metric tells the tale : a rating based on medically amenable mortality , which gives a sense of how often people die of causes for which medical interventions should be available .
In 1990 , before Taiwan ’ s single-payer program @ @ @ @ @ @ @ rating around 60 , far behind the United States ’ rating of 80 .
In 2016 , Taiwan had nearly caught up with the US , topping 85 ; the US sat at 88 , trailing its socioeconomic peers in Europe .
There is no doubt that medical care in Taiwan is better under single-payer , though it improved from a much worse status quo than the American system .
Today , Americans die prematurely of heart disease and lung cancer at higher rates than the Taiwanese .
People in Taiwan live a @ @ @ @ @ @ @ are populations that encounter early deaths from alcohol use and stroke , just as some disadvantaged groups do in the United States .
Yet overall , Taiwan spends 6 percent of its GDP on health care , about a third of what the United States does .
There is no comparison between the Taiwanese system of yesteryear — a 40 percent uninsured rate and the risk of financial catastrophe — and the one that exists today .
In the early 2000s , with health spending growing too quickly , the national health insurance @ @ @ @ @ @ @ , a set pool of money that would cover all the medical services in a given year .
Hong-Jen Chang , then the NHIA director , remembers seeing his effigy being decapitated in protests by hospital supporters .
The opposition was overwhelming , and he had to resign over that decision in 2004 .
That was also shortly after the first premium increase was approved .
NHIA Director-General Dr. Po-Chang Lee told me that , after the presidential election this month , he would pitch the new government on increasing copayments so patients @ @ @ @ @ @ @ visit the doctor or hospital .
It may take more than that .
Shou-Hsia Cheng , the NTU professor , predicted Taiwan would soon have to reevaluate its payments for end-of-life care .
The country is currently debating how to expand long-term care for an aging population ; it ’ s not covered by the national health plan .
The financial crunch is coming .
The NHIA , which ran surpluses for a while after the last round of rate increases , is now about to see its reserves run out .
“ @ @ @ @ @ @ @ or increase the copayment , or we have to delete some coverage items , ” Chang , the former NHIA director , says .
“ That will happen — not in two years , perhaps in 10 years .
It will happen.
” But in Taiwan , the need for premium increases or hospital budget caps isn ’ t considered an indictment of national health insurance , at least if approval ratings for the system are anything to go by .
It ’ s part of the evolution of the system they have @ @ @ @ @ @ @ is so popular , Taiwanese leaders are confident patients will be willing to do what ’ s needed to keep single-payer viable .
“ They will adjust , ” Cheng , the professor , says .
“ I believe so.
” Taiwan is realizing the dream of “ health care as a human right ” Since the beginning , the debate in Taiwan has been about balancing the imperatives of equity and access that underpinned the national health insurance program .
Perhaps there ’ s been no greater demonstration of that than seeing @ @ @ @ @ @ @ the mountain township of Xiulin , where Tien was making her rounds .
A decade into the single-payer experiment , when Hong-Jen Chang was in charge of NHIA , health care access in places like Xiulin was still lacking .
So he decided to start the rural care delivery program that covers Tien and her patients .
On the same day she treated the Taroko woman at her clinic , Tien ventured out to visit a bedridden stroke patient in his home and showed the same warmth , offering him a cheerful thumbs-up @ @ @ @ @ @ @ A few doors down , a diabetes patient with gout welcomed a nurse into his house , parakeets chirping at the front door , so she could take his blood sugar readings , something she does two or three times a week .
Meanwhile , in the town hall , a pop-up Chinese medicine clinic was set up , and patients filed in to get acupuncture treatments .
Chang told me a health care delivery program like this was the natural endpoint for the single-payer experiment , a necessary extension of its services @ @ @ @ @ @ @ it , the work of Taiwanese health reform would always be incomplete .
“ That ’ s the essence of universal health coverage , ” he says .
“ The principle of health [ as a ] human right is that everybody regardless of geography , religion , gender , age should have the right to access.
” The people here seem grateful .
Wong Shin-Fa , a 63-year-old Taroko man , stopped me on the side of the road in Xiulin and asked me what I was doing there .
When I @ @ @ @ @ @ @ health care , he told me a story .
He had a Taroko friend in Los Angeles who broke his arm , he told me , with a government health worker interpreting .
Rather than get it fixed in the United States , his friend decided to fly back to Taiwan and have it mended there because he said it would be cheaper .
Shin-Fa knew Tien and her shock of pink hair .
He said she ’ s famous around those parts .
He told me , “ The government takes good @ @ @ @ @ @ @ Pon is an editorial photographer based in Taipei , Taiwan .
This series was made possible by a grant from The Commonwealth Fund .
All content is editorially independent and produced by our journalists .

HUALIEN COUNTY, Taiwan — Thirty years ago, before she dyed her hair pink to cover up the white, Dr. Huei-wen Tien came to Xiulin, a township on the east coast of Taiwan severed from the island’s urban centers by a formidable mountain range.
She had agreed to serve for 10 years in an aboriginal community in exchange for her medical education. Unconventional by nature — her motorcycle helmet says “Punk” — Tien says she wanted a challenge. She found one here, where about 15,000 people, mostly of the Taroko tribe, live near the lush gorges of a national park that shares their name.
Diabetes, alcoholism, and heart disease are common problems among the Taroko. The indigenous people have endured displacement, forced assimilation, and discrimination over the centuries. They are also poorer than the ethnically Han Chinese who make up most of Taiwan’s population.
But they never have to worry about one thing: their health care. In Taiwan, everybody is covered. The Taiwanese health care system is built on the belief that everyone deserves health care, in Xiulin just as much as anywhere else. The costs to patients are minimal. And the government has set up special programs to deliver care to the people in Xiulin and their neighbors in Hualien County.
On a warm October afternoon, in a government health clinic in the foothills of the Zhongyang (Central) Mountain Range, Tien saw an older Taroko woman she’s treated for decades. They have a comfortable rapport. The doctor teased the patient for her high blood sugar, asked what she had for breakfast, and insisted the woman take her diabetes medication that she skipped that morning. (The woman said she was busy.)
Tien then inserted the woman’s national health insurance card into a chip reader to pull up her medical record on the computer. The cards are ubiquitous in Taiwan, the signature of its single-payer health care system, carried by everyone from the woman in Xiulin to a venture biotech executive I met in Taipei.
In the 1990s, Taiwan did what has long been considered impossible in the US: The island of 24 million people took a fractured and inequitable health care system and transformed it into something as close to Sen. Bernie Sanders’s vision of Medicare-for-all as anything in the world.
I came here last October to learn what it takes to set up and sustain such a system. It’s one of several stops around the globe that Vox made this past fall, in an effort to learn how other countries tried to achieve universal and affordable health care. Our project, Everybody Covered, was made possible by a grant from The Commonwealth Fund.
There’s clearly a need for lessons. Compared to the rest of the developed world, America spends more money on health care and produces worse outcomes. By one advanced metric — mortality for causes that should be avoidable with accessible, high-quality health care — the United States ranked last among the G7 countries in 2016. America’s infant mortality rate is almost double that of some of its peers. Nearly one in 10 Americans lack insurance. People go bankrupt over medical bills. Yet Americans still spend about twice as much money on health care per capita as the average comparable country.
No health care system is perfect. But most of America’s economic peers have figured out a way to deliver truly universal coverage and quality care. The United States has not.
“Canada and virtually all European and Asian developed nations have reached, decades ago, a political consensus to treat health care as a social good,” health care economist Uwe Reinhardt wrote in his book Priced Out shortly before his death in 2017. “By contrast, we in the United States have never reached a politically dominant consensus on the issue.”
Taiwan made its choice in the 1990s and embraced single-payer. It has required sacrifice: by doctors who believe they’re forced to see too many patients every day; by patients with complex and costly conditions who can’t always access the latest treatments; by citizens who have been asked from time to time, and will be asked again, to pay more for their health care than they did before.
The vast majority of Taiwan’s citizens today approve of their health care system. They know it isn’t a utopia. The country has made hard choices to keep this program sustainable, and it will need to do so again. That is what it takes to realize the single-payer dream.
Taiwan took a broken system and built a new national health insurance program
Extraordinary circumstances paved the road to Taiwan’s single-payer system.
In the 1980s, Taiwan wasn’t yet a democracy, but the stirrings of popular rule could be felt. At the time, about 40 percent of Taiwanese people lacked health insurance — some people lost everything, even their house, if they had a medical crisis. Desperate to outflank reformers, the ruling government convened high-profile meetings to fix its health care system.
One guest at a 1989 conference was the German-born Reinhardt, a Princeton economist who was married to Taiwan-born scholar Tsung-Mei (May) Cheng.
Reinhardt, who later co-wrote the seminal paper “It’s The Prices, Stupid” about American health care and helped define the health policy debate in the US in the 2000s, was asked what system he thought Taiwan should adopt. He thought it over and talked about it with his wife for a couple of nights in their hotel room.
He finally delivered his answer: single-payer. One national health insurance plan, run by the government, covering everybody.
In Reinhardt’s view, single-payer would be the most equitable and efficient program. It was similar to systems already in place in Canada and the United Kingdom. He came up with the metaphor of the “single pipe” — through which all the money for health care would flow — to convey the concept to public officials.
It was a convincing presentation. As Cheng and her husband left to return to the United States, they didn’t know what would happen next. “We went back to Princeton,” Cheng recalls, “and six months later, we were told the government would accept your recommendation to go single-payer.”
The national government would eventually fast-track the implementation of the new system to 1995, hoping to get the chaotic transition period over before the first popular elections in 1996. There was plenty of skepticism leading up to it. Industry, experts, and the public alike doubted the program would succeed. Labor protesters threw paper money traditionally used in a funerary rite when the legislature passed the single-payer bill in 1994. A majority of people in Taiwan disapproved of the single-payer plan when it took effect.
But the program’s reputation quickly improved once people started to enjoy its benefits. Approval has dipped (when premiums were hiked in the 2000s) and risen (when the rural health care program that employs Tien in Xiulin was implemented) over the years, but there has always been a solid baseline of support. Today, approval of the national health insurance program hovers near its all-time high, over 80 percent. The system endures 25 years after it was established.
Part of its appeal is its simplicity. Everybody in Taiwan is insured through the National Health Insurance Administration (NHIA). They receive an ID card as proof of coverage, which also stores their medical records. The Taiwanese program runs with extraordinary efficiency: About 1 percent of its funding is spent on administration, according to a 2015 review by Cheng. (Compare that to the US, where researchers have estimated that private insurers spend around 12 percent of overhead, and hospitals spend around 25 percent on administrative work.) Experts say Taiwan’s advanced IT infrastructure deserves a good share of the credit.
The benefits are quite comprehensive: hospital care, primary care, prescription drugs, traditional Chinese medicine. Patients must make copays when they visit the doctor or fill a prescription or go to the ER, but they are generally low, 360 NTD (about $12) or less. Lower-income patients are given an additional break on their cost-sharing obligations. Higher-income patients can take out private insurance for certain things not covered by the single-payer program.
The system is mostly funded by payroll-based premiums, with contributions from workers and their employers, supplemented by more progressive income taxes and tobacco and lottery levies. Premiums have been raised twice in the past 18 years to cover the growing cost of the program. The most recent rate increase in 2010 moved the payroll income tax rate from 4.55 percent to 5.17, a 14 percent increase.
In the early 2000s, again at Reinhardt’s recommendation, Taiwan converted to global budgets to pay for health care as another cost-control measure. This means that every year, government officials and private providers sit across a table and negotiate rates for services, with an annual cap set on the total payments to hospitals and doctors that the government will make. Health spending has stayed flat in recent years as a percentage of GDP, and it is growing at a slower rate in Taiwan than in the United States.
Taiwanese patients use a lot of health care, and it puts a strain on providers
What it all adds up to is a system that patients seem broadly happy with — maybe too happy, according to doctors and economists I met.
“I believe we are too kind to our patient[s],” says Shou-Hsia Cheng, a health economics professor at National Taiwan University (NTU) who has worked at NHIA on and off over the years, “which is not a good thing, actually.”
Taiwanese people take advantage of their cheap, accessible health care. The average number of physician visits per year (12.1) is nearly twice that of other developed economies. There was a dramatic spike in use after single-payer was passed: A 1997 JAMA research paper led by Shou-Hsia Cheng found that physician visits among the newly insured doubled in the first year of the program compared to the year before.
That has had predictable downsides: Hospitals get crowded in Taiwan. The capacity of health care providers to attend to everyone in need can be stretched pretty thin.
I visited the National Taiwan University Hospital, a red-brick building in the heart of Taipei from the Japanese colonial period, one weekday afternoon. All of the clinic lobbies were full. The registration desk, run take-a-number style, was bustling, beeps constantly pinging over the PA system as patients’ numbers were called.
On another morning, inside a north-central Taipei primary care clinic, several patients were already sitting along the walls, hooked up to machines receiving infrared therapy for chronic pain, just a few minutes after the doors opened. The one doctor on site looked a bit frazzled as he showed me around before his clinic filled up any further.
The scenes bring to mind something I heard from trauma surgeon Li-Jian Chien, a member of the Taiwanese doctors union that formed in 2012 out of the frustrations felt in the medical profession.
In Taiwan, he says, “the patient [is] in heaven” — but “the doctor is in hell.”
It’s the opposite of the United States, he elaborates, where high cost sharing leads people to skip necessary care for serious conditions.
Chien says national health insurance with negligible cost sharing has pushed doctors to the brink. His friend and fellow physician Bing-Hong Lin exclaimed at one point during our interview: “We are not the Avengers!”
Surveys conducted by the government show health care providers have rather mixed opinions on the single-payer system — a significant plurality, 43 percent, said they were “neutral” in 2018 — a sharp contrast to the public’s sky-high favorability.
Chien says he sometimes sees the same patient dozens of times every year in the emergency department where he works, often for problems that aren’t emergencies. The low costs mean patients have little incentive to avoid the ER.
“Everyone wants to live forever, but it’s impossible,” Chien says. “Some people abuse emergency, abuse health care.”
At the same time, because Taipei has a lot of traffic accidents, injured drivers and pedestrians come through his emergency department’s doors all the time. His attention is divided when it shouldn’t be.
Lin has started doing cosmetic medicine for adults on the side because he has become so frustrated by his pediatric practice. It’s a more lucrative field, paid for privately by patients, with a less demanding workload. His is not an uncommon choice, according to experts. Lin still bitterly remembers being called back early from leave he had taken in 2005 to attend his father’s funeral, because there was a staffing shortage at the hospital where he was doing his residency.
Taiwanese hospitals and clinics are understaffed compared to the rest of the world: There are about 1.7 doctors in Taiwan for every 1,000 patients, which is well below the average of 3.3 in other developed countries. There are especially shortages of specialists in less urbanized parts of the country.
“Taiwan’s low ratios would be considered inadequate by OECD standards,” Tsung-Mei Cheng wrote in 2015, “especially in view of the high utilization of health care services in Taiwan.”
The country does excel at keeping wait times short for services like cataract and hip replacement surgeries. But providers are feeling the strain.
Taiwanese doctors work about 10 more hours a week on average than those in the United States. A 2016 survey of hospital physicians found that working overtime was prevalent, and doctors who worked a lot of overtime were more likely to say they might leave the hospital where they worked.
Crowded facilities, like the NTU Hospital, are the norm. Hospitals supplement their medical payments with high-margin non-health care services — food courts, parking, and so on — to keep themselves solvent.
The worry is that Taiwan’s national health insurance has given patients such a good deal on medical care that they are overwhelming the system.
Patients must make sacrifices, too, like when a drug is too expensive to cover
The patients have their own grievances. They’ve seen their premiums hiked and more taxes introduced over the past two decades, and they will probably be asked again soon to chip in more money.
And though the benefits are comprehensive for most people, Taiwan still doesn’t cover everything. Costly treatments for rare conditions are sometimes excluded.
A new drug for spinal muscular atrophy — a genetic disorder that progressively breaks down the patient’s muscle tissue, resulting in early death — came on the market in the US in 2017. The first year of treatment costs $750,000. Yi Jie Li, a 25-year-old woman with spinal atrophy and an outspoken advocate who wrote the 2017 book 7,300 Days: The Most Ordinary Luxury, penned a letter to the NHIA pleading with it to cover the drug for the patients it could help.
The department replied in a letter, and the president of Taiwan called her on the phone. They said they would do their best. But the drug still isn’t covered.
New medicines sometimes debut in Taiwan a full five years after they came on the market in the United States. For patients who need those medications, every day of waiting is a trial.
“Now the medicine is there,” Li says, “but you cannot use” it.
In some rural parts of the country, medical understaffing means less access to specialists and pediatricians. High use has frustrated doctors in the cities, but it’s patients who suffer if it’s hard for them to see a doctor or nurse.
Even though Taiwanese patients get a good deal on health care, they don’t come across as entitled. Some of the patients I met, including those who have faced the gravest diagnoses, seem acutely aware of the trade-offs demanded of them to keep a single-payer system sustainable.
Gloria Lin was diagnosed with breast cancer shortly before national health insurance took effect; today she is president of the Taiwanese Cancer Patient Association. Her group plays a part in talks between government and providers about what will be covered (and for how much).
She told me that of course she wants to see every new cancer drug covered by the government plan. But she also understands why that’s impossible: The system would become too expensive.
“We don’t want it [to go] bankrupt,” she says. “We have to work hand to hand together to solve the problem. … We have to be sensible for each other.”
Sustaining a single-payer system requires hard choices for patients, providers, and taxpayers
National health insurance achieved what the Taiwanese government hoped it would. Everybody can afford health care. People are living longer, healthier lives. But the ever-growing cost of providing health care to everybody makes it challenging for the program to remain financially sustainable.
The government keeps having to ask doctors, hospitals, and patients to make sacrifices to keep single-payer running. That’s not usually a political winner. No elected official is running on a campaign of higher premiums and higher copays.
But it helps that national health insurance has proven so popular. People want to make it work because single-payer has clearly improved Taiwanese lives.
One metric tells the tale: a rating based on medically amenable mortality, which gives a sense of how often people die of causes for which medical interventions should be available. In 1990, before Taiwan’s single-payer program was implemented, the country held a rating around 60, far behind the United States’ rating of 80. In 2016, Taiwan had nearly caught up with the US, topping 85; the US sat at 88, trailing its socioeconomic peers in Europe.
There is no doubt that medical care in Taiwan is better under single-payer, though it improved from a much worse status quo than the American system.
Today, Americans die prematurely of heart disease and lung cancer at higher rates than the Taiwanese. People in Taiwan live a little longer in general, though there are populations that encounter early deaths from alcohol use and stroke, just as some disadvantaged groups do in the United States. Yet overall, Taiwan spends 6 percent of its GDP on health care, about a third of what the United States does.
There is no comparison between the Taiwanese system of yesteryear — a 40 percent uninsured rate and the risk of financial catastrophe — and the one that exists today.
But hard choices still loom.
In the early 2000s, with health spending growing too quickly, the national health insurance office decided to institute the global budgets, a set pool of money that would cover all the medical services in a given year. Hong-Jen Chang, then the NHIA director, remembers seeing his effigy being decapitated in protests by hospital supporters. The opposition was overwhelming, and he had to resign over that decision in 2004. That was also shortly after the first premium increase was approved.
NHIA Director-General Dr. Po-Chang Lee told me that, after the presidential election this month, he would pitch the new government on increasing copayments so patients pay more out of pocket if they visit the doctor or hospital.
It may take more than that. Shou-Hsia Cheng, the NTU professor, predicted Taiwan would soon have to reevaluate its payments for end-of-life care. The country is currently debating how to expand long-term care for an aging population; it’s not covered by the national health plan.
The financial crunch is coming. The NHIA, which ran surpluses for a while after the last round of rate increases, is now about to see its reserves run out.
“Either we should increase the premium rate or increase the copayment, or we have to delete some coverage items,” Chang, the former NHIA director, says. “That will happen — not in two years, perhaps in 10 years. It will happen.”
But in Taiwan, the need for premium increases or hospital budget caps isn’t considered an indictment of national health insurance, at least if approval ratings for the system are anything to go by. It’s part of the evolution of the system they have built. And because the underlying program is so popular, Taiwanese leaders are confident patients will be willing to do what’s needed to keep single-payer viable.
“They will adjust,” Cheng, the professor, says. “I believe so.”
Taiwan is realizing the dream of “health care as a human right”
Since the beginning, the debate in Taiwan has been about balancing the imperatives of equity and access that underpinned the national health insurance program. Perhaps there’s been no greater demonstration of that than seeing the health care system at work in the mountain township of Xiulin, where Tien was making her rounds.
A decade into the single-payer experiment, when Hong-Jen Chang was in charge of NHIA, health care access in places like Xiulin was still lacking. So he decided to start the rural care delivery program that covers Tien and her patients.
On the same day she treated the Taroko woman at her clinic, Tien ventured out to visit a bedridden stroke patient in his home and showed the same warmth, offering him a cheerful thumbs-up as she went through her exam. A few doors down, a diabetes patient with gout welcomed a nurse into his house, parakeets chirping at the front door, so she could take his blood sugar readings, something she does two or three times a week. Meanwhile, in the town hall, a pop-up Chinese medicine clinic was set up, and patients filed in to get acupuncture treatments.
Chang told me a health care delivery program like this was the natural endpoint for the single-payer experiment, a necessary extension of its services to reach a vulnerable population. Without it, the work of Taiwanese health reform would always be incomplete.
“That’s the essence of universal health coverage,” he says. “The principle of health [as a] human right is that everybody regardless of geography, religion, gender, age should have the right to access.”
The people here seem grateful. Wong Shin-Fa, a 63-year-old Taroko man, stopped me on the side of the road in Xiulin and asked me what I was doing there. When I said I was an American reporting on health care, he told me a story.
He had a Taroko friend in Los Angeles who broke his arm, he told me, with a government health worker interpreting. Rather than get it fixed in the United States, his friend decided to fly back to Taiwan and have it mended there because he said it would be cheaper.
Shin-Fa knew Tien and her shock of pink hair. He said she’s famous around those parts. He told me, “The government takes good care of the Taroko people.”
Byrd Pinkerton contributed reporting to this story.
Ashley Pon is an editorial photographer based in Taipei, Taiwan.
The Everybody Covered project can be found at vox.com/covered. This series was made possible by a grant from The Commonwealth Fund. All content is editorially independent and produced by our journalists.


vox--2020-01-14--Wuhan pneumonia outbreak: What we know and don’t know

The mysterious virus causing dozens of people to fall sick with pneumonia in China has now popped up in a woman in Thailand — the first case of international spread since the outbreak was announced on December 31 .
The woman — a 61-year-old from China — had traveled to Bangkok from Wuhan , the mainland Chinese city of 19 million that ’ s currently the center of the outbreak , according to the World Health Organization ( WHO ) and the Bangkok Post .
Sixteen people who sat near the woman on her flight have so far tested negative @ @ @ @ @ @ @ is now recovering at the Bamrasnaradura Infectious Diseases Institute outside of Bangkok .
But what ’ s most significant about this case is that the woman never visited the Wuhan food market that ’ s been linked to the outbreak , according to a WHO spokesperson .
Instead , she “ reported a history of visiting [ other ] local markets in Wuhan on a regular basis prior to the onset of illness on January 5 , 2020.
” This could mean the new virus has the potential to spread from person to @ @ @ @ @ @ @ animal carrying the virus to humans , as health authorities have been suggesting .
Or , that there are animals at other markets shedding the virus — and that it may have already moved beyond Wuhan .
The spokesperson added that while there ’ s “ no clear evidence of human-to-human transmission , ” the precise way the virus is spreading “ has not yet been determined and human-to-human transmission is always a concern when patients have respiratory symptoms.
” For now , the outbreak centers around a single food market in Wuhan @ @ @ @ @ @ @ of China ’ s most populous provinces .
Health officials in Wuhan have reported that the patients with the virus so far were “ mainly business staff and purchasers ” at the Huanan South China Seafood Market , where vendors peddle seafood as well as animals such as birds and rabbits .
This suggested that the new virus had spread to humans from one of the animals there .
With the first case in Thailand , WHO warned about the possibility of broader spread and said it was considering organizing an emergency committee @ @ @ @ @ @ @ called , a panel of independent experts would discuss whether the outbreak is dire enough to constitute a “ public health emergency of international concern , ” a rare designation the WHO gives to diseases that pose a global threat .
China is sharing information about the outbreak fast — a contrast to SARS Because health authorities are dealing with a new virus , the picture of this outbreak — and its seriousness — is shifting rapidly .
The outbreak in Wuhan was only declared on December 31 .
By January 9 , @ @ @ @ @ @ @ that 15 of the people who had become ill tested positive for the new virus .
By January 11 , scientists in China shared the genetic sequence of the new virus and the WHO applauded China ’ s efforts .
“ WHO is reassured of the quality of the ongoing investigations and the response measures implemented in Wuhan , and the commitment to share information regularly , ” the agency said in a statement .
This was also a contrast to the SARS outbreak of 2003 , when China was heavily criticized for @ @ @ @ @ @ @ long .
But other aspects of the outbreak bear a startling resemblance to SARS , which also involved a then-new virus when it was discovered in 2003 .
The virus jumped from civet cats — a food delicacy in China — to humans , and went on to spread to two dozen countries .
It eventually killed 774 people and infected more than 8,000 .
The one patient death “ marks this virus as a significant concern ” To date , authorities in Wuhan have reported 41 patients with the novel coronavirus infection @ @ @ @ @ @ @ severely ill , and two have been discharged from the hospital .
One patient — a 61-year-old man with underlying health problems , including chronic liver disease — died on January 9 .
The man went into the hospital with respiratory failure and severe pneumonia .
He had bought food from the Wuhan market regularly and tested positive for the new virus .
The leading hypothesis is that the disease is the result of a new coronavirus , a member of the same family of viruses as SARS .
Coronaviruses attack the respiratory @ @ @ @ @ @ @ within the lungs .
“ There are tons of coronaviruses , ” said Vincent Munster , an emerging viral diseases researcher at the National Institute of Allergy and Infectious Diseases .
Most infect mammals , including bats .
Two of the six that are known to infect humans , SARS and MERS , can cause severe pneumonia and even death .
The rest lead to milder symptoms , like a common cold .
In the current outbreak , the main symptoms reported are fever followed by difficulty breathing , the WHO said .
@ @ @ @ @ @ @ have lesions in both lungs .
According to the Bangkok Post , the patient in Thailand had neither fever nor respiratory symptoms , and might be discharged in a few days .
The death of one patient “ marks this virus as a significant concern , ” said Peter Daszak , the president of EcoHealth Alliance , a US global health research organization working in China .
Researchers will need to confirm that this new virus is without a doubt the driver of the outbreak , said Marion Koopmans , who studies emerging @ @ @ @ @ @ @ of virology at Erasmus Medical Center in Rotterdam .
They ’ ll then need to figure out the range of illness the virus causes in the confirmed cases .
“ If [ the new virus ] is indeed the likely cause , and seeded at the market , a key question is how transmissible this is , ” Koopmans said .
Viruses that spill over from animals may not be very transmissible “ if they sit deep in the lungs and are not shed easily , ” she added .
That would mean @ @ @ @ @ @ @ potential of this virus might still be limited.
” But , again , the Thailand case suggests the potential for human-to-human spread .
And it ’ s possible , Daszak said , that the virus was incubating in patients for a couple of weeks , and that the secondary cases — from people who were directly exposed to the animal carrying the virus — are only now going to start popping up .
If that ’ s the case , “ the scope of this outbreak expands massively , ” he added .
@ @ @ @ @ @ @ China and one is traveling .
I don ’ t understand why there are so many cases if there ’ s no human-to-human transmission.
” Health officials would also need to find out which animal is spreading the virus to humans — the “ natural reservoir ” of the virus — and how the virus made the jump , and then make sure that animal is contained .
“ We don ’ t know where the virus came from , ” Daszak said .
“ We don ’ t know the geographic origin @ @ @ @ @ @ @ ’ s now known to be lethal.
” At the moment , the WHO is not recommending any measures for travelers nor is it advising against travel or trade restrictions on China , even on the cusp of China ’ s Lunar New Year holiday , during which hundreds of millions of people are expected to travel .
( A new study found the top travel destinations out of Wuhan are Asian mega cities , including Bangkok , Hong Kong , Tokyo , and Taipei . )
The market that ’ s been @ @ @ @ @ @ @ for disinfection , and health investigators are following 739 close contacts of the patients , including 419 medical staff , to see if they develop symptoms .
Officials in Wuhan say there have been no new cases there since January 3 .


vox--2020-01-14--What to expect at the last Democratic debate before the Iowa caucuses

It ’ s happening : The final Democratic debate before the Iowa caucuses is here .
Top contenders for the Democratic Party ’ s presidential nomination will take the stage at Drake University in Des Moines , Iowa , on Tuesday , January 14 .
The debate will start at 9 pm ET and last for two hours .
CNN and the Des Moines Register are hosting the debate , which will be moderated by CNN anchor Wolf Blitzer , CNN political correspondent Abby Phillip , and the Des Moines Register ’ s chief politics reporter , Brianne Pfannenstiel .
@ @ @ @ @ @ @ the network will also livestream the debate .
Six candidates made the cut in both polling and donation qualifications and will appear at Tuesday ’ s event : That means six other candidates will be left off the stage : The Democratic National Committee has gradually increased the debate qualifications throughout this cycle , and the threshold for January is the highest yet : Candidates have to get at least 5 percent support in four DNC-approved national polls or 7 percent support in two early primary voting state polls , and they must @ @ @ @ @ @ @ ’ s up from the December debate , when candidates had to get at least 4 percent support in at least four national polls or 6 percent support in two single-state polls in early voting states .
They also had to have received donations from at least 200,000 people .
The criteria have garnered some grumbling among some contenders who didn ’ t make the cut .
Ahead of the December debate , Sen. Cory Booker , who failed to make the stage , spearheaded a letter signed by other major candidates asking @ @ @ @ @ @ @ ask candidates to meet either the polling or the donor standard .
The DNC appears to have no plans to make that change .
( Booker dropped out of the race the day before the debate . )
Bloomberg is self-funding his campaign , so he ’ s making no attempt to meet the DNC ’ s criteria .
After Tuesday , you can expect at least three more debates before the year even enters its third month : one in Manchester , New Hampshire , on Friday , February 7 ; the @ @ @ @ @ @ @ February 19 ; and another in Charleston , South Carolina , on Tuesday , February 25 .
The race is getting tighter as primary season approaches The stakes of the race feel extra-high as primary season approaches .
The Iowa caucuses take place on February 3 , and voting advances at a pretty quick clip from there : New Hampshire on February 11 , Nevada on February 22 , South Carolina on February 29 , and then Super Tuesday on March 3 , when multiple states vote .
Nationally , Biden has a @ @ @ @ @ @ @ , followed by Sanders , Warren , Buttigieg , and Bloomberg .
The race is pretty tight among the top four in Iowa and New Hampshire ( Bloomberg isn ’ t campaigning heavily in either state and is instead focusing on Super Tuesday ) .
But once results start to come in , the race could change pretty quickly , especially if there are surprises on who over- and underperforms , including potential surprise contenders like Klobuchar .
So Tuesday could get contentious .
Not only is voting close , but this will @ @ @ @ @ @ @ ’ ve seen onstage together this election cycle .
That will give them more opportunities to make the case for their candidacies — and to draw contrasts with others .
Biden and Sanders have been more critical of one another in recent weeks as the pair have appeared increasingly like the two frontrunners in the race .
Warren last week released a bankruptcy plan , indicating she might go after Biden on a bankruptcy bill he advocated for in 2005 .
Tensions have been simmering between Warren and Buttigieg for months , and @ @ @ @ @ @ @ Buttigieg in recent debates .
Steyer has largely avoided much direct conflict — he knows he ’ s a long shot , and honestly , he ’ s probably just happy to be there .

It’s happening: The final Democratic debate before the Iowa caucuses is here.
Top contenders for the Democratic Party’s presidential nomination will take the stage at Drake University in Des Moines, Iowa, on Tuesday, January 14. The debate will start at 9 pm ET and last for two hours.
CNN and the Des Moines Register are hosting the debate, which will be moderated by CNN anchor Wolf Blitzer, CNN political correspondent Abby Phillip, and the Des Moines Register’s chief politics reporter, Brianne Pfannenstiel. You can watch on CNN, and the network will also livestream the debate.
Six candidates made the cut in both polling and donation qualifications and will appear at Tuesday’s event:
Former Vice President Joe Biden
Former South Bend, Indiana, Mayor Pete Buttigieg
Sen. Amy Klobuchar (D-MN)
Sen. Bernie Sanders (I-VT)
Sen. Elizabeth Warren (D-MA)
Billionaire activist Tom Steyer
That means six other candidates will be left off the stage:
The Democratic National Committee has gradually increased the debate qualifications throughout this cycle, and the threshold for January is the highest yet: Candidates have to get at least 5 percent support in four DNC-approved national polls or 7 percent support in two early primary voting state polls, and they must have at least 225,000 donors.
That’s up from the December debate, when candidates had to get at least 4 percent support in at least four national polls or 6 percent support in two single-state polls in early voting states. They also had to have received donations from at least 200,000 people.
The criteria have garnered some grumbling among some contenders who didn’t make the cut. Ahead of the December debate, Sen. Cory Booker, who failed to make the stage, spearheaded a letter signed by other major candidates asking the DNC to reconsider its requirements and ask candidates to meet either the polling or the donor standard. The DNC appears to have no plans to make that change. (Booker dropped out of the race the day before the debate.) Bloomberg is self-funding his campaign, so he’s making no attempt to meet the DNC’s criteria.
After Tuesday, you can expect at least three more debates before the year even enters its third month: one in Manchester, New Hampshire, on Friday, February 7; the next in Las Vegas on Wednesday, February 19; and another in Charleston, South Carolina, on Tuesday, February 25.
(The pattern here: The debates are all just days ahead of the caucuses and primaries in the respective dates they’re being held.)
The race is getting tighter as primary season approaches
The stakes of the race feel extra-high as primary season approaches. The Iowa caucuses take place on February 3, and voting advances at a pretty quick clip from there: New Hampshire on February 11, Nevada on February 22, South Carolina on February 29, and then Super Tuesday on March 3, when multiple states vote.
Nationally, Biden has a sizable lead across an average of polls, followed by Sanders, Warren, Buttigieg, and Bloomberg. The race is pretty tight among the top four in Iowa and New Hampshire (Bloomberg isn’t campaigning heavily in either state and is instead focusing on Super Tuesday). But once results start to come in, the race could change pretty quickly, especially if there are surprises on who over- and underperforms, including potential surprise contenders like Klobuchar.
So Tuesday could get contentious. Not only is voting close, but this will be the smallest number of candidates we’ve seen onstage together this election cycle. That will give them more opportunities to make the case for their candidacies — and to draw contrasts with others.
Biden and Sanders have been more critical of one another in recent weeks as the pair have appeared increasingly like the two frontrunners in the race. Warren last week released a bankruptcy plan, indicating she might go after Biden on a bankruptcy bill he advocated for in 2005. Tensions have been simmering between Warren and Buttigieg for months, and Klobuchar has also trained her fire on Buttigieg in recent debates. Steyer has largely avoided much direct conflict — he knows he’s a long shot, and honestly, he’s probably just happy to be there.


vox--2020-01-14--Fox News goes to desperate lengths to gin up outrage over clip of Vince Vaughn chatting with Trump

The morning after a clip of actor Vince Vaughn having a brief , amicable conversation with President Donald Trump and first lady Melania Trump in a private box at the national championship college football game in New Orleans went viral , Fox News went to desperate lengths to make it seem as though Democrats are mad about it .
The problem , however , is that there isn ’ t much evidence anyone aside from right-wingers is actually mad .
In fact , Fox News ’ s article about how Vaughn supposedly “ faces liberal outrage after he was seen @ @ @ @ @ @ @ prominently features a tweet from Washington Examiner staffer Siraj Hashmi , who is hardly a liberal , sarcastically quipping that “ Ladies & gentlemen , I regret to inform you Vince Vaughn is CANCELED ” — but the tweet is presented in David Aaro ’ s article as though Hashmi is a liberal who meant it earnestly .
Hashmi later noted on Twitter that the Fox News article caused right-wing trolls to flood his Instagram page with abusive comments .
And the few other examples of “ liberal outrage ” in the piece @ @ @ @ @ @ @ Twitter .
The clip of the conversation between Trump and Vaughn — a libertarian who supported Rand Paul ’ s presidential bid — was originally posted to Twitter by former Deadspin staffer Timothy Burke , who wrote , “ I ’ m very sorry to have to share this video with you .
All of it , every part of it.
” As you ’ d expect , a few left-wing accounts did react did Burke ’ s clip with comments like , “ Sad .
Vince Vaughn is one of my favorites @ @ @ @ @ @ @ but this , so gross ...
I don ’ t need a Wedding Crashers sequel anymore.
” But the idea that there was some sort of concerted liberal backlash to clip is make-believe aimed at ginning up outrage .
Beyond the article on Fox News ’ s website , “ Vince Vaughn blasted for talking to Trump at game ” was a prominent topic on Tuesday ’ s Fox & Friends .
Despite a dearth of examples of Vaughn being blasted , hosts Brian Kilmeade and Steve Doocy went as far as to @ @ @ @ @ @ @ slippery slope toward a second civil war .
“ Unless America talks to the other side and we can just talk to each other , they might as well just split the country right in half , ” Doocy said .
Later , despite not being able to cite a single example of a prominent Democrat expressing outrage toward Vaughn , White House spokesperson Hogan Gidley told hosts that “ Democrats seem to be more upset at this exchange than they do at [ Iranian military leader Qassem ] Soleimani killing Americans citizens.
@ @ @ @ @ @ @ to portray liberals as irrational and “ triggered , ” Fox News accidentally illustrated the extent to which that entire discourse is projection .
In trying to own the libs , they owned themselves .
The news moves fast .
To stay updated , follow Aaron Rupar on Twitter , and read more of Vox ’ s policy and politics coverage .

The morning after a clip of actor Vince Vaughn having a brief, amicable conversation with President Donald Trump and first lady Melania Trump in a private box at the national championship college football game in New Orleans went viral, Fox News went to desperate lengths to make it seem as though Democrats are mad about it.
The problem, however, is that there isn’t much evidence anyone aside from right-wingers is actually mad.
In fact, Fox News’s article about how Vaughn supposedly “faces liberal outrage after he was seen with Trump during national championship game” prominently features a tweet from Washington Examiner staffer Siraj Hashmi, who is hardly a liberal, sarcastically quipping that “Ladies & gentlemen, I regret to inform you Vince Vaughn is CANCELED” — but the tweet is presented in David Aaro’s article as though Hashmi is a liberal who meant it earnestly.
Hashmi later noted on Twitter that the Fox News article caused right-wing trolls to flood his Instagram page with abusive comments. And the few other examples of “liberal outrage” in the piece were gleaned from the far fringes of Twitter. (Fox News still hasn’t figured out that Hashmi isn’t actually liberal as of Tuesday afternoon — his tweet was falsely cited as an example of “liberal cancel culture” on Outnumbered.)
The clip of the conversation between Trump and Vaughn — a libertarian who supported Rand Paul’s presidential bid — was originally posted to Twitter by former Deadspin staffer Timothy Burke, who wrote, “I’m very sorry to have to share this video with you. All of it, every part of it.”
I'm very sorry to have to share this video with you. All of it, every part of it. pic.twitter.com/ELMbDHZbZq — Timothy Burke (@bubbaprog) January 14, 2020
As you’d expect, a few left-wing accounts did react to Burke’s clip with comments like, “Sad. Vince Vaughn is one of my favorites. I always knew he was Republican but this, so gross ... I don’t need a Wedding Crashers sequel anymore.” But the idea that there was some sort of concerted liberal backlash to the clip is make-believe aimed at ginning up outrage.
Beyond the article on Fox News’s website, “Vince Vaughn blasted for talking to Trump at game” was a prominent topic on Tuesday’s Fox & Friends. Despite a dearth of examples of Vaughn being blasted, hosts Brian Kilmeade and Steve Doocy went as far as to suggest that the Vaughn incident is a slippery slope toward a second civil war.
“Unless America talks to the other side and we can just talk to each other, they might as well just split the country right in half,” Doocy said.
“We tried that once,” replied Kilmeade.
Doocy: "Unless America talks to the other side and we can talk to each other, they might as well just split the country right in half"
Kilmeade: "They tried that once"
Doocy: "Well they did, but that's what we're going to. If you can't talk to each other, we're in big trouble" pic.twitter.com/lELNNSjAd7 — Bobby Lewis (@revrrlewis) January 14, 2020
Later, despite not being able to cite a single example of a prominent Democrat expressing outrage toward Vaughn, White House spokesperson Hogan Gidley told the hosts, “Democrats seem to be more upset at this exchange than they do at [Iranian military leader Qassem] Soleimani killing Americans citizens.”
“Good point,” host Ainsley Earhardt replied.
Hogan Gidley says LSU-Clemson's cheers for Trump were the most incredible cheers he's ever heard, "a unifying moment" ruined by Democrats being madder at Vince Vaughn than Qassem Soleimani, an absolutely ridiculous non sequitur that isn't even true. Ainsley says "good point." pic.twitter.com/z7wW3WlkOj — Bobby Lewis (@revrrlewis) January 14, 2020
The irony is that in trying to portray liberals as irrational and “triggered,” Fox News accidentally illustrated the extent to which that entire discourse is projection. In trying to own the libs, they owned themselves.
The news moves fast. To stay updated, follow Aaron Rupar on Twitter, and read more of Vox’s policy and politics coverage.