Can Health Insurance Boost Fertility?
The Fertility Effect of National Health Insurance in Taiwan
"Without the high level of immigration that the U.S. has traditionally enjoyed, we might have fertility problems as severe as Taiwan’s, and be facing the challenges of shrinking workforce that Taiwan is facing today—we might yet in the future."
The Fertility Effect of National Health Insurance in TaiwanBy Elyse Mark/Fulbright Scholar
When I arrived in Taipei two years ago, I knew relatively little about local Taiwanese culture or issues. With an undergraduate background in English and Chinese, most of my academic knowledge was limited to English literature and the politics of mainland China. I was drawn to Taiwan by its reputation for vibrant democracy, encouraged by professors and friends alike who raved about Taiwan’s open educational environment, remarkable food scene, and multicultural colonial history.
Through the generosity of Fulbright and the Taiwanese government, over the past two years my understanding of this island has changed and grown, along with my research interests at National Chengchi University.
When I first came to NCCU, I intended to study global climate change policy. But after two years of living in Taipei and engaging with local community through volunteer opportunities at local shelters, language exchanges with classmates, and more, I’ve chosen a thesis topic closer to (my new) home: Taiwanese fertility.
Low fertility is one of many demographic trends affecting Taiwan, and an issue that will only grow in social, economic, and political importance in the years to come. Since I moved to Taiwan in 2016, the political landscape of the United States has also changed dramatically. We have a new president and administration, with new goals and views on topics like immigration and healthcare.
My research on healthcare and low fertility in Taiwan is intimately related to my concern for similar issues in the United States. Without the high level of immigration that the U.S. has traditionally enjoyed, we might have fertility problems as severe as Taiwan’s, and be facing the challenges of shrinking workforce that Taiwan is facing today—we might yet in the future.
The following is a sample of the first few chapters of my graduate thesis, a quantitative analysis on the effect of national health insurance (NHI) implementation on Taiwanese childbearing decisions.
Have you read? Additional reading on National Health Insurance in Taiwan.
Can Health Insurance Boost Fertility? The Fertility Effect of National Health Insurance in Taiwan
In the 20th century, Taiwanese fertility underwent a dramatic transformation, declining from a peak total fertility rate of 7.04 births per woman in 1951 to below-replacement level fertility in 1984. Since then, fertility rates have stagnated below 2.1 births per woman until the present day (G. H. Lee & Lee, 2014).
Low fertility is not an isolated Taiwanese problem, but rather a demographic crisis endemic to many economically developed countries, and felt acutely in Western Europe and East Asia. Sub-replacement fertility does not automatically bring about population decline. When the momentum of a large childbearing cohort is lost, however, and in the absence of immigration to offset low birthrate, low fertility causes population shrinkage.
While this might lower the environmental burden of a large population, sustained low fertility threatens state capacity to provide pensions for aging populations, promote stable economic growth, and fund vital public services like education or healthcare.
From Japan to Norway, nations around the world have undertaken natalist policies in an attempt to boost fertility, ranging from the provision of public childcare to anti-discrimination employment laws and paid parental leave (Nakajima & Tanaka, 2014; Rindfuss, Guilkey, Morgan, & Kravdal, 2010).
Previous studies on the efficacy of pronatal policy aimed at increasing domestic fertility through cash or non-cash incentives in developed countries have yielded mixed results. Most governments work concurrently through implicit and explicit policy channels to promote childbearing, which presents analytical challenges for researchers hoping to identify successful pronatal incentives.
Because fertility decisions lie at the intersection of social, economic, and cultural crossroads, intercountry generalization is unreliable, if not impossible. Little consensus exists regarding whether or not policy incentives are able to stimulate fertility at all, much less which types of incentive structures are the most effective. This thesis narrows the broader academic debate over pronatal policy solutions to sub-replacement fertility by concentrating on the Taiwanese case during the 1990s.
The primary purpose of the study is to determine the effect of national health insurance (NHI) implementation on the childbearing decisions of Taiwanese women, working on the premise that NHI coverage almost universally lowered financial barriers to childrearing.
Given its inclusion of various birth and child healthcare benefits, NHI may be considered a form of implicit pronatal policy in Taiwan, and one that circumvented contemporary political opposition to other more explicit forms of pronatal policy. Data for this paper are from the Women’s Marriage, Fertility, and Employment Survey (WMFES), conducted periodically by the Statistical Department of the Taiwanese Ministry of the Interior since 1979.
The study uses multivariate OLS regression and difference-in-differences (DID) designs to analyze the fertility effects of the universal implementation of Taiwanese NHI in 1995, examining conditional fertility and monthly birthrate as outcome variables, respectively.
Background: Fertility Transition in Taiwan
Taiwan has undergone a well-documented demographic reversal over the last century, transforming from an island with high fertility to low fertility in the 1950s, and from low fertility to sub-replacement levels beginning in the 1980s.
Fertility decline on the island has lowered fertility from its peak TFR of 7.04 children born per woman in 1951 to a stagnant 1.75 between 1986 and 1997, decreasing again to approximately 1.12 by 2007, where it remains stable today. Beginning in the 1920s, the decreasing death rate fast-tracked Taiwan’s population growth.
Combined with an increase in birth rate after World War II, Taiwan’s fertility peaked in the 1950s with a crude annual birth rate of over 40 children per 1000 population. The combination of a household registration system and periodic national knowledge, attitude, and practice (KAP) family planning surveys since 1965 reflects long-standing state interest in tracking population trends, making Taiwanese fertility an ideal case for exploration.
The 1950s to 1980s was generally a period of fertility reduction for Taiwanese women of childbearing age. Government introduction of the 1964 Family Planning Program, combined with increased opportunities for private economic gain, radically influenced Taiwanese childbearing preferences.
The program employed civil servants as Pre-pregnancy Health Workers (PPHWs) or part-time Village Health Education Nurses (VHENs) in each of Taiwan’s 361 townships, tasking them with traveling door-to-door to private residences to recruit women into the program (Montgomery & Casterline, 1993).
Through the family planning program, PPHWs provided recruits with various contraceptives such as intrauterine devices, oral contraceptives, condoms, and distributed propaganda encouraging smaller family sizes.
Presence of the family planning program during Taiwan’s fertility decline from the 1960s onward and high usage of contraceptives by Taiwanese women indicates the program was successful. In their analysis of diffusion of fertility control in Taiwan, however, Montgomery and Casterline (1993) find that the actual estimate of the program impact varies dramatically depending on statistical design.
Weighted least squares regression shows the program reducing marital fertility no more than 5% from 1968-80, with increases in marital fertility in the early years of the program, while their diffusion-based curves put that number somewhere between 5 and 22%.
Li (1973) supports the claim that the family planning program neither induced nor increased Taiwanese fertility decline 1954-1970, pointing to evidence from Taichung (a target area of the program) to show that action programs had little appreciable effect on childbearing. Rather, they point to decreased infant mortality as likely explanatory variable throughout the country, and rising educational levels as an important urban factor.
Nuptiality and martial fertility have also been cited as causes for Taiwanese fertility decline. Sun, Lin, and Freedman (1978) first showed that about 1/3 of the decrease in birth rate 1961-1984 was caused by changing marriage patterns, while in contrast Feeney (1991) claims that nuptiality contributed nothing to fertility change in this period.
His study shows a sustained high level of marriage and motherhood for Taiwanese women throughout the 1980s, asserting that the contrast between his and the Chang, Freedman, and Sun (1987) study is due to methodological differences related to his focus on women’s probability of first marriage and Chang et al. examining age specific birth rate.
However, his later claim that Taiwan “may not be below replacement level after all” (in the 1990s) belies the strength of that argument (Feeney, 1991, p. 476). Chang (2006) found that 2/3 of the decrease in birth rate 1965-1980 was attributable to declining marital fertility, and the remaining 1/3 due to nuptiality patterns.
In 1983, the combination of an extremely low death rate and a large cohort of women of childbearing age resulted in a high population growth rate, which prompted the Taiwanese government to push a second wave of the family planning program.
During the 1980s, statistics show fertility reduction for women under 30 years of age and a trend of delaying childbearing until the late twenties; by the 2000s the average age of mothers at first birth was into the early thirties (see Figure 1; plotted with data from R.O.C. Ministry of the Interior). Despite overall fertility decline, martial fertility actually increased between 1985 and 2007 (Luoh, 2007 as cited in Lee & Lin, 2016).
Taiwan has extremely low extramarital fertility, and childbearing has been named as the de facto cause of marriage for many Taiwanese women (K. Chen & Yang, 2005 as cited in Lee & Lin 2016).
Pronatal Fertility Policy
Taiwanese fertility policy reflects its demographic reversal, with a two-decade delay. Clear antinatalism underlies the 1964 national family planning program, which boosted contraceptive use and promoted the social and economic advantages of small families; by 1992, however, the revised Guideline for Population Policy acknowledged the need for more stable population growth in Taiwan.
The “link between Taiwan’s family planning program and rapid economic progress” obstructed the state’s ability to increase Taiwanese family size, as did pressure to adopt a universal pension plan in the late 1990s (M. Lee & Lin, 2016, p. 270).
Explicit pronatal policy did not pass until the 2008 publication of a Pronatal Population Policy White Paper, due in part to backlash from feminist and environmentalist groups throughout the 1990s and 2000s, who questioned the gendered and environmental consequences of increasing the national population.
Actual quantitative fertility targets were not published until the 2013 revision of that paper, along with strategies to address low fertility. In the midst of this controversy, 1995 passage of National Health Insurance (NHI) in Taiwan included several incentives for higher fertility, such as free prenatal and neonatal care, child delivery, child health insurance, one-month cash benefit for childbirth, and complete premium coverage for low-income families.
By the end of 1995, 97% of the population had registered for NHI coverage (L. Chen, Chen, & Yang, 2008). Prior to NHI, only women covered by Government Employee Insurance had access to free prenatal care through public health insurance. Given the pronatal incentives in NHI, the present study aims to determine the effect of nationwide implementation of National Health Insurance on Taiwanese fertility.
Given the endogeneity of healthcare availability to childbearing decisions, this study uses the 1995 implementation of NHI to estimate the impact of national healthcare on Taiwanese fertility. We first approach this question using OLS regression to test for correlation between completed childbearing and an NHI dummy, among other demographic factors.
In the second approach, difference-in-differences methodologies estimate the effect of 1995 NHI implementation on the treatment group of Taiwanese women and state-insured control group. Our data sources are the 1979-2016 waves of the Women’s Marriage, Fertility, and Employment Survey conducted by the Statistical Department of the Taiwanese Ministry of the Interior.
We hypothesize that the 1995 NHI policy change increased the fertility of Taiwanese women around the cutoff date despite sub-replacement national fertility beginning in the 1980s. OLS analysis, however, fails to show a positive correlation between NHI and women’s fertility in Taiwan.
Further, DID estimations using a maternal age and a conception time both reject the hypothesis that lowering the cost of childbearing through NHI stimulated Taiwanese fertility. Our study concluded that future research on low fertility and pronatal policy is needed to determine what kind of public health policy is most effective at promoting Taiwanese childbearing.
Edited by Tomas Lin
About the Author
Elyse Mark is a visiting fellow at the East West Center in Washington, researching US-Japan global health cooperation. She is a 2018 graduate of the International Master's Program in International Studies at National Chengchi University, and a 2016 alumna of Penn State University where she earned BAs in English and Chinese from the Schreyer Honors College.
The Foundation for Scholarly Exchange (Fulbright Taiwan) is one of 49 bi-national/bilateral non-profit organizations established to administer the Fulbright educational exchange program. For more information on the grants see the Fulbright Taiwan website. Research & Reflections is an online publication of submissions from Fulbright Taiwan grant recipients. We hope that it can help fulfill the Fulbright Taiwan's mission of cross-cultural understanding and knowledge-generation. Read more at Research & Reflections.