Does the Universal Health Insurance Program Affect Urban-Rural Differences in Health Service Utilization Among the Elderly? Evidence From a Longitudinal Study in Taiwan


  • H.H. Chang appreciates partial funding support from National Science Council of Taiwan under grant no. NSC99-2410-H-002-063. All authors appreciate the Bureau of Health Promotion, Department of Health and National Health Research Institutes in Taiwan for providing the data. The interpretation and conclusions contained herein do not represent those of Bureau of Health Promotion, Department of Health or National Health Research Institutes. For further information, contact: Hung-Hao Chang, PhD, Associate Professor, Department of Agricultural Economics, National Taiwan University, No 1, Roosevelt Rd, Sec 4, Taipei, 10617 Taiwan; e-mail


Purpose: To assess the impact of the introduction of Taiwan's National Health Insurance (NHI) on urban-rural inequality in health service utilization among the elderly.

Methods: A longitudinal data set of 1,504 individuals aged 65 and older was constructed from the Survey of Health and Living Status of the Elderly. A difference-in-differences model was employed and estimated by the random-effect probit method.

Finding: The introduction of universal NHI in Taiwan heterogeneously affected outpatient and inpatient health service utilization among the elderly in urban and rural areas. The introduction of NHI reduced the disparity of outpatient (inpatient) utilization between the previously uninsured and insured older urban residents by 12.9 (22.0) percentage points. However, there was no significant reduction in the utilization disparity between the previously uninsured and insured elderly among rural residents.

Conclusions: Our study on Taiwan's experience should provide a valuable lesson to countries that are in an initial stage of proposing a universal health insurance system. Although NHI is designed to ensure the equitable right to access health care, it may result in differential impacts on health service utilization among the elderly across areas. The rural elderly tend to confront more challenges in accessing health care associated with spatial distance, transportation, social isolation, poverty, and a lack of health care providers, especially medical specialists.