Familial Foundations of the Welfare State : Building the National Health Insurance Systems in South Korea and Taiwan 978-3-319-58712-7, 3319587129, 978-3-319-58711-0

Table of contents :
Front Matter ....Pages i-xv
Introduction (Hye Suk Wang)....Pages 1-18
Welfare Politics: Building Welfare Institutions (Hye Suk Wang)....Pages 19-40
(De-)Familialization in Social Policy in East Asia (Hye Suk Wang)....Pages 41-71
Historical Development of NHI in S. Korea: Why not Equal Protection for Female Workers’ Families? (Hye Suk Wang)....Pages 73-106
Historical Development of NHI in Taiwan: De-familialization Path of Welfare Politics (Hye Suk Wang)....Pages 107-137
Conclusion (Hye Suk Wang)....Pages 139-146
Back Matter ....Pages 147-151

Citation preview

Familial Foundations of the Welfare State Building the National Health Insurance Systems in South Korea and Taiwan

Hye Suk Wang

Familial Foundations of the Welfare State

Hye Suk Wang

Familial Foundations of the Welfare State Building the National Health Insurance Systems in South Korea and Taiwan

Hye Suk Wang Yonsei University Seoul, Korea (Republic of)

ISBN 978-3-319-58711-0 ISBN 978-3-319-58712-7  (eBook) DOI 10.1007/978-3-319-58712-7 Library of Congress Control Number: 2017940622 © The Editor(s) (if applicable) and The Author(s) 2017 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Cover design by Thomas Howey Printed on acid-free paper This Palgrave Macmillan imprint is published by Springer Nature The registered company is Springer International Publishing AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Acknowledgements

Some might wonder about the page for the acknowledgement and appreciation, which might be too big for my work. I, as well, consider spending my time for such pages as pretty presumptuous. However, one important reason has made me devote myself writing these pages; I have had so much help from countless people and organizations. This book would have not been finished if I worked all alone. The page, therefore, shall also be the confession of my feeling of helplessness and of despair during the field works and the actual time of writing the book. As this book derives from my doctoral research, first gratitude should go to the institutions which supported my research. I have received generous help as a Ph.D. candidate when I completed the dissertation. First, I would like to express my warm appreciation for those who have financially supported me during my fieldwork. POSCO TJ Park Foundation has supported my travel fee and the money required for my nine-month of fieldwork. The organization also encouraged my situation as a Korean researcher who has always been interested in Asian regional studies. Furthermore, the 6-month of Taiwan Fellowship from MOFA of Taiwan has provided me with the critical networks for me to exchange the information with Taiwanese researchers far fetching beyond the mere fieldwork. Finally, Lee Min-ju Scholarship from Yonsei University has furnished the environment for me to complete my fieldwork, which had gone too far beyond the expected time period. I also appreciate Prof. Kuo-Hsien Su and Prof. Kuo-Ming Lin of Department of Sociology of the National Taiwan University, v

vi  Acknowledgements

Hsin-Huang Michael Hsiao of Academia Sinica, and all the graduate students of the Department of Sociology, the National Taiwan University who have warmly welcomed me. My life and conversations with them for a year have given me a great chance to acknowledge the bond of sympathy that the contemporary scholars could share, going beyond the regional background of East Asia. By expressing my deepest appreciation for all the research foundations and organizations, which have supported my research during my two-year-long of field research, I hope the book could be a little compensation for their hospitality. I also want to thank my friends who are currently enrolled in their masters and PhDs in sociology department, graduate school of Yonsei University, who have shared the research center in Widang building for a long time. Also, the life of the female PhDs from my department, whom I would call the top 1% intellectuals of Korea, has evinced that love for family and passion for learning are the two sides of the same coin. It also confirmed to me that the story I have expressed in this book is not only about my life but also about everyone’s. Further, my gratitude goes to the professors of sociology department in Yonsei University who have instructed me for a long time from my undergraduate life until the time I get my Ph.D. Especially I feel that I have fell into a great debt for those who have been the members of my dissertation committee: Prof. Yong-Hak Kim, and Prof. Wang-Bae Kim. Also, Prof. Kyung-zoon Hong and Prof. Mee-Sook Lee, who have instructed me as my assistant judges despite being an utter stranger to me, affirmed that the value of reciprocity is not a mere past but an old future that can still remain as an ethical and academic resource in the modern society. No word would dare to fully express my feeling of appreciation for my supervisor, Prof. Seok-Choon Lew. I shall make the analogy for him with the shoulder that my research stands on, and that I would never dare to climb up, simultaneously. My further appreciation shall now go towards my research community 529 thanks to Prof. Seok-Choon Lew who has introduced me to the community. My 10-year experience with them has further affirmed me that not every organization is a market or a hierarchy. I would like to further express my appreciation to my husband Lung-ta Wei. He has continuously given this amateur researcher on Taiwan, his hand to discover and to understand necessary materials for understanding the Taiwanese society from the period of my fieldwork.

Acknowledgements

  vii

Also, he has meticulously proofread my dissertation in regard with the parts on Taiwan, and his comments should authorize him as an unofficial co-author of the book. In preparing the final draft, I have the fortune to have Kyu-Eun Kim and Min Hyeong Ki to provide a proofreading. Also, Sarah from Macmillan deserves my appreciation for contacting me, an utter stranger in East Asia, encouraging, and leading me to bravely decide my dissertation-level work to be published in the world’s academic field. Finally, I shall show my deepest gratitude for my family, who has patiently waited for my graduation and completion of my Ph.D. I had only one nephew when I started the research, but now I have four nieces and nephews in total; my parents’ frowns have deepened; and my grandmother passed away right before her 100th birthday. Family is the biggest keyword throughout this book. The macro role of family, as an invisible hand, which structures a state’s official system going beyond the micro level of taking care of incompetent family members in private area has been dealt with throughout my work. My personal acknowledgement on the mighty power of family as I aged upon has played an important role in deciding the theme of the book. In this sense, I dedicate this book to my family who has full-heartedly supported me throughout the process of writing the dissertation. Furthermore, I now have one more hope for the book to be consumed. It shall be my greater pleasure when Korean families would have a better understanding on Taiwan, the home country of my husband, my new family.

Contents

1 Introduction  1 2 Welfare Politics: Building Welfare Institutions   19 3 (De-)Familialization in Social Policy in East Asia   41 4 Historical Development of NHI in S. Korea: Why not Equal Protection for Female Workers’ Families?   73 5 Historical Development of NHI in Taiwan: De-familialization Path of Welfare Politics   107 6 Conclusion  139

References   147

Index   149

ix

Key Terms

and

Abbreviations

Dependents (Taiwan)/ (S. Korea) Bureau of National Health Insurance (Taiwan) Civil Servant Dependent Health Insurance Civil Servant Insurance (Taiwan) Department of Health, Executive Yuan (Taiwan) National Health Insurance Corporation (S. Korea) The National Health Insurance Statistics  (Taiwan)/ (S. Korea) Mainlanders Taiwanese Aboriginal Taiwanese Han Chinese ( ) Labor Insurance (Taiwan) Minnan ( ) Hakka ( ) Chinese Cultural Renaissance Summaries of Population and Housing Census in Taiwan-Fukien Area  (Taiwan) xi

xii  Key Terms and Abbreviations Department of Government Employees’ Insurance, Central Trust of China (Taiwan) Social Indicators (Taiwan) Annual Statistics on Human Resources ( ) (Taiwan) Bureau of Labor Insurance (Taiwan) KMT Kuomintang (Taiwan) DGBAS Directorate General of Budget, Accounting and Statistics, Executive Yuan (Taiwan) KOSIS Korea Statistical Information Service (S. Korea)

List of Figures

Fig. 1.1 Three phases of NHI development in S. Korea and Taiwan   13 Fig. 2.1 Four levels of institutional analysis in the new institutional economics  31 Fig. 3.1 Status of female’s participation in economic activity in S. Korea and Taiwan   51 Fig. 3.2 Scope of dependents in S. Korea and Taiwan   55 Fig. 3.3 Comparison of the premium calculation method in S. Korea and Taiwan’s NHIs   58 Fig. 3.4 Status of the dependent ratio of the employee and the self-employed insurance in S. Korea’s NHI   62 Fig. 4.1 Status of the insured and the dependents of the NHI of S. Korea (unit: 1000 persons)   77 Fig. 4.2 Expansion process of parents’ dependent entitlements   79 Fig. 4.3 The interplay of two forms of culture in shaping the NHI in S. Korea   88 Fig. 4.4 Causal model between institution and actor   101 Fig. 5.1 Social insurance scheme of Taiwan (before 1995)   108 Fig. 5.2 Ethnic segregation between the civil servants insurance and labor insurance   115 Fig. 6.1 Interaction between institution and actor and institutional changes   140

xiii

List of Tables

Table 3.1 Status of number of Korea’s NHI insured by category (unit: 1000 persons) Table 3.2 Categories of Taiwan’s NHI Table 3.3 Status of number of Taiwan’s NHI insured by category (unit: person, %) Table 3.4 Status of the dependent ratio in the NHI in S. Korea and Taiwan by year (unit: 1000 persons) Table 3.5 Average population per household and family in S. Korea and Taiwan (unit: person) Table 3.6 Status of dependents of the Korean NHI by kinship and year (units: persons) Table 3.7 Status of the dependent ratio of Taiwan’s NHI by categories Table 4.1 Types of households in S. Korea Table 4.2 Status of the insured of the NHI (employee insurance) by gender (unit: person) Table 5.1 Status of population coverages of the Civil Servant related insurances and the Labor Insurance in Taiwan (unit: %) Table 5.2 Status of the Taiwan’s family structure by ethnicity (unit: %) Table 5.3 Dependent ratio of the civil servant group Table 5.4 Status of coverage of the Civil Servant related insurances and Labor Insurance to the population (unit: %) Table 5.5 Status of number of dependents of the NHI of Taiwan (in 1995) (unit: 1000) Table 5.6 Average size of Taiwanese families (unit: %)

44 45 46 49 49 56 65 81 82 109 115 122 122 133 133 xv

CHAPTER 1

Introduction

Puzzle: Why Are/Aren’t We Families? This book starts from a personal curiosity that I happened to get from the trivial round of daily life. Like any graduate student, I had lived as an economically inactive person without a stable income, and therefore, did not pay any direct tax despite being over thirty. Fortunately, for students whose scope of activities were limited to college or home, there had been not many chances to realize what that shabby truth meant in life outside of school. Then, one day, I happened to fully realize what the economically unstable status of mine meant in Korea, the so-called “welfare state.” In the Korean welfare state, every Korean citizen is obliged to be insured by the medical insurance run by the state, that is, the National Health Insurance (hereafter, NHI). In turn, the citizens have to pay the insurance fee based on their income to the state. Then, what about economically inactive people like me, who do not have stable income and therefore cannot pay insurance fees? Fortunately, the Korea’s NHI system also recognizes such population as eligible for insurance. They can enjoy the medical benefits by depending on their family members who are insured under the NHI, that is to say, who pay the insurance fees. If there is one insured in a family, other family members can get a free ride on his/her eligibility. Moreover, economically inactive family members, regardless of their gender or age, can secure their medical welfare through their dependence on the economically active provider without taking a burden of financial contribution. This is how I could survive in the Korea’s welfare state without any © The Author(s) 2017 H.S. Wang, Familial Foundations of the Welfare State, DOI 10.1007/978-3-319-58712-7_1

1

2  H.S. Wang

contribution for a long time, since I reached adulthood. I had depended on my father, who had been a head of household as well as my provider, in order to enjoy the medical benefits from S. Korea’s NHI. More surprisingly, in Korea’s NHI, the number of free-riders like me occupies 42% of the total population that is covered by the insurance (as of 2015). One day, however, when I visited the hospital for minor ailments, I found out that I was enrolled as the dependent of my sister who had lived separately for more than 10 years since her marriage. It surprised me in two ways. What surprised me at first hand was that I was no longer enlisted as the dependent of my father. After he retired, he had been marked as an economically inactive person and lost his entitlement as a provider. Even though he still supports me informally, the formal institution abolished his status as a family provider based on his status in labor market. The fact that he cannot be my provider anymore and that he has reached the age of being a dependent, made me feel somewhat sad. Another surprise came from the generosity of the Korea’s NHI, which recognizes not only retired father but also incomeless unmarried sister as family dependents, even though they do not belong to one household. According to a Confucian saying, routinely cited but of the doubtful origin, “a married daughter is no better than a stranger,” or “female, once married, belongs to her husband’s family.” I was enrolled as a dependent of that stranger officially under the S. Korea’s NHI system, from which I reaffirmed the strong family affection. To me, the NHI is translated as the one and only official institution that recognizes me and my sister as one family. The curious observation motivated me to conduct the research, based on which this book has been developed. The NHI of S. Korea offers generous and abundant entitlements to a large scope of family members without charging them only because they are bounded under the name of a family: where does the specificity of NHI come from? Does it reflect the resilience of familialism in the Korean society in general? Can I witness the similar family-benevolent policies in other societies where the familial culture of the Confucian tradition still dominates? In what process has S. Korea established such a family-benevolent institution?

Why S. Korea and Taiwan? To verify the first germinal hypotheses on the uniqueness of Korea’s NHI, I turned to the nearby East Asian countries to look for a comparable case. I was lucky enough to find one case in Taiwan. The basic

1 INTRODUCTION 

3

settings of the NHIs in Taiwan and S. Korea share some commonalities: compulsory and universal social insurance programs based on family units, which encompass not only the insured but also their dependents (Son 2003; Gould et al. 2006; Lee et al. 2008; Lee 2012; Wang 2015). This is why S. Korea and Taiwan offer the empirical evidence based on which some scholars build the welfare models, the so-called “Confucian welfare state” (Jones 1993; Hong 1999), the “East Asian welfare model” (Goodman et al. 1998), or the “Patriarchal welfare state” (Pateman 2006[1988]). Moreover, Taiwan is equipped with other favorable conditions to be the counterpart of S. Korea. First, they have similarities in their economic maturity and development strategies. Comparative studies on welfare states should pay attention to different degrees of economic maturity in each country because welfare itself is a function of industrialization (Wilensky 1975). That’s why the industrialism still claims its validity. Comparing S. Korea and Taiwan can control the influence of those economic factors because take-off timing and the final result of the industrialization in two countries are quite similar (Shin and Chang 2003). Moreover, S. Korea and Taiwan have established a similar development model. Among four little dragons who achieved the economic growth throughout the post-Second World War period, S. Korea and Taiwan adhered to similar developmental strategies and patterns of industrialization (Thurbon 2001).1 The most distinctive commonality is the role of the state in designing and managing the catching-up system (Barette and Whyte 1982; Shin and Chang 2003; Davis 2004). The state’s heavy intervention in the market facilitates the development of authoritarianism as well as modern and well-functioning bureaucracies (Tang 2000, 64, 89).2 Concerning the relationship between the state and the market or the state and the society, it means that the states in S. Korea and Taiwan have exerted a high level of autonomy and capacity (Jung 2011). In addition, the military threat from Communist forces in the two countries explains how and why the authoritarian developmental states put forward a number of social initiatives in the first place. More importantly, the legacy of state intervention during the industrialization process paves the way for the state to intervene easily in the welfare as well. For example, in the West, governments that had intervened in the market with industrial policies during their development processes such as France or Germany still play a more interventionist role than governments that had adhered to liberal or laissez-faire strategy

4  H.S. Wang

such as the United States (Esping-Andersen 1990). In this regard, the similarity in the role of the state during the catching-up period in both countries can control the possibility that different industrialization strategies and historical backgrounds differentiate the role of the state in the development of welfare. The second reason is that they share the cultural background in common, especially, Confucian tradition. As a historical background, the two countries have been under the continued influence of China (Rubinstein 1999; Hahm 2003). Among these influences, the most fundamental one is the Confucian tradition. The Confucianism was not only the political ideology governing the international relationships around Imperial China but also an individual’s worldview or ethic. It prescribes people how to see the world around them and how to behave in their relationships with others (Hahm 2003). Compared to the Western philosophy that stressed the individuality, the most distinctive characteristic of Confucianism can be the importance bestowed upon interpersonal relationships and communities, especially family. Hence, in S. Korea and Taiwan, families have the utmost priority over each individual family member. In other words, the collective or public interests take precedence over the individual autonomy or freedom. Naturally, families, the most fundamental and primary group in society, have the absolute priority in every concern. To summarize, the commonalities that S. Korea and Taiwan share, such as economic development, industrialization processes, authoritarian regimes and democratization, cultural heritages and so on, offer the proper conditions to conduct a small-N comparison research study.

The Two NHI Systems, Similar but Different Considering the commonalities of S. Korea and Taiwan enlisted above, it seems to be quite natural that they would have built the similar familialistic NHI systems. The two societies both manifest familialism, which stemmed from the Confucian tradition. Not only that, they have gone through the similar modernization processes during the nation state building and economic development after the Second World War. Their familialistic welfare systems, which are witnessed in the two societies today, are a predictable outcome of their commonalities in historical legacies and the modernization path.

1 INTRODUCTION 

5

However, to complicate matters, I should face a salient contradiction that emerged early on in comparing the two cases. As Chap. 3 illustrates, even though S. Korea and Taiwan have built a seemingly similar familialistic welfare regime, Taiwan’s NHI is somewhat stingy with families, compared to S. Korea’s NHI. Taiwan’s NHI recognizes only limited scope of family members as legitimate dependents who can free ride on the system. The degrees of familialization of their NHI systems, which mean “the quality of social policies that enhance individuals’ reliance on the family and maximize individuals’ command of economic resources dependently upon familial or conjugal reciprocities,” vary greatly (Esping-Andersen 1999). Taiwan’s NHI shows a relatively lower degree of familialization than that of Korea. In an extreme example, it does not recognize even parents and children living under the same roof as one family. In this system, adult children, like me, regardless of their status in the labor market, should be insured independently from their family.

In Search of an Answer: Culture and Institutions The superficially similar but different-in-principle NHI systems of S. Korea and Taiwan pose the research question of this book. How did S. Korea build the welfare institution encompassing such a broad family relation? Why did Taiwan build the welfare institution that is stingy to families? How can we explain these institutional differences in the two NHIs? To account for the differences in welfare institutions, this book attests the two competing views on the causal relationship between culture and institutions. The first view assumes the differences in welfare institutions as originating from the different family cultures of the two societies. This assumption necessitates a priori the fundamental difference in family culture between the two countries. The second view interprets the differences as stemming from the different political and economic situations during the post-war period. From this view, the two societies, despite the similar cultural template of familialism or the same influence of Confucianism and taken-for-granted priority in families, had faced the different economic and political development paths, which led them to build idiosyncratic welfare institutions. Therefore, different familial norms inscribed in their welfare institutions are outcomes of the institutionalization process of their welfare systems under specific economic and political situations.

6  H.S. Wang

Culture Matter? The first hypothesis has been the conventional answer of the cultural determination theory, which postulates culture as the determinant variable. In this view, culture is defined as norms and values shared by all members of a society; considering the topic of the book, culture here can be specified as familialism or norms and values governing relationships among family members. It can be argued that the dominant family cultures in the two countries have contributed to making of such dissimilar welfare institutions. Following this logic, we can assume that the familialism in S. Korea is so resilient that all Koreans internalize the familialistic norms and values as taken-for-granted and have tried to apply them even in formal institutions; finally, not only NHI but also most of the formal institutions have been built embedded in this value system. Meanwhile, the Taiwanese culture has had a weak or narrow family norm, and thus the familialism is only applied in the private sphere and does not interfere with the realm of formal institutions. To attest the first of these contending hypotheses on the influence of culture, this book will examine and compare the dominant family cultures of the two societies at the time when their NHI systems were formulated and transformed. Even though this book partially depends on the cultural explanation, it does not deny that this frame has some limitations. First, it does not or need not to specify the concrete actors in the micro-level who convey such norms or values and build institutions based on them. They are treated as “cultural dopes” who are destined to accept these norms without resistance; in other words, they are presumed to be oversocialized (Granovetter 1985). However, the cultural force cannot operate on its own and therefore requires agents who mobilize and exercise it in the institution buildings. Secondly, considering its tendency that has treated culture just like a black box, it also ignores the possibility of other factors intervening or mediating the relationship between (family) culture and (welfare) institutions and thereby their presumed causal relationship between culture and institutions can have a tautological problem. The historical institutionalism stresses that the social causation is not always path dependent; it cannot be guaranteed that the same operative forces will generate the same results everywhere because such forces will be mediated by the contextual features of a given situation (Hall and Taylor 1996, 941). When

1 INTRODUCTION 

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applying this claim to the casual relationship between culture and welfare institutions, the fact that a specific family culture is dominant in a society is one thing; the fact that such a dominant culture could also exert its force in the political process of welfare institution building is another. This book considers welfare politics as a series of welfare institutions building processes. Through welfare politics, welfare institutions are created to govern the distribution of scarce resources among various actors. Like other institutional building processes, the problem is that it is not easy to derive social consensus on the principle of governance because actors are equipped with different and sometimes conflicting interests and preference as well as embedded in an idiosyncratic value system (Hall and Taylor 1996, 941). As the historical institutionalism suggests, the process of institutional creation is not always the social interaction of freely-contracting individuals or voluntary agreement by the relevant actors who expect gains from cooperation. Especially, welfare politics involve a political struggle over the principle regarding how to (re)distribute socially scarce resources. Inevitably, this process requires actors who actively participate in the welfare politics and try to build a specific welfare institution for some interests or motives by advocating and voicing a specific culture. Without such actors, informal norms or values cannot be institutionalized into formal welfare institutions. Therefore, this book analyzes the political processes in the welfare politics; which one among various family norms is selected and claimed, by whom and for what reasons?

Welfare Politics as the Institutionalization Process of Culture If what matters is not culture but the political process regarding institution building, then, we should correct the early questions. How could Korean families succeed to influence their state to build such a familybenevolent welfare institution through welfare politics? Meanwhile, why did Taiwanese families not demand (or fail to demand) the state to build the institution that protects their families? These questions require us to attest the second possibility that their dissimilar NHI systems could have been formed through the different institutionalization processes, despite their similar family traditions

8  H.S. Wang

or cultures. Therefore, this book compares the welfare politics around the NHI in each country and the process of how family norms and values are mobilized and practiced in welfare politics, with its focus on the interaction between actors and institutions. In this sense, this book intends to challenge the culturalism that has considered individuals as cultural dopes who passively internalize and practice norms. Rather, it highlights how strategically actors can choose and resist specific institutions according to the contexts and situation they face (Swidler 2001). This may sound like the actors are calculus or rational, aiming to maximize their material or psychological interests. But like a conventional wisdom, they have only bounded rationality (Simon 1957). Their rationality is bounded by given/prior institutions in two ways. First, institutions posit the specific incentive structure, based on which actors rationally calculate the economic or political opportunities as well as constraints and thereby make their choice of action. Secondly, institutions shape the interests that actors pursue or the preference they intend to realize. In this regard, their rationality itself is socially constituted. This research pays attention to the two levels of given institutions which could influence the rationality of individuals: welfare systems in the earlier stages and formal/informal institutions regarding family. First, it focuses on formal rules and designs inscribed by welfare institutions in the initial stages; they, as given institutions, impose not only material but also normative incentive structure on actors as well as structure their interests. Institutions militate in favor of some groups and against others. Therefore, institutions distribute power or resources unevenly across social groups by giving some groups of interests disproportionate access to the decision-making process. As such, the past line of policy conditions subsequent policy by encouraging societal forces to organize along some lines rather than others, to adopt particular identities, or to develop interests in policies that are costly to shift (Hall and Taylor 1996, 941). At the same time, various formal and informal institutions around families can influence individuals as well as governments. Family institutions vary from formal family norms propagated by the state’s social policy to informal family ideals shared only in subgroups as well as family reality as individuals’ lived experiences. This book elaborates how formal and informal family institutions can structure individuals’ behaviors in seeking their material and normative interests and the perception of interests per se.

1 INTRODUCTION 

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Too much focus on the importance of given institutional settings could fall into the trap of path dependence. Institutions are seen as relatively persistent features of the historical landscape and one of the central factors pushing the historical development along a set of path. Then, how can institutional changes be explained? Only through critical junctures such as an economic crisis or military conflicts? (Hall and Taylor 1996, 942) This book aims to explain institutional changes not only by relying on exogenous factors but also by highlighting the roles of actors in the political process. Through a political process, actors are to pursue their interests under the constraints structured by the institutions. Nevertheless, these constraints cannot bind actors’ choice of actions thoroughly (Swidler 2001). Actors do not necessarily accept constraints or internalize the moral or cognitive template provided by institutions as they are because they are not a cultural or judgmental “dope” (Garfinkel 1984, 68; Swidler 1986). Especially, when constraints operate as obstacles to the actors’ goals, they try to escape and circumvent those institutional constraints, or sometimes transform institutions per se. In particular, those who cannot maximize their interest under given institutional settings will enter into a resistance against those institutions and attempt to change them. In order to legitimize their resistance and claims, they reinvent and utilize an alternative cultural tool. In turn, those who favor those institutions also enter into the counter-movement and mobilize the existing culture under the name of tradition or customs. Strategies induced by actors in a given institutional setting may ossify over time into worldviews, which are propagated by formal organizations and ultimately shape even the self-images and basic preferences of the actors involved in them, to the degree that they are so conventional or taken-for-granted (Hall and Taylor 1996, 940). It implies that culture can be dependent variable, conditioned by the institutionalization process of culture or the political process of institution building, as the cultural constructivism notes. Culture is the outcome of welfare politics, in which actors and institutions interact. In this regard, culture is not something like destiny inherited from the past, but changing and reconstructed repeatedly through interaction between institutions and actors. This approach explains the origin of cultures, which is later considered and certified as deep-rooted tradition, and further, the social origin of the cultural diversity of our time.

10  H.S. Wang

What Motivates Actors? The importance of culture in welfare institution building further explains the motives of actors. In welfare politics, actors intend to maximize not just material well-being: they seek to define and express their identity in socially appropriate ways. Sociological institutionalism also stresses that institutional changes occur not just because of means-ends efficiency but in pursuit of social goals such as identities, legitimacy, or social appropriateness (Hall and Taylor 1996, 949). It implies that the most fundamental motive in human behaviors can be found in social, normative, or moral dimensions. Even when people pursue purely economic goals, they feel obliged to justify their behaviors morally, not to deviate from social appropriateness. Hence, the pursuit of economic goals is normally accompanied by that of noneconomic ones such as sociability, approval, status, and power (Granovetter 1992, 4). Economic action (like all action) is socially situated, and cannot be explained by economic motives alone. The fact that actors, through strategic choices of action, pursue not only material interest but also chase their motives in broader term implies that the mere changes in economic conditions (that is, economic incentive or disincentive structure embedded in formal institutions) do not automatically stimulate social changes. Rather, this book argues that material and economic interests can be secondary in explaining individual behavior as well as social changes (Zelizer 2005). This book will prove the fundamental motive of individual behaviors in the level of moral and normative needs of humans (Honneth 1996). Honneth (1996, 160), based on the fact that social conflicts occur when not only mere economic interests but also the implicit rules of mutual recognition are violated, highlights the moral dimension of social conflicts with the concept of “recognition struggle.” Following his claim, this book will explain institutional changes by relating them to “normative claims that are structurally inherent in mutual recognition relations” (Honneth 1996, 2). This book’s main goal is to explain the diversity of the East Asian welfare regime from the cultural perspectives. Most of the existing studies on the welfare state highlight formal variables in determining the development of the welfare state, such as industrialization (Wilensky 1975), power resource mobilization (Korpi 1983), or state’s welfare intervention (Orloff and Skocpol 1984). By explaining the welfare development

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solely from the perspectives of economic or political formalism (Geertz 1973, 5), they dismiss culture or norms’ role and therefore allow no room for cultural diversity. Even those who highlight the importance of culture or norms offer only vague relations between culture and institutions. They could not answer why the economic or political rationality does not lead to the convergence of welfare institutions in every society (Guillen 2001). The importance of familialism as culture is to go beyond these formal factors and bring families back in to explain the state welfare’s development as well as diversity.

Methods of Inquiries: Comparison, Research Period, Data collection This book aims to compare the introduction of the similar welfare institution in the two societies that share the socio-economic backgrounds in common, S. Korea and Taiwan. The first part of the cross-national comparison is intended to verify the commonalities and, more importantly, the major differences in the national health insurance systems in S. Korea and Taiwan, which is the main dependent variable to be explained. The comparative research, focused on the (de-)familialization effect of the two systems, demonstrates their welfare institutions are embedded in different family ideals, regarding the size and composition of family as well as the responsibilities and rights among family members. The second part of the book traces the origin of their idiosyncratic welfare systems neither from the idiosyncratic family cultures as traditional inheritance nor cultural legacy from the past. Rather, it articulates how their family realities have been created and diverged in the course of coping with their social and historical contexts. Therefore, the cases compared in the book are not just the two countries. It also compares the initial and later periods of welfare institution building of each country and historical changes in their characteristics. In sum, it compares the different time periods of each case. Through this withinthe-system comparison, it elucidates how institutions and actors interact through welfare politics from the two dimensions; how institutional settings in the initial stage conditioned the incentive structure, under which actors have to play the game as well as actors’ interests and preferences, and, in turn, how strategic choices of action by actors can lead to the institutional changes or, by contrast, constitute institutional inertia in the later stage.

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Research Period This book’s research period covers from the establishment of the first national insurances equipped with medical benefits in S. Korea and Taiwan, to their conversion to a compulsory insurance, which covered the whole population living in the country. In the case of S. Korea, the research covers from 1963, when the first medical insurance act was legislated, to 2000, when the National Health Insurance law was legislated and covered the whole population under one integrated scheme. In the Taiwanese case, it covers from the 1950s, when the Labor Insurance (in 1950) and the Civil Servants’ Insurance (in 1958) initiated to offer sickness benefits, to 1995, when they were integrated and developed to the National Health Insurance. In sum, the research compares S. Korea’s 37 years and Taiwan’s 45 years of the development history of medical insurances. The medical insurance of S. Korea and the Labor Insurance of Taiwan initiated in 1963 and 1950 respectively. In this initial stage, they were both the first social insurance with medical benefits and both were on a voluntary basis, targeting only specific groups. Though their insurances in this initial period are evaluated as ineffective and virtually dead letter, they have significance as they laid the institutional foundations for the later development of their medical welfare system. Later, their insurances developed into compulsory ones, though still targeting specific groups of wage earners: 1977 in S. Korea and 1958 in Taiwan. With the additional revisions, the medical insurance in S. Korea extended its coverage to the rural areas in 1988 and reached the stage that it encompassed almost all the population. The Labor Insurance of Taiwan extended its coverage to the private companies with more than 5 workers as to cover most of the wage earners in 1979. In the last stage, as with the launching of the National Health Insurance in 2000 in S. Korea and in 1995 in Taiwan, both developed into compulsory and universal health insurances. The development history of the two insurance systems can be divided into three phases: “initial institution building (voluntary/targeted)”— “institution expansion (compulsory/targeted)”—“institution integration (compulsory/universal).” Fig. 1.1 juxtaposes their different phases of the development process on a timeline. It affirms that their NHI systems have gone through a similar development path.

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Fig. 1.1  Three phases of NHI development in S. Korea and Taiwan

Data Collection First, the research collected the detailed information on the historical development of the two countries’ welfare institutions, targeting not only the NHI but also other official welfare institutions run by the state. Laws and regulations of each NHI can be collected relatively easily through each institution that manages the insurance system. The central administrative organizations of the two countries’ NHI are following: the “Bureau of National Health Insurance” ( ) under the Department of Health, Executive Yuan ( ) in Taiwan, and the “National Health Insurance Corporation” ( ) under the Ministry of Health and Welfare in S. Korea. These two authorities offer related laws and regulations. In addition, they annually publish The National Health Insurance Statistics ( ) in Taiwan and ( ) in S. Korea). All these materials and data can be collected through their websites. Moreover, their online database systems offer various statistics and surveys on their NHIs as well as other welfare programs.3 Next, the research collected data that show the changes in families of each country, regarding their structures, average size and functions during the designated research period. The research collected Korea’s population/household data from KOSIS (Korea Statistical Information Service) offered by the Korea’s national statistical office. In the case of Taiwan, the data after 1975 were drawn from Taiwan’s national statistical office, DGBAS (Directorate General of Budget, Accounting and Statistics, Executive Yuan: ), and the data

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before 1975 were collected from “Knowledge, Attitudes, and Practice of Contraception in Taiwan: Family and Fertility Survey” (Hereafter, KAP-Fertility). KAP-Fertility Survey has been conducted by Academia Sinica since 1965, targeting married Taiwanese women aged between 20 and 44. The survey reveals the targeted populations’ family relations, fertility, family planning, and family demographics. To collect the data in the level of actors in the welfare politics and fish out their interests and motives in the NHIs, this research went through daily newspapers of each country published during the designated research period. Of course, newspapers may provide limited data for the research to derive a thoroughly reliable analysis. However, as this book mainly focuses on the past events from 30 years ago, it is impossible to interview the government official, Ministry personnel, or the insured from that period. Nevertheless, newspapers convey various voices of the government and administrators, people, academic intellectuals, and professionals at that time directly and impartially.4 Nevertheless, as the analysis relies on the selected news articles that conveys a partial voice of a particular group on the specific historical phase, the result can risk over-generalization or sample bias. Therefore, it tries to take a balanced approach to the contested views of various groups who were for and against the welfare system. Based on the evidences collected from the newspaper articles on the NHIs, this book compares historical changes in family discourses in the welfare politics of the two societies. It scrutinizes how the insured, as individuals or families, responded to the NHIs. It focuses on how they voiced not only their family interests but also their own ideals of families or family realities to be recognized by the state’s formal welfare institutions. Plus, it also compares how the governments selected and propagated certain family ideal as a basic model for their NHIs and why they did so. Moreover, from a cultural aspect, it elaborates on the strategies and tools that were utilized by each group.

Outline of the Book Following this introductory chapter, Chap. 2 presents an analytical and theoretical framework based on which each chapter of the book is organized. By drawing on theories of welfare politics and policy, the framework offers an analytical tool to help organize and compare the empirical evidences from S. Korea and Taiwan. Especially, this chapter stresses the

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role of culture in the institutional buildings. Plus, it discusses how to analytically differentiate “family” as culture, actors, and institution and link each level to institutional changes of the welfare institutions. Chapter 3 presents the puzzle of various East Asian welfare regimes in detail, focusing on their (de-)familization effects. According to the existing welfare regime typology debates, S. Korea and Taiwan have been categorized as conservative welfare state regimes with low commodification, high stratification, and high familialization effects. These two cases have been often cited as references to exemplify familialism in the East Asian welfare regime. This chapter refutes this widely accepted consensus on East Asian welfare model, by comparing the NHI systems of S. Korea and Taiwan. It describes how the welfare institution defines the scope of family and how economic responsibilities and welfare rights should be shared/redistributed among family members. The comparison of the different familialization effects leads the readers to pay attention to the origins of their different welfare regimes. To trace these origins, Chaps. 4 and 5 go back to the initial stage of welfare politics and illuminate on the historical and empirical details of NHI in S. Korea and Taiwan. Chapter 4 is dedicated to explaining the S. Korea NHI, from the late 1970s, when the first NHI was launched, to the early 1990s, which is on the eve of the East Asian financial crisis. Intriguingly, the initial system established by the developmental state was based on a relatively narrow scope of family, that is, patrilineal stem family. Then, the core question is how the initial NHI has developed into today’s “gender-equity extended” family norms. It pays attention to the two actors who led the development—female workers and the developmental state—and illustrates how the female workers’ interests and the developmental state’s policy interests could have been interlocked during the rapid industrialization period. At the same time, it highlights that the two actors shared the goal but varied in motives. To interpret the female workers’ motives in their resistance, the chapter highlights their motives in terms of Honneth’s conception of recognition struggle. In the state’s side, it explains why the past government accepted their claims from the logic of the productivist welfare state, which is the other side of the same coin of the Korean developmental state. Chapter 5 is dedicated to explaining the Taiwanese NHI, from the early 1950s, when the first national insurances were launched to offer medical benefits for limited employees in private and public sectors, to 1995, when they were integrated to the universal NHI and expanded nation-wide.

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This chapter pays attention to the initial outlay of welfare institutions in the 1950s and highlights the fact that the initial welfare system targeted two unique ethnic groups separately: Mainlanders ( ) and Taiwanese ( ). The two ethnic groups were highly differentiated and segmented not only in welfare programs but also in politics, economies, culture, and especially family realities. This chapter scrutinizes how the basic family model manifested in the early welfare institution, which was designed on the basis of Mainlanders’ family reality, only 10% of the population, was adopted and developed to the universal NHI in 1995, which was established for everyone. In the process, it highlights how the specific features of the early institutional design functions as disincentive structure, which made Taiwanese families take it more rational to withdraw from the welfare politics around the NHI, and finally incurred the decoupling between family realities in the informal sector and welfare institutions in the formal sector. This will explain why the family recognition struggle had not been resilient in Taiwanese welfare politics, not like the Korean case. As a concluding chapter, Chap. 6 includes two parts. First, recalling the analytical framework suggested in Chap. 2, it brings pieces spread in Chaps. 4 and 5 together to complete the puzzle on the variety of East Asian welfare regimes and wrap all these things up. This chapter offers a set of theoretical propositions about how the three factors—historical legacies, institutional arrangements of welfare system, and diversity of family realities—contribute to the formation of their unique welfare regimes with different degrees of (de-)familialization. Second, focusing on the state, this chapter explains how the state’s policy interests in each country could be coupled or decoupled with the families from the historical perspective of the two authoritarian regimes and their long-term changes. It ends by discussing the recent changes in families in each society such as the increase of one-person household, low fertility, and aging and the rising demands for restructuring their NHIs to cope with these demographical changes or crisis.

Notes 1.  Meanwhile, other two little dragons (Singapore and Hong Kong) are said to have succeeded through the “complementing strategy” (Shin and Chang 2003). 2. It is another commonality that South Korea and Taiwan had maintained an authoritarian regime until the democratization in the late 1980s or the early 1990s (Wong 2004; Woo 2004).

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3. http://www.nhi.gov.tw and http://www.nhic.or.kr. 4. News articles were collected by using keyword search engines which each news site provides and news portal sites, by using keywords, “NHI,” “dependent,” and “family” in sequence.

References Barette, Richard, and Martin King Whyte. 1982. Dependency Theory and Taiwan: Analysis of a Deviant Case. American Journal of Sociology 87 (5): 1064–1089. Davis, Diane. 2004. Discipline and Development: Middle Class and Prosperity in East Asia and Latin America. Cambridge: Cambridge University Press. Esping-Andersen. 1990. The Three Worlds of Welfare Capitalism. Princeton, NJ: Princeton University Press. ———. 1999. Social Foundations of Postindustrial Economies. New York: Oxford University Press. Garfinkel, Harold. 1984. Studies in Ethnomethodology. Cambridge: Polity Press. Geertz, Clifford. 1973. Interpretation of Cultures: Selected Essays. New York: Basic Books. Goodman, Roger, Gordon White, and Huck-Ju Kwon (eds.). 1998. The East Asian Welfare Model: Welfare Orientalism and the State. London: Routledge. Gould, Robin, Naoki Ikegami, Michael D. Barr, Tung-liang Chiang, Derek Could, and Soonman Kwon. 2006. Advanced Asia’s Health Systems in Comparison. Health Policy 79 (2–3): 325–336. Granovetter, Mark S. 1985. Economic Action and Social Structure: The Problem of Embeddedness. American Journal of Sociology 91 (3): 481–510. Granovetter, Mark. 1992. Economic Institutions as Social Constructions: A Framework for Analysis. Acta Sociologica 35: 3–11. Guillen, Mauro F. 2001. The Limits of Convergence: Globalization and Organizational Change in Argentina, South Korea, and Spain. Princeton, NJ: Princeton University Press. Hahm, Chai Bong. 2003. Family Versus the Individual: The Politics of Marriage Laws in Korea. In Confucianism for the Modern World, ed. D. Bell and C.B. Hahm, 334–359. Cambridge: Cambridge University Press. Hall, Peter A., and Rosemary C.R. Taylor. 1996. Political Science and the Three New Institutionalisms. Political Studies 44: 936–957. Hong, Kyung-Zoon. 1999. Social Welfare Regime in Korea. Seoul: Nanam (In Korean). Honneth, Axel. 1996. The Struggle for Recognition: The Moral Grammar of Social Conflicts. Cambridge, MA: MIT Press. Jones, Catherine. 1993. The Pacific Challenge: Confucian Welfare State. In New Perspectives on the Welfare State in Europe, 198–217. London: Routledge.

18  H.S. Wang Jung, Jai Kwan. 2011. Popular Mobilization and Democratization: A Comparative Study of South Korea and Taiwan. Korea Observer 42 (3): 377–411. Korpi, Walter. 1983. The Democratic Class Struggle. In The Democratic Class Struggle, ed. W. Korpi, 7–25. London: Routledge and Kegan Paul. Lee, Yong-Gab. 2012. The Re-compositions of Family Members in the NHI. Health and Social Science 31: 22–54 (In Korean). Lee, Sang-Yi, Chang-Bae Chun, Yong-Gab Lee, and Nam Kyu Seo. 2008. The National Health Insurance System as One Type of New Typology: The Case of South Korea and Taiwan. Health Policy 85 (1): 105–113. Orloff, Ann Shola, and Theda Skocpol. 1984. Why Not Equal Protection? Explaining the Politics of Public Social Spending in Britain, 1900–1911, and the United States, 1880s–1920. American Sociological Review 49 (6): 726–750. Pateman, Carole. 2006[1988]. The Patriarchal Welfare State. In The Welfare State Reader, eds. C. Pierson and F. G. Castles, 134–151. Cambridge, UK: Polity Press.  Rubinstein, Murray A. (ed.). 1999. Taiwan: A New History. New York: M. E. Sharpe. Shin, Jang-Sup, and Ha-Joon Chang. 2003. Restructuring Korea Inc. London, New York: Routledge Curzon. Simon, Herbert. 1957. Administrative Behavior. New York: Macmillan. Son, Annette H.K. 2003. The Extension of Entitlement to Health Insurance in South Korea and Taiwan: A Historical Institutional Approach. Economic and Industrial Democracy 24 (3): 455–478. Swidler, Ann. 2001. Talk of Love: How Culture Matters. Chicago: The University of Chicago Press. Swidler, Ann. 1986. Culture in Action: Symbols and Strategies. American Sociological Review 51: 273–286. Tang, Kwong-leung. 2000. Social Welfare Development in East Asia. New York: Palgrave. Thurbon, Elizabeth. 2001. Two Paths to Financial Liberalization: South Korea and Taiwan. The Pacific Review 14 (2): 241–267. Wang, Hye Suk. 2015. Familialisation Effects of the State Welfare: Focused on the National Health Insurances in S. Korea and Taiwan. Asia Pacific Journal of Social Work and Development 25 (1): 29–41. Wilensky, Harold. 1975. The Welfare State and Equality: Structural and Ideological Roots of Public Expenditures. Berkeley: University of California Press. Wong, Joseph. 2004. Healthy Democracies: Welfare Politics in Taiwan and South Korea. Cornell: Cornell University Press. Woo, Myungsook. 2004. The Politics of Social Welfare Policy in South Korea: Growth and Citizenship. Lanham, MD: UPA. Zelizer, Viviana. 2005. The Purchase of Intimacy. New Jersey: Princenton University Press.

CHAPTER 2

Welfare Politics: Building Welfare Institutions

The first generation of the welfare debates has focused on articulating the main drive which leads the development of the welfare state. They mainly exploit political or economic variables, such as industrialization (Wilensky and Lebaux 1958; Wilensky 1975), power resources mobilization of labor class (Korpi 1983; Esping-Andersen 1985), or roles of states (Flora and Alber 1981; Skocpol and Amenta 1986; Orloff and Skocpol 1984). Political or economic factors mentioned above do influence welfare development. However, their explanatory capacity is limited to the quantitative expansion of the welfare state and cannot confront the historical variety or detailed historiography of the welfare states (Esping-Andersen 1990, 13–17, 106–107). Due to this foible, the second generation, from the qualitative dimension, mainly explores the diversity of the welfare states and opens up a new field of cross-national comparison on the welfare regimes, that is, “welfare regime typology business” (Abrahamson 1999). The welfare regime refers to “the combined, inter-dependent way in which welfare is produced and allocated between state, market, and family” (Esping-Andersen 1999, 34). That is to say, the welfare regime can be identified with its distinct welfare mixture of state, market, and family. Since Esping-Andersen’s ambitious works in 1990 and 1999, researchers have tried to identify the distinct welfare mix of one country or a specific region. Their comparative research outcomes have served not only as snapshots for the cross-national variance in welfare regimes of capitalist © The Author(s) 2017 H.S. Wang, Familial Foundations of the Welfare State, DOI 10.1007/978-3-319-58712-7_2

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societies but also as springboards for the historical variance in welfare mix of a specific country, from diachronic and synchronic perspectives. It would be a waste of pages to summarize all the existing literatures or compare their perspectives on the welfare states. Hence, this chapter limits its range of discussion to the diversity of the welfare regimes from cultural perspectives. In the earlier chapter, I presented the puzzle of the variant welfare regime in Korea and Taiwan in terms of the relationship between the family and the state—why Korea has a highly familialistic welfare institutions, whereas Taiwan has welfare institutions that are stingy to families. It entails the core questions of the first and second generations of welfare debates regarding the diversity of welfare regimes and the determinant factor of such outcomes: how distinct the welfare institutions of the two countries are and why. In searching for answers to this research question, this chapter first discusses how existing scholarship has approached and explained the welfare regimes and welfare politics. This chapter discusses the two core concepts, “de-commodification” and “de-familialization,” based on which a library of welfare regime studies has advanced and pinpoints the basic tenets of welfare regime typology debates. The first aim of this chapter is to show that the existing political economy approach fails in situating the family properly in the welfare development or the welfare regime. This failure stems from the cultural poverty of the approach; it fails to conceptualize family as a cultural entity. The second purpose is to underscore the importance of institutions, to usher a more meaningful understanding of the origins and processes of diverse welfare politics in East Asia. Welfare politics is a series of processes, in and through which formal institutions and principles governing the redistribution of welfare goods or services are created and drawn. The discussion explores the classical problem on how institutions originate and change, from cultural and institutional perspectives, and the chapter will offer the framework for understanding and comparing the welfare institutional building and changing processes of S. Korea and Taiwan. The central contention of the discussion is what influences welfare institution building. This research asserts the importance of institutional legacies, especially welfare institutions in earlier periods, in establishing the incentive structure and thereby structuring individuals’ choice of actions. As such, the authoritarian legacies and the specific configurations of earlier welfare institutions in S. Korea and Taiwan critically shaped individuals’ mode of interest articulation and their achievements in welfare politics.

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The third purpose of the chapter is to explain the institutional changes from actor’s roles in welfare politics by highlighting their motives. Institution-building processes have been explained mainly from economic interests of individuals. Although economic-structural and organizational characteristics of the given welfare institutional arrangements structure the individuals’ choice of action, what motivates individuals’ actions is not only economic incentive and material interests but also moral and normative motives given from cultural and social environments. Therefore, this chapter will offer the framework to synthesize the influences of not only efficiency but also historical legacy and social value and to analyze the mutual influences between individual actors and institutions, in order to understand the divergence of welfare politics and its outcomes.

De-commodification and De-familialization, Revisited The welfare regime refers to “the combined, inter-dependent way in which welfare is produced and allocated between state, market, and family” (Esping-Andersen 1999, 34). Based on the examination and comparison on social policies of 18 OECD countries, Esping-Andersen proposes the three distinct welfare regimes: liberal, conservative, and social-democratic welfare regimes. Since his welfare states typology, many research studies have concentrated their efforts on conducting crossnational or cross-regional comparative research studies and classifying them into one of his welfare regime types. The aim of this book is not to compare the welfare regimes of S. Korea and Taiwan. Instead, it heads our attention to his core concepts, de-commodification, and de-familialization. First, focused on the welfare state and market nexus, his first work in 1990 estimates how the welfare state plays against market, on the basis of the “de-commodification.” De-commodification refers to “the degree to which individuals or families can uphold a socially acceptable standard of living independently of market participation (Esping-Andersen 1990, 37)”. And in his later work in 1999, adding the dimension of the welfare state and family nexus, Esping-Andersen again estimates how the welfare state plays against families, on the basis of “de-familialization.” Among the three axes of welfare mix, Esping-Andersen’s interest lies in the welfare state’s role in the welfare regime. His typology and concepts got critics as much as attention. The first attack, related to the de-commodification, was that his analysis was

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centered on the relationship between the state and the (labor) market (Abrahamson 1999, 409–411; Ditch et al. 1998). They criticize that his typology fails in integrating the civil society, especially roles of family or networks in the informal dimension and does not pay attention to the gender issue. Such critics were most aggressively raised by the feminist camp. They insist that the political economy approach to the welfare regime, including Esping-Andersen’s works as an exemplar, does not take the gendered nature of welfare states or social policies into account; this approach does not acknowledge that the de-commodification of the welfare state has the importance only to the wage earners in the labor market, that is, the male breadwinners. The Western states have developed the welfare institutions of “male breadwinner model,” benefitting mainly males who belong to the formal labor market. They assume that the male head of the household would be paid a family wage, sufficient to support his children and wife and mother who performed domestic labor without payment (Fraser 2000, 1). The fact that the gendered division of labor between “male=bread-winner” and “female=dependent/caregiver” inside families and the labor market is inscribed in social policies, showing that the family-related eligibility targeted for family dependents outside the labor market is socially structured. It implies that even though social policies intend to de-commodify, that is, to relieve the commodity status of labor, their effect can be realized only partially; the de-commodification of social policies can be effective only to male laborers, leaving females commodified or pre-commodified. Moreover, they argue that the social policies themselves can reinforce the inequality between men and women in the labor market as well as within a family. From this perspective, the welfare state itself produces social stratification as well as gender stratification (Esping-Andersen 1999; Sainsbury 2001). Nevertheless, Esping-Andersen applied the decommodification under conceptualizing women based on an undifferentiated status of citizens, and thereby neglected the female’s complex role as “needs-bearing clients and rights-bearing consumers of service, and political citizens” (Fraser 2000). The feminist critics on the de-commodification have two implications. First, how much de-commodifying potentials social policies do have is one thing, and how much such policies can de-commodify the welfare regime is another. Secondly, the degree to which one welfare regime is de-commodified cannot be simply reduced to the de-commodifying

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potential of the social policies (Esping-Andersen 1999, 47): No matter how high the commodifying potential of a social policy is, as the historical institutionalism argues, the same potential does not always generate the same results because “effects of such policies will be mediated by the contextual features of a given situation often inherited from the past” (Hall and Taylor 1996, 941). Such critics explain why Esping-Andersen (1999) adds the “de-familialization” of the welfare states to catch the relationship between the state and families in his later work. In his terminology, “de-familialization” is the effect or potential of “policies that lessen individuals’ reliance on the family” and that maximize individuals’ command of economic resources independently of familial or conjugal reciprocities (EspingAndersen 1999, 45; Lister 2000). According to Esping-Andersen (1999, 45), “familialism” has two following significances: familialism is used to denote (1) “pro-family” politics in a Christian conservative effort to restore traditional family values, and (2) in Scandinavia, the women-friendly welfare state, that is, an active policy committed to lessening the caring burdens of the family. Using the first definition, he concludes that “a familialistic welfare regime is one that assigns a maximum of welfare obligations to the household” based on the principle that families take the primary responsibility in offering welfare services to their members in need, and that the state should not intervene in the family’s welfare function because it could hamper the self-help tradition or ideology. He conceptualizes the “de-familialization” of the welfare state by its role in lessening individual’s reliance on families for welfare needs by absorbing the caring burdens of the family. Therefore, the welfare state reacts therefore against the family with its “de-familialization” as it reacts against the market with its “de-commodification.” Between the two terminologies, his description of the familialistic characters of the East Asian welfare regime is closer to the first meaning. Especially, the familialistic characters of social policies in the regions offer the solid ground, based on which he categorizes East Asia to the conservative welfare regime. His two versions of familialism imply that Esping-Andersen’s welfare mix is intrinsically tied to the implicit presupposition on the zerosum relationship between a state and a family or between a state and a market. The aim of his work is to identify the welfare regime typology by discerning the different combination of welfare mix among

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“state-market-family” by weighing the relative combination ratio that each provider makes in welfare responsibilities. And the explicit purpose of the welfare state is to lessen individuals’ reliance on market or family. In other words, the main task of the welfare state is to crowd out the market as well as families of welfare mix. To exemplify the familialistic welfare regime that assigns a maximum of welfare obligations to the household, he evinces a highly familialistic nature of the conservative welfare state with examples of legal prescription that parents (or children) should be responsible for their children (or parents) in case of need. In this regime, social assistance is granted only to individuals whose parents or adult children fail to support them. In sum, “the more familialistic the welfare state, the less generous are family benefits” (Esping-Andersen 1999, 83). Inversely, he defines the “de-familialization” as the effect or potential of the “policies that maximize individuals command of economic resources independently of familial or conjugal reciprocities” (Esping-Andersen 1999, 45): the more the welfare state (absorbs caring responsibilities), the less familialism (Esping-Andersen 1999, 67). In his model, it is presumed that the state and families are vying for individuals’ welfare. The first problem in his dealing way of familialism is witnessed in measuring the de-familialization through the welfare state. It is estimated by the government’s role in welfare production and distribution (EspingAndersen 1999, 52), with operational indices such as (1) overall servicing commitment (nonhealth family service expenditure as a percentage of GDP), (2) overall commitment to subsidizing child families (the combined value of family allowances and tax deductions), (3) the diffusion of public child care (daycare for children less than 3 years), (4) the supply of care to the aged (percentage of aged 65+ receiving home-help services (Esping-Andersen 1999, 61). His indices are focused on measuring the spending of the welfare state and its population coverage. However, we cannot assume that all spending equally counts (EspingAndersen 1990, 19). The point is not the spending per se, but its quality and contents. Even though the states spend the large share for the benefits to families with an aim for de-familialization, their outcomes could vary according to the way in which such spending is distributed as planned; it could set individuals free from family relationship in securing their welfare or inadvertently maximize individuals’ reliance on family. Therefore, the de-familialization of the welfare regime should be measured not by the spending of a welfare state but by the contents of its programs.

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This is why this book conceptually and analytically differentiates the de-familialization of the welfare regime and the de-familialization effect of the welfare state. The former can be confirmed by the quantitative proportion, which family or state occupies in supplying care service. Meanwhile, the latter refers to welfare state’s capacity or potential of de-familialization, which can be estimated from institutional designs of social policies such as how they stipulate the individual or familial entitlement. Especially, to estimate the latter, this book pays attention to the conditions of eligibility: whether the welfare state’s entitlement is based on the individualized and universal entitlement or the status within the family as caregiver or care-receiver.

East Asian Welfare Regime and Familialism Esping-Andersen’s assumption on the zero-sum relationship between state and family is also reflected in his way of conceptualizing the two meanings of familialistic social policies. The first meaning of familialistic welfare is manifested in the liberal welfare regime, which maximizes the role of families and minimizes the role of states so that it is constrained to subsidiary intervention. The second meaning of familialistic welfare is manifested in the social democratic welfare regime in which the state absorbs the family’s burden in care services, therefore minimizes the role of family. The two familialistic models are treated as if they were different models based on contrasting principles, existing in separate continents. However, in the real world of welfare capitalism, the two lines of family policies, based on the two principles of family responsibilities and state’s intervention, coexist not as a deviant case but as a welfare regime, especially in the emerging welfare states in the East Asia. In his welfare regime typology, the East Asian welfare state, though limited to the observation on Japanese cases, belongs to the conservative type that develops social policies of a fairly high degree of de-commodification with the blend of strong corporatist traits, status segmentation, and familialism (Esping-Andersen 1999, 81). Also, the Confucianism, prevalent in East Asia including Japan, playing the role of functional equivalence as the Catholic in the Western Europe, has contributed to the establishment of the conservative characters of their welfare regimes. Ironically, stressing the first meaning of “familialism” also appears in some studies which challenge the typology focused on Western state welfare and try to construct East Asia as a distinct welfare regime (Ku

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1997; Aspalter 2002; Kwon 2004): “Confucian welfare state” (Jones 1993; Hong 1999), “East Asian welfare model” (Goodman et al. 1998), “Patriarchal welfare state” (Pateman 2006 [1988]), “Developmental welfare state” (Kwon 2004), and so on. All these terms are invented to illuminate unique and distinct features of the East Asian welfare regime, which cannot be compared to the Western cases. In their debates, the region’s unique characteristics such as stress on economization rather than redistribution, “anti-welfarism,” and “the roles of family” are also affirmed as the elements of a unique model that differentiates from the Western typology (Goodman et al. 1998; Chan 2003). This model can be interpreted as another expression for “household economy” that presupposes the traditional, Confucian, and extended families taking the role of offering welfare services to individuals by encompassing them in the kinship networks. They insist that such roles of families persist despite the advent of modern welfare state or hamper the establishment and development of the welfare state. This shows that the familialism in the East Asian welfare model debates also denotes the first meaning that assigns a maximum of welfare obligations to the household and assumes the underdevelopment of welfare states. However, regarding the importance of family, the East Asian welfare regime shows a unique nature which does not fit to the typology derived from the Western experiences (Walker and Wong 2005). In the context of East Asia, both the meanings of familialism can be witnessed simultaneously. Familialism in the East Asian welfare regime debates can be interpreted in two ways based upon the usages of the terms. The first interpretation proposes that in the informal sector, families offer welfare goods and services to their family members in need (Chang 1997; Holliday 2000; Lew et al. 2011; Boucher 2014). The second interpretation claims that welfare institutions in the formal sector, be it state or market, have been constituted based on a family model (O’Connor 1993; Lister 2000; Fraser 2000). The first interpretation is consonant with the first meaning of the familialistic regime of Esping-Andersen, epitomizing apparently welfare laggards or the residual welfare state that stresses the obligation of family in taking care of their members. However, in the second interpretation, the familialistic welfare regime develops the social policies based on the family model, which assumes the gendered division of domestic care services as well as the intergenerational reciprocity between caregiver generation and care-receiver generation. In this model, family is the locus of reproducing, caring,

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and educating children as well as caring the old. The social policies are centered to helping families perform the function continuously without failure. Therefore, abundant privileges are given to the caregiver generation regardless of caregiver’s gender or status in labor market. In the care-receiver’s side, in order to access the state’s welfare services, it costs less to rely on one’s dependent status in family such as the relationship with wage-earner of household and intergenerational relationship than to claim the individual eligibility. Likewise, abundant benefits are given to households with more dependents in priority in the form of free of contribution or tax deduction. Meanwhile single or married couples without any responsibility in caring children and the old aged is disadvantaged. In this model, it is hard to draw a line analytically between the state and family. The fact is that family and state are so interlocked that it is impossible to separate how much proportion of the state or family contributes to individuals’ welfare services. In this regime, the state–family relationship is not a zero-sum; rather, the more familialistic the welfare state, the more generous the family benefits. This book aims to extend the debates on the de-familialized welfare state, encompassing not only gender relationship but also intergenerational relationship between caregiver and care-receiver. In the post-industrial capitalist societies, the risks are not only entailed in the gender-segregated labor market but also the instability of labor market itself. Not only female as a caregiver but also a dependent as a care-receiver (children and parents), who are perpetually or temporarily excluded from the labor market as well as family, are at risks now. As female’s independence necessitates “de-familializing” their caregiving obligation, dependents also need to ‘de-familialize’ their welfare services free from fragile and capricious institutions of family: De-familialization is not the prerogatives of female.

Culture Matters? Another problem is that Esping-Andersen assumes that the different welfare regimes could be the function of the welfare state’s intervention through social policies of de-commodification and de-familialization. But not always. The degree to which the welfare regime is de-familialized can be the outcome of state’ intervention or nonintervention. Or, it could be the influence of other factors than welfare states. Nevertheless, in his logic, the independent variable is simply assumed to be the state’s roles.

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In line with this, some critics have tried to find the origin of diverse welfare regimes from a cultural perspective, and even to construct East Asia as a distinct welfare regime (Ku 1997; Holliday 2000; Aspalter 2002; Kwon 2004). Firstly, Goodman and Peng (1996, 195), based on analysis of social policies in Japan, S. Korea, and Taiwan, fleshed out the characteristics of East Asian welfare as the “conservative social welfare state.” They argue that the three societies draw on the common “language of Confucianism,” which stresses “respect for seniors, filial piety, paternal benevolence, the group before the individual, conflict avoidance, loyalty, dutifulness, lack of complacency, striving for learning, entrepreneurship and meritocracy.” This language has been powerfully utilized in debates on the social welfare system stressing economization rather than redistribution, anti-welfarism, and the roles of family. Some emphasize the importance of Confucianism as cultural resources shared in East Asian societies and suggest the “Confucian welfare state” model (Jones 1993; Hong 1999). Based on the analysis of social welfare systems in S. Korea, Hong Kong, Singapore, and Taiwan, Jones (1993, 214) points out that these Confucian welfare states are characterized by the “conservative corporatism without (Western-style) worker participation, subsidiary without the Church, solidarity without equality, and laissez-faire without libertarianism.” This model can be interpreted as the “household economy” welfare state that presupposes the traditional, Confucian extended families. All these studies demand the necessity to consider family institutions or family culture in debates on the welfare state in the historical and cultural context of the East Asian familialism. However, it is not easy to introduce families into welfare state debates. First of all, we have to settle down on how to define family. Especially, in the East Asian context, family has various layers of meanings. First, families are “collective actors” grounded on unique perception and behavior logic. Second, they are “institutions” that lead production, distribution, and consumption based on unique modus operandi. Finally, they also function as the “adaptation mechanism” that assists the social process of governance, control, resistance, and negotiation in which various individuals and state participate (Chang 1997). The multilayered meanings of families in the East Asian context imply that families should be treated as cultural entities rather than objective or material entities. If we conceptualize family as a cultural entity, the debate becomes even more complicated. The difficulty condenses into the problem of addressing how culture, abstract and obscure, influence the specific and

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concrete welfare institutions. It inevitably requires the explanation on the complicated mechanism that mediates the relationship between culture and institution. Nevertheless, most of the existing studies only suggest a simple correlation or affinity between the existence of certain values and specific welfare institutions. They usually compare the national values and relate their differences to characteristics and patterns of social policies in modern democratic capitalism societies (Rimlinger 1971, 62, 91; Coughlin 1980). However, the similar values can be crystalized into the two polarized policy outcomes as it is witnessed in the two drastically different familialistic policies of Europe and Scandinavia. It implies that the institutional difference cannot be simply reduced to culture. Therefore, they cannot explain the casual mechanism through which values or cultural orientations are crystalized into specific welfare institutions. Moreover, they conceptualize values or cultures as something analytically vague, obscure, and quite static. Due to these shortcomings, they fail to grasp the historical dynamics in welfare institutions and their changes, and eventually become trapped in cultural determinism (Brooks and Manza 2006). One should note that culture in a society is neither homogenous nor continuous. The existence of various cultures in a society indicates an incoherent and fragmented nature of culture (Swidler 2001, 6; Chan 2009, 275). Therefore, for a specific culture to be dominant in a society, it has to involve a political process in a form of cultural struggles between one group that conveys a specific value and culture and the other group that supports the alternative value and culture (Wang and Choi 2012). Moreover, the process through which such values and cultures are crystalized into specific policies or institutions, that is, the “institutionalization of culture” is a problem that belongs to a totally different dimension. This requires the conflicts and negotiation among various actors and between actors and state, i.e., politics.

Cultures Behind the Institutional Creation and Changes Based on the theoretical concerns discussed in the previous section, it can be concluded that we need a re-conceptualization of culture in order to explain the institutional changes that are brought about by the multilayered variables surrounding families. We need a concept of culture that acknowledges the possibility of changes and the variety of institutions. In

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particular, a new concept should recognize the autonomy of actors in the institutionalization process of culture, which produces cultural diversity. Here, noteworthy are the two different conceptions of culture. Swidler (2001) and Chan (2009) point out that there are two different paradigms in defining cultures in cultural sociology. The first meaning of culture, following the Weberian and Parsonian tradition, refers to a subjective and coherent meaning system shared by all members in a society such as belief, norms, values, or ideology (Alexander 1990; Alexander and Smith 1993). This kind of culture, that is, a de facto social structure, means social forces that lead individuals to act and think in a particular way (Swedberg 1994, 255). This classical conception of culture cannot explain why people who share the same cultural values and face the same structural constraints differ in their actions. Instead, other scholars insist that culture is not so much a set of shared meanings that propels human actions in a coherent and homogenous way, than a grab-bag of odds and ends or more exactly “repertoire” or “tool-kits” from which individual actors construct their “strategies of action” or “repertoire of strategies” to solve various kinds of problems (Smelser 1992; Swidler 2001, 7; Chan 2009, 273). Their re-conceptualization of culture as “tool-kits” implies that people select among parts of culture (tradition, norms, rituals, symbols, and so on), picking up and putting aside cultural resources for practical uses. This concept of culture can overcome the problem that the existing cultural analysis have faced in explaining changes of culture and integrating actors and institutions into their analytical frame. Plus, the emphasis on actor’s voluntary and autonomous choice of actions can contribute to explaining the cultural diversity and changes. The tool-kit concept of culture does not necessarily entail denying the importance of the first meaning of culture. Regardless, actors have to play in a broad field of cultures which existing institutions have framed. It is the cultural context that provides tool-kits which they are to utilize and mobilize. In this sense, actors are embedded in the first meaning of culture. Nevertheless, actors do not necessarily accept given institutional constraints (Swidler 2001). Actors, especially those who cannot maximize their interest under institutional constraints, start to enter into a resistance against those institutions. In order to legitimize their resistance and claims morally, they reinvent and utilize an alternative culture. In turn, those who favor those institutions also enter into the counter-movement and mobilize the existing culture under the name of tradition or customs. As a result, a new

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culture or custom is created, or an existing culture is reinvented and reinforced. Thus, culture is not predestined automatically from tradition in the past, but consistently constructed and reconstructed (Geertz 1973). Then, how can we explain institutional changes with the two concepts of culture? If we apply the institutional economics to the two concepts of culture, it becomes easier to understand. It helps us to analytically grasp how and which level of culture operates in the serial process of institutional changes. Williamson (2000), criticizing that the existing debates and analysis done by the new institutional economics have dealt with institutions without exact conceptualization and differentiation, suggests four levels of institutional analysis: social embeddedness, institutional environment, (organizational) governance, and individual alignment. Figure 2.1 summarizes and visualizes four levels of the institutions analysis. The top level is the “social embeddedness” level (L1). This is where the norms, customs, mores, traditions, and religion are located. Level 1 is considered as given, and institutions at this level change very slowly (Geertz 1973). Many of these informal institutions have mainly spontaneous origins, which means that individual actors’ deliberative choice of a calculative kind is minimally implicated. The Level 1 institutions are “adopted and thereafter display a great deal of inertia—some because they

informal institutions, customs, traditions, norms, religion

L1

Social Embeddedness

L2

Institutional Environment

formal rules of the game -esp. property (polity, judiciary, bureaucracy)

Paternal states, Familial welfare regime

L3

Organizational Governance

play of the game -esp. contract (aligning governance structures transactions)

The NHI’s dependent system

L4

Individual Alignment

resource allocation and employment (Prices and quantities: incentive alignment)

Familialism

Cultures as shared values and norms

Cultures as Tool-kits

Welfare politics (interaction between actors and state)

Fig. 2.1  Four levels of institutional analysis in the new institutional economics. Source Williamson 2000, 597

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are functional (as with conventions); others take on a symbolic value with a coterie of true believers; many are pervasively linked with complementary institutions (formal and informal), etc.” (Williamson 2000, 597). Among these complementary institutions, formal ones constitute the second level. The second level is referred to as the “institutional environment,” (L2) which includes formal institutions such as the executive, legislative, judicial, and bureaucratic functions of government as well as the property rights and of contract laws. The institutions of L2 function as the “first order economizing,” that is, “getting the formal rules of the game right.” They are partly “the products of evolutionary processes, but design opportunities are also posed (Williamson 2000, 598)”. Such formal rules shape the incentive structure of organizations and actors in the third level of “organizational governance” (L3), which affects the resource allocation among actors in the next level of “individual alignment” (L4). Level 4 is the terrain in which individual actors interpret the incentive structure posed by the institutional environments (L3), choose their action to maximize their interests based on the calculation of the incentive structure, and align their interests with others’ in the process. This level 4 is a realm of microscopic and calculative rationality of the individuals, but due to the institutional constraints from the upper levels, this rationality is fundamentally bounded (Williamson 1988). This alignment process includes interaction between institution and individual actors as well as strategic interaction among actors who have various interests and motives, not only material but also moral, normative and social. If connecting the institutional view and the cultural view, the first meaning of culture belongs to the level of social embeddedness (L1): this level provides the cultural context, that is, a tool–kit which are full of various values, norms, tradition, and customs for actors in the lower levels. L2, L3, and L4 can be shaped differently, depending on the parts of tools that are appropriated, mobilized, and linked to experience by actors. Strategic mobilization and appropriation of cultural resources, that is, the second meaning of culture operates broadly in the L2, L3, and L4. Institutionalist’s distinction of cultures can be applied to the topic of this book. Cultural or behavioral orientation of familialism belongs to L1, whereas specific family norms belong to the L2 of the institutional environment. Familialism refers to cultural, normative, or behavioral orientation which prioritizes family over other values, while family norms are related to preference or idealization of a certain type of families. It is undeniable that familialism has been the deeply rooted cultural orientation in Korean and Taiwanese society. However, the idealized family norms varied over

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time. When the initial welfare institutions, including the NHI, launched in the two societies, paternal family norm was in force: this norm was pervasively linked with complementary institutions in the L2, such as the patrilineal family-related law which authorized the superior status of father and son in a household, labor market and industrial policy which favored male labor force, or welfare institutions which protected only families of the male bread-winner model. Under such institutional arrangements (L2)’ influence, the specific organizational governance, that is, the economic incentive and disincentive structures had been formulated and designed in L3. For example, the wages between males and females were manipulated disportionately in order to push males into the labor market while letting females stay at home and carry out domestic services. The dependent systems under the NHI, which set the rules in distributing the medical services and demanding the different insurance fees among family members, also belong to L3. Individuals were to seek their interests within this institution, even if the institution goaded them to modify their interest and confirm to its rules of games. However, those who could not secure or maximize their interest under the given incentive structure, would enter into resistance to the institution of L3. In their trials for adoption and circumvention or resistance and changes, actors would draw on alternative cultural tools from L1 or L2 in order to circumvent cultural barriers that the institution in L3 has set.

Recognition Struggles in the Welfare Politics Changes in the institutions and the actors’ motives have been explained mainly from the two dichotomized approaches: either a bottom–up approach focusing on individual actors’ economically rational calculation or a top–down approach stressing the influence of abstract culture or norm. Their contrasting orientation can be summarized as “under-socialized” and “over-socialized” (Granovetter 1985). This book, rather than displacing economic perspectives with culture one or vice versa, aims to bring together the two perspectives to explain changes in institutions and the actors’ motives. Linking the economic analysis and the cultural analysis can compensate the shortcomings of the two dichotomized perspectives on the institutional changes. In the process, it will argue that the interaction between the strategic and autonomous utilization of culture by actors and the play of abstract culture result in institutional changes. This approach will help articulate the multidimensionality of actors’ motives behind institutional changes and the complex net of meanings of their actions in which economic, normative, or moral orientations are interwoven together.

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In particular, this book tries to conceptualize cultural tools or repertoires that actors strategically utilized and mobilized from a broad sets of tool-kits as family identity and family recognition struggle. Honneth (1996, 160), based on the fact that social conflicts occur when not only mere economic interests but also the implicit rules of mutual recognition are violated, highlights the moral dimension of social conflicts with the concept of “recognition struggle.” It means that feelings of being disrespected and treated with injustice or feelings of hurt and violation are the motivational force that initiates perpetuates the social struggle. Honneth identifies three patterns of recognition necessary for an individual’s development of identity: love, rights, and solidarity. The first mode of recognition termed “love” refers to our physical needs and emotions being met by others and takes the form of our primary relationships (close friends, family, and lovers). The second mode of recognition termed “rights” refers to the development of moral responsibility, developed through our moral relations with others. It is a mutual mode of recognition “in which the individual learns to see himself from the perspective of his/her partner in interaction as a bearer of equal rights” (Honneth 1996, 194). The denial of rights through social and legal exclusion or by social ostracism can threaten one’s sense of being a full-fledged and respected member of society, equally endowed with moral rights (Honneth 1996, 133). Therefore, this form of struggle relies on the general and universal feature that makes him or her a legally capable subject equal to other citizens (Honneth 1996, 113). Contrary to the second form based on equality, the last mode of recognition termed “solidarity” relies on certain personal traits or particular characteristics (their own accomplishments and forms of life) that distinguish a person or a specific group from others and show a person or a specific group to be especially valuable (Honneth 1996, 113, 126). It is essential for developing our self-esteem and for how we become “individualized,” for it is precisely our personal traits and abilities that define our personal difference (Honneth 1996, 122). The struggle can be characterized as “social” to the extent that its goals can be generalized beyond the horizon of individuals’ intentions and to the point where they can become the basis for a collective movement. At this stage, the struggle can constitute “politics of recognition” (Honneth 1996, 162). Politics of recognition is also “politics of identity” in that an individual wants his/her specific identity to be recognized in his/her society (Taylor 1994). The contents of identity rely on the intersubjective relation with others. Thus, the

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identity, the centerpiece of recognition, can be acquired in the process of “recognition struggle” (Honneth 1996, 126–127; Markell 2008). As Fraser (1997) puts, “politics of recognition” is “to correct cultural injustices embedded in social modes of expression, interpretation, and communication.” Here, cultural injustices include cultural dominance, nonrecognition, and disrespect. Therefore, recognition struggles progress in a way that identity and cultural products of degraded group, through the cultural or symbolic alteration, can be uplifted and reevaluated or the cultural diversity can be endowed with the positive meaning (Fraser 1997). Politics of recognition is closely related to the rise of multiculturalism. In the past, the nation state guaranteed the economic, political, and social rights for all citizens, that is, the citizenship. The goal of the traditional “citizenship-as-right” model was to enhance a common national identity among citizens. This model was premised on the assumption that “normal” citizen referred to the able-bodied, heterosexual white male. Those who deviated from this model of normalcy were subject to exclusion, marginalization, silencing, or assimilation (Kymlicka 2002, 327–328). However, as multicultural phenomena beyond the traditional boundary and concept of nation states increase, those who have been silenced, marginalized, or defined as “deviant” from the so-called normal citizen, such as race, culture, gender, ability or sexual subaltern groups, demand a more inclusive conception of citizenship which recognizes (rather than stigmatized) their identities and accommodates (rather than excludes) their differences: this movement can be labeled as politics of recognition, politics of difference, or identity politics (Taylor 1994, 25). Most of existing literature on politics of recognition applies this conception to the social movements of those who are excluded from the boundary of citizenship and identity defined by the modern nation state and explores how they claim their own identity and rights, that is, “differentiated citizenship” based on their social and cultural differences. In doing this, they mainly focus on the second and third patterns of recognition to account for the political movements. Especially, the researches which apply the concept of recognition to redistribution struggles, stress the second type of recognition which demands the universal and equal citizenship in the civil society. This orientation alludes the separation between the private sphere where intimate and primary relations dominate and the public sphere of the state or civil society where individuals are treated as

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undifferentiated citizenships. It also assumes the evolutionary relations between these two spheres; subjects, with the development of self-identities, go beyond the realm of intimacy and participate in the public sphere as fullfledged citizens. However, it is obvious that the recognition politics operate in both the public and private spheres (Taylor 1994, 37). Therefore, this book tries to reject the linear evolution of self-identities. Rather, it highlights the overlapped features of the three forms of identities in the politics of recognition. In addition, it argues that individuals can flexibly and selectively shift their identities to maximize their interests in the welfare politics. Also, this book claims the break with the existing perspective, which underscores solely the moral and normative dimension of struggles. The moral dimension of recognition struggle does not mean that this type of struggle always stems from purely moral and normative motivation. The material interests are closely related to moral and normative ones (Kymlicka 2002, 328): “the negation or forfeit of specific rights and the objective inequalities in the distribution of material opportunities” can lead individuals to experience feelings of being disrespected and treated with injustice or disdain (Honneth 1996, 161). In particular, “when the social esteem for a person or group is so obviously correlated to the level of control over certain goods, only the acquisition of those goods can lead to the corresponding recognition” (Honneth 1996, 166). However, this book pays attention to the possibility that such experiences can lead the subject to go beyond the mere economic struggle and result in the moral transformation of the subject. This is because the strategic and practical use of cultural resources in the initial stage may culturalize or moralize the actor’s motive in the process of srtuggle and, therefore, alter the character of struggle in the later stage as well as the motive of actors (Honneth 1996, 168). In this context, this book also rejects Swidler’s assumption that strategic utilization or mobilization of cultures is motivated by little less than practical or instrumental incentives. Contrary to her view, in the light of moral aspect of recognition struggle, practical motive does not solely construct the whole process of institutional changes. Ironically, instrumental and moral motives act together and reinforce each other in the process, which lead to institutional changes in the end. To test this hypothesis, this book interprets the multilayered meanings of actors’ motives and demonstrates the two motives’ operation in the historical changes of the NHI in S. Korea and Taiwan. More specifically, practical and economic motives will be evaluated within the economic incentive structure that the state’s welfare systems have posited on family. In

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addition, moral motives will be explained by “normative claims that are structurally inherent” in relations of familial recognition from the perspective of social recognition (Honneth 1996, 2). To this aim, it will compare the welfare politics in S. Korea and Taiwan, focused on institutional changes of their NHIs. In the process, it will scrutinize how the multiple identities of actors, for example, gender, ethnicity, family in private sphere and laborer and citizenship in public sphere, have coupled and de-coupled, and how their different combinations of identities have affected the outcomes of their welfare politics as well as their welfare developmental path.

References Abrahamson, Peter. 1999. The Welfare Modeling Business. Social Policy and Administration 33 (4): 394–415. Alexander, Jeffrey. 1990. Analytic Debates: Understanding the Relative Autonomy of Culture. In Culture and Society: Contemporary Debates, ed. J. Alexander and S. Seidman, 1–27. New York: Cambridge University Press. Alexander, Jeffrey, and Philip Smith. 1993. The Discourse of American Civil Society: A New Proposal for Cultural Studies. Theory and Society 22: 151– 207. Aspalter, Christian. 2002. Democratization and Welfare State Development in Taiwan. England: Ashgate. Boucher, Anna. 2014. Familialism and Migrant Welfare Policy: Restrictions on Social Security Provision for Newly Arrived Immigrants. Policy and Politics 42 (3): 367–384. Brooks, Clam, and Jeff Manza. 2006. Social Policy Responsiveness in Developed Democracies. American Sociological Review 71: 474–494. Chan, Cheris Shun-ching. 2009. Creating a Market in the Presence of Cultural Resistance: The Case of Life Insurance in China. Theory and Society 38: 271–305. Chan, Joseph. 2003. Giving Priority to the Worst Off: A Confucian Perspective on Social Welfare. In Confucianism for the Modern World, ed. D. Bell and C.B. Hahm Chai Bong, 236–253. Cambridge: Cambridge University Press. Chang, Kyung-Sup. 1997. Modernity Through the Family: Familial Foundations of Korean Society. International Review of Sociology 7 (1): 51–63. Coughlin, Richard M. 1980. Ideology, Public Opinion and Welfare Policy. Berkeley: Institute of International Studies, University of California, Berkeley. Ditch, John, Helen Barnes, Jonathan Bradshaw, and Majella Kilkey. 1998. European Observatory on National Family Policies: A Synthesis of National Family Policies 1996. New York: University of York, Social Policy Research Unit.

38  H.S. Wang Esping-Andersen, Gøsta. 1985. Politics Against Markets. Princeton, NJ: Princeton University Press. ———. 1990. The Three Worlds of Welfare Capitalism. Princeton, NJ: Princeton University Press. ———. 1999. Social Foundations of Postindustrial Economies. New York: Oxford University Press. Flora, Peter, and Jens Alber. 1981. Modernization, Democratization and the Development of Welfare States in Western Europe. In The Development of Welfare States in Europe and America, ed. P. Flora and A. Heidenheimer, 37–80. New Brunswick, NJ: Transaction Books. Fraser, Nancy. 1997. Justice Interruptus: Critical Reflections on the Post-socialist Condition. New York: Routledge. ———. 2000. After the Family Wage: A Postindustrial Thought Experiment. In Gender and Citizenship in Transition, ed. B. Hobson, 1–32. New York: Routledge. Geertz, Clifford. 1973. The Interpretation of Cultures. New York: Basic Book Classics. Goodman, Roger, and Ito Peng. 1996. The East Asian Welfare States: Peripatetic Learning, Adaptive Change, and Nation-Building. In Welfare States in Transition: National Adaptations in Global Economies, ed. G. EspingAndersen, 192–224. London: Sage. Goodman, Roger, Gordon White, and Huck-Ju Kwon (eds.). 1998. The East Asian Welfare Model: Welfare Orientalism and the State. London: Routledge. Granovetter, Mark S. 1985. Economic Action and Social Structure: The Problem of Embeddedness. American Journal of Sociology 91 (3): 481–510. Hall, Peter A., and Rosemary C.R. Taylor. 1996. Political Science and the Three New Institutionalisms. Political Studies 44: 936–957. Holliday, Ian. 2000. Productivist Welfare Capitalism: Social Policy in East Asia. Political Studies 48: 706–723. Hong, Kyung-Zoon. 1999. Social Welfare Regime in Korea. Seoul: Nanam. (In Korean). Honneth, Axel. 1996. The Struggle for Recognition: The Moral Grammar of Social Conflicts. Cambridge, MA: MIT Press. Jones, Catherine. 1993. The Pacific Challenge: Confucian Welfare State. In New Perspectives on the Welfare State in Europe, 198–217. London: Routledge. Korpi, Walter. 1983. The Democratic Class Struggle. In The Democratic Class Struggle, ed. W. Korpi, 7–25. London: Routledge and Kegan Paul. Ku, Yeun-Wen. 1997. Welfare Capitalism in Taiwan: State, Economy, and Social Policy. New York: St. Martin’s Press. Kwon, Huck-ju. 2004. Transforming the Developmental Welfare States in East Asia. Houndmills, Basingstoke: Palgrave Macmillan: UNRISD.

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Kymlicka, Will. 2002. Contemporary Political Philosophy: An Introduction. New York: Oxford University Press. Lew, Seok-Choon, Woo-Young Choi, and Hye Suk Wang. 2011. Confucian Ethics and the Spirit of Capitalism in Korea: The Significance of Filial Piety. Journal of East Asian Studies 11 (2): 171–196. Lister, Ruth. 2000. Dilemmas in Engendering Citizenship. In Gender and Citizenship in Transition, ed. B. Hobson, 33–83. New York: Routledge. Markell, Patchen. 2008. Recognition and Redistribution. In The Oxford Handbook of Political Theory, ed. J. Dryzek, B. Honig, and A. Phillips, 450– 469. New York: Oxford University Press. O’Connor, Julia S. 1993. Gender, Class, and Citizenship in the Comparative Analysis of Welfare State Regimes: Theoretical and Methodological Issues. The British Journal of Sociology 44 (3): 501–518. Orloff, Ann Shola, and Theda Skocpol. 1984. Why Not Equal Protection? Explaining the Politics of Public Social Spending in Britain, 1900–1911, and the United States, 1880s–1920s. American Sociological Review 49: 726–750. Pateman, Carole. 2006 [1988]. The Patriarchal Welfare State. In The Welfare State Reader, ed. C. Pierson and F.G. Castles, 134–151. Cambridge, UK: Polity Press. Rimlinger, Gaston Victor. 1971. Welfare Policy and Industrialization in Europe, America and Russia. New York: Wiley. Sainsbury, Diane. 2001. Gendering Dimension of Welfare States. In Rethinking European Welfare, ed. J. Fink, G. Lewis, and J. Clarke, 115–129. London: Sage. Skocpol, Theda, and Edwin Amenta. 1986. States and Social Policies. Annual Review of Sociology 12: 131–157. Smelser, Neil. 1992. Culture: Coherent or incoherent. In Theory of Culture, eds. R. Munche and N.J. Smelser, 3–28. Berkeley: University of California Press. Swedberg, Richard. 1994. Markets as Social Structures. In The Handbook of Economic Sociology, ed. N.J. Smelser and R. Swedberg, 255–282. Princeton: Princeton University Press. Swidler, Ann. 2001. Talk of Love: How Culture Matters. Chicago: The University of Chicago Press. Taylor, Charles. 1994. The Politics of Recognition. In Multiculturalism: Examining the Politics of Recognition, ed. C. Taylor and A. Gutman, 25–73. Princeton: Princeton University Press. Walker, Alan, and Chack-kie Wong. 2005. East Asian Welfare Regimes in Transition: From Confucianism to Globalisation. Bristol, UK: The Policy Press. Wang, Hye Suk, and Woo-young Choi. 2012. Cultural Boundaries of Families: A Comparative Approach to the September 11 Attacks and ROKS Cheon’an Sinking. Society and Theory 20: 265–306. (In Korean).

40  H.S. Wang Wilensky, Harold. 1975. The Welfare State and Equality: Structural and Ideological Roots of Public Expenditures. Berkeley: University of California Press. Wilensky, Harold, and Charles N. Lebaux. 1958. Industrial Society and Social Welfare. New York: Russell Sage Foundation. Williamson, Oliver E. 1988. The Economics and Sociology of Organization: Promoting a Dialogue. In Industries, Firms and Jobs: Sociological and Economic Approaches, ed. G. Farkas and P. England, 159–185. New York: Plenum Press. Williamson, Oliver E. 2000. The New Institutional Economics: Taking Stock, Looking Ahead. Journal of Economic Literature 38 (4): 595–613.

CHAPTER 3

(De-)Familialization in Social Policy in East Asia

The purpose of this chapter is to closely examine and compare the welfare regimes of S. Korea and Taiwan. The analytical focus is laid on how familialized their welfare regimes are, in other words, how much individuals of each regime rely on family in fulfilling their welfare needs. This will clarify the diversity of the familialistic welfare regime of the East Asia. It implies that it is difficult to single out the general familialistic welfare model from the East Asian cases: even though those institutions may seem to contain the similar family-orientation, how much familialized their regimes are can vary in degrees. Plus, this chapter explains the different degrees of familialization of the two welfare regimes as the outcomes of their welfare states’ internvention through the social policies of different “familialization effects.” Thus, this chapter demonstrates that the different nature of each regime is not a reflection of their distinct family reality or the persistent influence of family tradition or culture, but the result of the intervention of the welfare state. To these aims, this chapter, based on the assumption that familialism can have distinctive characteristics clearly differentiating itself from the Western welfare regime, starts with highlighting the commonalities of the National Health Insurances (hereupon, NHI) between S. Korea and Taiwan to compare the East Asian welfare regime with the Western one. Next, it closely examines the diversity inside East Asian welfare regimes by comparing the two insurances in detail, and the different familialization effects of welfare states of S. Korea and Taiwan. © The Author(s) 2017 H.S. Wang, Familial Foundations of the Welfare State, DOI 10.1007/978-3-319-58712-7_3

41

42  H.S. Wang

The National Health Insurance Programs in South Korea and Taiwan As the welfare states, both nominally and virtually, there are several welfare institutions in S. Korea and Taiwan to compare. S. Korea legislated the Industrial Accident Compensation Insurance and the NHI in 1963 and established the National Pension Insurance in 1986 and 1989 and the National Employment Insurance Program in 1995. Taiwan introduced the medical benefits for workers in 1950 and 1958 under the umbrellas of the Labor Insurance and the Civil Servants’ Insurance and extended them to the Farmers’ Health Insurance in 1989. Also, the Old-age Social Assistance Programs was established in 1993 and a new Unemployment Insurance scheme was introduced under the umbrella of the Labor Insurance in 1998 (Aspalter 2002; Lin 2002). Among several social welfare institutions in the two countries, this research focuses on the National Health Insurance (hereafter, NHI) programs. In S. Korea, the first health insurance program began in 1963, with limited benefits to the employees of large enterprises (with 500 and more employees) and public sector. Later, it was extended to a universal NHI program (國民健康保險) in 1997 (Son 2003). In Taiwan, the NHI Program was launched in the early 1950s though limited to industrial workers and employees of the public sector and was extended to a universal NHI (全民健康保險) which covers the whole population in 1995 (Son 2001). The existence of a similar universal insurance program covering a similar time span of evolution is one of the reasons why this research lays the focus on the NHI Program. Moreover, both the NHIs evince the typical characteristics of the conservative welfare regime. First, like compulsory social insurances in the Western European counterpart of the conservative regime, the NHIs of S. Korea and Taiwan grant entitlement on the basis of work performance: the entitlement depends on one’s status in the labor market and financial contributions (Esping-Andersen 1990, 48). If compared to the social democratic model which stipulates the entitlement as universal and equal rights of citizenship, the NHIs of S. Korea and Taiwan could seem to have a low potential in de-commodification. However, the degree of de-commodification in the conservative regime also depends on how much it relaxes the actuarial principle, which relates the benefit to prior financial contributions. From these criteria, both NHIs of S. Korean and Taiwan reveal the high degree in de-commodification. Though financial contribution should be

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43

made based on their incomes in order to get entitlement, the benefits are not based on the actuarial principle. To exemplify, in the NHIs in S. Korea and Taiwan, all the insured receive the same benefits in the same range of coverage regardless of how much or how long they have made the financial contribution. Both NHIs are deliberately designed to induce the income transfer, especially the vertical redistribution, between the high-income group and the low-income group within the system. In this regard, they exhibit a high degree of decommodification. The second commonality which the NHIs of S. Korea and Taiwan share as the conservative regime is that they are “differentiated and segmented into distinct occupational- and status-based social insurance” (Esping-Andersen 1990, 24, 69). The aim of occupational- and statusdifferentiated social insurance is to consolidate divisions among wageearners by legislating distinct programs for different class and status groups, each with its own unique set of rights and privileges. Secondly, this model aims to tie the loyalties of the individual directly to the monarchy or the central state authority (Esping-Andersen 1990, 24). The particularly privileged welfare provision for the civil servant groups manifests these features. As a result, the conservative regime develops myriads of status-based segmented social insurance programs. In both S. Korea and Taiwan, the civil servant is the first occupational group that the state’s welfare programs targeted. Following the social insurance for the civil servant group, other occupation- and employment status-based insurances were established, which resulted in the differentiated and segmented social insurance schemes in both countries. However, the NHIs of both countries have been converted to universal and compulsory programs: the earlier segmented programs have been integrated into one organization through several restructuring processes and now their NHIs cover the whole population and offer them the equal benefits. At least in the NHIs, their prior conservative characteristics such as privileged welfare provision for civil servants or employees in strategic industrial sector were abolished. Nevertheless, in their NHIs, some conservative legacies of social stratification are enshrined within the occupational-based differentiated NHI programs with its own unique set of entitlements and financial contributions. The earlier NHI of S. Korea contained four subcategories on the basis of the insured’s occupation: civil servants, private school teachers, employees, and others (self-employed in rural and urban areas). In spite of the integrating process from 1997 to 2000, the NHI has arrived the

44  H.S. Wang Table 3.1  Status of number of Korea’s NHI insured by category (unit: 1000 persons) Year

1980 % 1985 % 1990 % 1995 % 2000 % 2005 % 2010 %

Employee Company

Public/School

Subtotal

5,380,968 58.32 12,214,830 67.88 16,155,231 40.21 16,744,064 38.04 17,577,672 38.30 22,561,285 47.61 27,746,938 56.73

3,780,030 40.97 4,209,661 23.39 4,603,361 11.46 4,815,146 10.94 4,826,200 10.52 4,672,013 9.86 4,636,588 9.48

9,160,998 99.29 16,424,491 91.27 20,758,592 51.67 21,559,210 48.98 22,403,872 48.82 27,233,298 57.47 32,383,526 66.21

Self-employed

Total

– – 375,242 2.09 19,421,431 48.34 22,456,690 51.02 23,491,877 51.19 20,158,754 42.54 16,523,269 33.79

9,226,365 99.29 17,994,913 93.36 40,180,023 100.01 44,015,900 100.00 45,895,749 100.01 47,392,052 100.01 48,906,795 100.00

Data National Health Insurance Service of Korea

present frame of the dualized system between the employee insurance and the self-employed insurance. Table 3.1 shows the two categories of Korea’s NHI and the number of insured respectively. Likewise, Taiwan’s initial welfare programs offered the medical benefits only to civil servants and wage-earners and later had established the different and segmented insurance schemes according to the insured’s occupation. The newly launched NHI in 1995 categorizes the insured into six groups according to their occupational status and the earlier frame is still applied today. Table 3.2 summarizes the occupational status of the six categories and Table 3.3 shows the number of insured of each category. The last and most important commonality can be found in the familialistic feature of both NHIs. In both programs, the state takes the role of an “insurer” and the beneficiary of the insurance is divided into two categories, “the insured” and “the dependents.” The insured refers to a beneficiary who contributes to the finance of the insurance, in other words, those who pay the insurance fees. The dependent (眷屬 or 被扶養者), on the other hand, refers to a beneficiary who has no stable income and therefore is maintained by the insured.1 In both systems, in order to qualify the dependent eligibility, the applicants must pass the income-asset test, and more

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Table 3.2  Categories of Taiwan’s NHI Classification of the insured Category 1

Civil servants, volunteer servicemen, public office holders Private school teachers Employees of publicly or privately owned enterprises or institutions Employers, Self-employed Independent professionals and technical specialists

Category 2

Occupation union members Foreign crew members Members of farmers’, fishermen’s and irrigation associations Military conscripts, alternative servicemen, military school students on scholarships, widows of deceased military personnel on pensions, prisoners Low-income households Veterans and their dependents, other individuals

Category 3 Category 4

Category 5 Category 6

Data Taiwan’s National Health Insurance Administration (http://www.nhi.gov.tw/English/webdata/ webdata.aspx?menu=11&menu_id=591&WD_ID=591&webdata_id=3153)

importantly, prove the familial (blood or marital) relationship between the insured and the applicants. The existence of the “dependent system” signifies that these policies are based on family as its primary unit of operation.2 This feature most drastically contrasts to the Western welfare states, especially the social democratic welfare regime in some Scandinavian countries. In this regime, under the scheme of the national health services, the health benefits are guaranteed to each citizen, regardless of their income, contribution (insurance fee), or status in family. To put simply, the eligibility in the social democratic welfare regime is based on the individual citizenship while in S. Korea and Taiwan it is determined by the familial membership. Also, the familialism inscribed in their NHIs is different from that of the liberal welfare regime, where it assigns a maximum of welfare obligations to the household, and therefore, the active family policies are extraordinarily undeveloped. The NHIs of S. Korea and Taiwan manifest the combination of the two meanings of familialism, as explained in the Chap. 2: the intervention of the welfare state that maximizes the individuals’ command of welfare services dependent on familial relationship. In this regard, the NHIs in S. Korea and Taiwan most clearly portray the familialistic nature, which is distinct from the familialism of Western welfare regimes, be it the social democratic or the liberal.

10,437,339 54.58 11,465,521 53.58 11,798,491 52.87 12,240,752 53.05

1995 % 2000 % 2005 % 2010 %

4,031,489 21.08 3,750,883 17.53 3,742,726 16.77 3,976,004 17.23

Category 2

Data Bureau of National Health Insurance of Taiwan

Category 1

Year 2,998,439 15.68 3,304,109 15.44 3,141,774 14.08 2,828,337 12.26

Category 3 69,059 0.36 68,579 0.32 – – 157,576 0.68

Category 4 111,452 0.58 146,335 0.68 211,614 0.95 271,211 1.18

Category 5

Table 3.3  Status of number of Taiwan’s NHI insured by category (unit: person, %)

1,477,273 7.72 2,665,399 12.45 3,420,042 15.33 3,600,607 15.60

Category 6

19,123,278 100.00 21,400,826 100.00 22,314,647 100.00 23,074,487 100.00

Total

46  H.S. Wang

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However, the welfare system prioritizing the family is not unique to the East Asian model. The countries, which develop mainly social insurance-oriented welfare systems, have established a similar health insurance policy based on families as a unit of the insurance. This tendency is reflected in the conservative welfare model which has developed focused on social insurances (Lee et al. 2008). According to Esping-Andersen’s typology, as the conservative welfare system includes the family of the insured as the constituents of the welfare system, some social policies of this regime also display the similar familialistic tendency (EspingAndersen 1999). Germany and Japan, which are considered to fall into this type, share a critical similarity in that they both classify family members of the insured as the subject of welfare as well as the qualified recipients. For example, Germany manages the national health insurance based on the dependent system similar to that of Korea and Taiwan. Its concept of “Familienversicherte,” similar to Korea’s “dependent,” includes the insured’s family members (spouse, children, grandchildren, and adoptees) who can be insured without an obligation to pay the insurance fee (Lee et al. 2005, 59–60). In this regard, not only the East Asian countries but also the conservative welfare regimes in Europe include a family unit within the boundary of the state’s social insurance. In sum, the NHIs of S. Korea and Taiwan, as one of the pivotal welfare institutions, portray the major characteristics of the conservative welfare regime: high de-commodification, high stratification, and low defamilialization. These commonalities offer the starting point from which this chapter embarks on comparing the different development paths the NHIs of the two countries had taken.

Different (De-)Familialization of the Welfare Regimes Statistical Differences of the Dependent System In the above discussion, I intentionally highlighted the common features of the NHIs of S. Korea and Taiwan in order to compare the familialism of the East Asian welfare regime to that of the Western welfare regimes. Now, with a magnifying glass, the difference or variance of the familialization within their welfare states will be explored. First, I compare the familialization of each NHI, by the proportion of relevant population covered by dependent eligibility (Esping-Andersen 1990, 49), which proves “how many proportion of the total population command

48  H.S. Wang

the NHI entitlement dependently on familial or conjugal reciprocities” (Esping-Andersen 1999, 45). Here, I employ the measuring index of “dependents ratio” and operationalize it to fit the NHI to show the number of dependents per one insured, that is, how many family members as dependents belong to one insured as a family’s chief provider. As mentioned earlier, both insurance programs have an internally divided operation system, which makes it difficult to compare the two programs as a whole. Therefore, I choose categories from the two systems that employ the most similar characteristics: “employee insured” from S. Korea’s NHI and “Category 1 insured” from Taiwan’s. These two categories target employees of private and public sectors with constant income and employer. Also, as shown in Table 3.1 and 3.3, 66.21% (S. Korea) and 53.05% (Taiwan) of the total insured population belong to those two categories, as of 2010. Moreover, both categories include the largest proportion among the total population covered by each NHI. Thus, the section focuses on these two categories’ dependent ratios in order to conduct a systematized and unified comparison. Table 3.4 shows the number of the insured and their dependents, and the dependent ratio of the NHIs in S. Korea and Taiwan. The table further illustrates that the dependent ratios of the two programs gradually decrease with the overall decrease in the household size in tandem with the industrialization and urbanization in two societies (see Table 3.5). Nonetheless, if the effects of the declining population and other demographical factors are controlled, it is possible to conclude that the dependent ratio of Korea’s NHI is about 2.5 times larger than that of Taiwan’s. For example, as of 2010, the number of the insured and their dependents in Korea’s program are 12,763,729 and 19,619,797 respectively, and the dependent ratio is 1.54. Among the employee category of S. Korea’s NHI, 40% of beneficiaries are the insured who command the independent eligibility based on their status in the labor market, and other 60% command their NHI benefits depending on their familial memberships. The proportion is shown as completely opposite in Taiwan. In the same year, the same number of beneficiaries of Taiwan’s program is divided into 7,542,605 of the insured (62%) and 4,698,147 of dependents (38%), and the dependent ratio is only 0.62. The dependent ratio in Taiwan’s NHI implies that only less than 40% of people command their welfare dependent on familial relationship. The seemingly similar familialistic NHIs of S. Korea and Taiwan reveal the gap in their degrees of familialization. In sum, the NHI of S. Korea shows a higher familialization than that of Taiwan’s.

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Table 3.4  Status of the dependent ratio in the NHI in S. Korea and Taiwan by year (unit: 1000 persons) Year

S. Korea (The employee) Beneficiaries

1980 1985 1990 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Taiwan (Category 1) Total

Insured

Dependents

2913 4947 6511 7166 7303 7282 6539 6803 7268 9267 9722 10,233 10,743 11,208 11,919 12,698 13,148 13,708 12,764

6248 11,478 14,247 14,393 14,612 14,758 14,268 14,914 15,136 18,564 18,663 19,287 19,979 20,697 21,248 21,402 21,911 22,356 19,620

9161 16,424 20,759 21,559 21,916 22,040 20,807 21,717 22,404 27,830 28,386 29,519 30,722 31,905 33,166 34,100 35,059 36,064 32,384

Ratio Beneficiaries

2.15 2.32 2.19 2.01 2.00 2.03 2.18 2.19 2.08 2.00 1.92 1.88 1.86 1.85 1.78 1.69 1.67 1.63 1.54

Insured

Dependents

– – – 5840 5867 6005 6097 6250 6429 6364 6417 6620 6825 6915 7051 7157 7119 7203 7543

– – – 4597 4812 4909 4947 4987 5037 5083 5042 5010 4955 4884 4868 4836 4811 4752 4698

Total

Ratio

– – – 10,437 10,679 10,915 11,044 11,236 11,466 11,447 11,459 11,630 11,780 11,798 11,920 11,993 11,930 11,955 12,241

– – – 0.79 0.82 0.82 0.81 0.80 0.78 0.80 0.79 0.76 0.73 0.71 0.69 0.68 0.68 0.66 0.62

Source The National Health Insurance Administration Bureau of S. Korea, each year; National Health Insurance Administration of ROC, The National Health Insurance Statistics, each year

Table 3.5 Average population per household and family in S. Korea and Taiwan (unit: person)

Year

S. Korea

Taiwan

1980 1990 2000 2010

4.5 3.7 3.1 2.7

4.8 4.0 3.3 3.0

Source In S. Korea, see the National Statistical Office, A National Census, each year; In Taiwan, for statistical data of 1956–1980, see Dept. of Household Registration Affairs, MOI, Summaries of Population and Housing Census in Taiwan-Fukien Area, and for statistical data of 1990–2010, see Directorate General of Budget, Accounting and Statistics Executive Yuan, R. O. C., 2010. Social Indicators

50  H.S. Wang

Families Explain the Gap in the De-familialization Between S. Korea and Taiwan? Then how can we explain the disparity between the dependent ratios of the two countries? Does this simply mean that the size of the Korean family is 2.5 times larger than that of the Taiwanese? To compare family realities in the two societies, it is necessary to examine the major index regarding families from socio-economic and demographical perspectives. However, Table 3.5, which summarizes the changing status of average sizes of families in S. Korea and Taiwan, dismisses such a naïve hypothesis. As in the table, the average size of families in S. Korea and Taiwan does not match with their gap in dependent ratio: Taiwan, despite the lower dependent ratio, has a slightly larger size of families than S. Korea. In fact, Korean and Taiwanese families, with the advent of industrialization, have experienced the structural tranformation such as the nucleaization, low birth rate, and aging of population (Freedman et al. 1978; Greenhalgh 1984; Weinstein et al. 1990; Chang 1987; Wang 2012). Therefore, there is no statistical evidences indicating that the Korean families are larger in size or have more dependents than the Taiwanese ones. Other studies hypothesize that the difference in the dependent ratio comes from the high employment rate in Taiwanese married women (Tchoe 1998). A wife with job can command her NHI entitlement as the insured independently. Meanwhile, a housewife should rely on the male wage earner, that is, the insured as a his dependent in order to get the health benefits from the state, which can lead a high dependent ratio. That is, the number of female spouses without income or job is larger in Korea, which causes a high dependent ratio in S. Korea. This argument indicates that the different family realities regarding the gendered division of domestic labor and the gender stratification of labor market can lead to the different dependent ratios. It implies that not the welfare state but families or (labor) market could play as determinant factors in influencing the de-familialization of the welfare regime. However, as in Fig. 3.1, which compares the status of female’s participation in economic activity in Korea and Taiwan from 1983 to 2010, not only Taiwan but also Korea shows a fairly high employment rate of the female population. Moreover, in the numerical data after 1995 when statistics of both NHIs become available, female’s participation in labor market in S. Korea is even higher than the female market participation rate of Taiwan. All in all, both countries exhibit only negligible differences in female economic participation rate and its changing patterns. It is hard to conclude that

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60.0 50.0 40.0 30.0 ---- S. Korea 20.0

––– Taiwan

10.0 0.0 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009

Fig. 3.1  Status of female’s participation in economic activity in S. Korea and Taiwan. Source S. Korea’s data from the National Statistical Office, Annual Statistics on Economically Active population, each year and Taiwan’s data from National Statistics, R. O. C., Annual Statistics on Human Resources, each year

the gap in dependent ratios, that is, the de-familialization of the two welfare regimes originates from the difference in the gendered labor market. In sum, the family realities in S. Korea and Taiwan, relating to their sizes and economic structures between genders, and their changing patterns, do not match with the disparity in the dependent ratios of each NHI. The family realities in S. Korea and Taiwan are quite similar. The only viable difference shall be the fact that the Taiwanese families reveal a slightly larger size than the Korean. Nevertheless, this difference fails to explain why most of the Taiwanese people command their welfare services independently from their familial memberships because the dependent ratio in Taiwan’s NHI is lower than that in S. Korea’s.

Familialization Effects of the Welfare States Measuring Familialization Effects of the Welfare States Then, what can be the main reason behind their varied familialization of the two welfare regimes? To answer this question, this section pays attention

52  H.S. Wang

to the different institutional arrangements built in the NHIs in S. Korea and Taiwan, which can function as an incentive structure. Some social policies can be explicitly designed to maximize individual’s command of state welfare entitlement dependently of his/her familial relationship, not based on individual citizenship. Such institutional designs show just the potential of familialization of social policy. The familialization of the welfare regimes as outcome depends on how individuals or families react to and make a different decision within the incentive structure given by the welfare state. In other words, the degree of (de-)familialization of the welfare regimes is not the linear function of the (de-)familialization potential built in the welfare state institution in itself, but could be filtered or refracted by the decisions made by individuals or families. Therefore, I use the term the (de-)familialization “effect” to mean the potentials of the welfare state’s policies in maximizing the (de-)familialization of one’s welfare supply, which can be estimated through institutional features of specific social policies, and differentiate it with the (de-)familialization of welfare regimes, which means the actual outcome of such institutional effects or other factors.3 First, variation in the familializing or de-familializing potential of the NHI in S. Korea and Taiwan, that is, the familializing or de-familializing effect of the welfare state, should be empirically identified. Considering the specificities of the East Asian contexts and the natures of NHI as a social insurance, this section measures the familializing or de-familializing effects, focused on two institutional dimensions of their NHIs: scope of the family dependents and dependents’ premium calculation method. Conditions for Entitlement as Dependents First of all, it is necessary to examine the conditions for entitlement as dependents, that is to say, “the rules that govern peoples’ access to dependent benefits: dependent eligibility rules and restriction on entitlements” (Esping-Andersen 1990, 47). Therefore, it requires comparing how each NHI in S. Korea and Taiwan defines the scope of kinship regarding who is entitled to the dependent eligibility. Laws and regulations of the NHIs in the two countries have undergone numerous amendments since they were first promulgated. According to each amendment, the content of each dependent system varies, of which processes are explained in Chaps. 4 and 5 in details. Therefore, this chapter grasps general patterns in how the two NHIs define families, based on which the dependents entitlements are determined. It will allow us

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to draw out the scope and definition of dependents that have persisted throughout such legal changes. According to Korea’s NHI Act, the “dependents” refers to the following categories: (a) spouses of the insured, (b) lineal ascendants of the insured (including linear ascendants of their spouses), (c) lineal descendants (including lineal descendants of their spouses) and their spouses of the insured, and (d) brothers/sisters of the insured who have no remuneration or income and therefore are mainly maintained by the insured (Paragraph 2 of Subsection 5 of Korean NHI Act). This Act acknowledges the lineal ascendants and descendants, collateral relatives, and any second-degree kinship of the insured as their dependents. In addition, the act offers the dependent entitlement to a broad range of family formed from marriage, let alone spouse, the spouse’s lineal ascendants (parents and grandparents), and descendants (in case of the remarriage). Obviously, both lineal and collateral relatives must satisfy two kinds of “eligibility test”: cohabitation and income/asset test, through which they should prove their economic incompetence and reliance on the insured, in order to be recognized as the dependents.4 According to the Taiwanese NHI Act, the “dependents” refers to: (a) the insured’s spouse who is not employed, (b) the insured’s lineal blood ascendants who are not employed, and (c) the insured’s lineal blood descendants within second degree of relationship who are either under 20 years of age and not employed, or are over 20 years of age but incapable of making a living, including those who are in school without employment (Paragraph 2 of Subsection 1 of Taiwanese NHI Act, amended June 29, 2010). Thus, the Act only recognizes the two generations of blood-linked descendants as “dependents” while it does not limit the insured’s lineal ascendants. It also does not extend the dependent entitlement to the insured’s collateral families. The dependent entitlement through marital relations is limited to the insured’s spouse. The spouse’s lineal ascendants, or the spouse’s parents (parents-in-law), cannot be qualified as dependents. The introduction of this chapter roughly compared the familialistic natures of the NHIs of S. Korea and Taiwan with German case as a representative case of the conservative welfare regime. If we compare the familialistic natures in details, focused on the conditions for dependent entitlement, especially the scope of family dependent, the NHIs of the three countries reveal a fundamental difference even though they are considered as constituents of the conservative regimes. The dependents

54  H.S. Wang

in German health insurance are pretty limited both in their scope and in their temporal status compared to those in Taiwan and Korea. German health insurance mostly recognizes spouses and children as the dependents; it excludes the insured’s ascendants such as parents or grandparents and the insured’s siblings. Even in the case of descendants, German insurance only acknowledges the lineal descendants within the second degree and thereby avoids including children’s spouses or great-grandchildren as dependents. The insured’s children also customarily lose their eligibility as dependents and should be insured individually, taking the responsibility for their own insurance fees once they reach adulthood (Lee et al. 2005). Thus, German policy reflects the conventional nuclear family model, which only includes the insured’s spouse and young children, while Korean and Taiwanese policies manifest the stem family model constituted by the insured’s spouse as well as lineal descendants and ascendants. Even though all of these three policies administer familialistic dependent system, the definition of family dependents in Korea and Taiwan differs from that of Germany. Nevertheless, even the dependent systems of Taiwan and Korea also show the disparities between each other. According to each Act, the dependent system of Taiwan and Korea demonstrates different definitions of family relations and different scopes of family, which implies different family norms. First, the scope of family members who can claim the dependents’ entitlements differs. In the NHI of S. Korea, the scope of dependents can be easily extended along the blood ties. It encompasses both lineal descendants and ascendants even without any limit to the degree of the relationship. It also includes collateral families (brothers and sisters of the insured) and spouses of lineal descendants (son- and daughter-in-law, grandchildren’s spouses). If applicants succeed to prove that they are incapable of maintaining themselves or lack a source of income, they can be registered as dependents of any family member. The distance of the blood relation between the insured and dependents, or their co-residence, does not matter. The Korean system shows the most generous definition of dependents. Taiwan also follows the fundamental principle that only the family members are eligible as dependents. Nevertheless, the Taiwanese system manifests a narrower range of dependents and applies much stricter criteria depending on the blood relation. The lineal ascendants of the insured may claim their eligibility without limitation on degrees, but, in the case

3  (DE-)FAMILIALIZATION IN SOCIAL POLICY IN EAST ASIA 

Brothers and Sisters

Grandparents

Grandparents

S. Korea-

Parents

Parents

Taiwan-

The insured

Spouse

55

+

* Spouse

Children

Children

Spouse

Spouse

Grandchildren

Grandchildren

Spouse

Fig. 3.2  Scope of dependents in S. Korea and Taiwan. *“Lineal ascendants of spouse and their spouses” applies to the remarriage cases

of the lineal descendants, only those within the second degree can obtain the entitlement. Collateral family members, in principle, are not eligible for entitling as dependents. The eligibility through marital relations is allowed only to spouse of the insured and is not extended to spouse’s parents. The Taiwanese program can be considered as the addition of lineal ascendants to the Germany’s nuclear family model. Figure 3.2 displays a visual scope of each policy. As seen in Fig. 3.2, the Korean part includes all the family lineage a person can imagine. Due to its generous rules, the Korean NHI includes various family ties as the dependents. Table 3.6 organizes the status of the employee insured’s dependents from 2001 to 2005, specifically illustrating the relationship between the insured and dependents. As shown in this table, the Korean NHI benefits a wide range of family and relatives including not only the spouse’s lineal ascendants (father-in-law and mother-in-law) but also the collateral relatives like siblings and their children (nephews and nieces). Moreover, lineal descendants’ spouses (sonand daughter-in-law) and even the insured’s parents’ collateral family

56  H.S. Wang Table 3.6  Status of dependents of the Korean NHI by kinship and year (units: persons) Year 2005. 12

2005. 2

2004. 2

2003. 2

2002. 2

2001. 2

Spouse 3,799,481 3,753,527 3,683,730 3,585,831 3,580,791 3,667,993 Parents 3,951,009 3,685,028 3,428,632 3,240,074 3,159,799 3,220,381 Father’s grand143,552 128,281 118,888 113,081 114,253 114,839 parents Mother’s 5303 4840 4202 3778 3600 3288 grandparents Children 8,189,161 7,975,080 7,751,542 7,529,107 7,383,747 7,085,526 Grandchildren 36,552 35,646 32,841 29,872 27,507 35,321 and their descendants Elder brothers 182,453 145,716 102,536 79,924 74,547 75,659 Younger broth520,867 459,270 392,343 348,698 347,236 360,448 ers Elder sisters 52,035 46,744 48,499 47,575 45,433 49,274 Younger sisters 111,256 120,737 155,692 183,761 207,316 254,969 Parents-in-law 460,229 419,935 368,933 324,907 298,618 291,094 Sons/daugh18,099 18,183 17,289 16,725 15,324 25,053 ters-in-law Step parents 1249 1103 819 706 558 439 Grandparents’1936 2069 1949 2338 2221 1923 in-law Grandchildren11 15 12 22 15 14 in-law Nephew or 2 7 9 4 10 1178 niece Parents’ broth1 2 2 3 5 60 ers Miscellaneous 13,878 13,886 12,920 11,903 10,530 10,462

members (uncles or aunts) are also included.5 Even though the data are limited to some specific periods, thus are not enough to infer the general trend, the table clearly indicates that in reality the dependent entitlement of Korean NHI is generous and flexibly applied. All in all, we can tentatively conclude that the NHIs in Korea and Taiwan are established on different family models. The Korean system employs the extended family model, which is the closest to the Confucian ideal of a family. Meanwhile, the Taiwanese system, even

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though the society is also a part of Confucian clusters and a more legitimate successor of the Chinese tradition, adopts the stem and nuclear family model, which is, in fact, not far from the Western family norm. Relating these institutional features of their NHIs to the de-femilialization effects, the broad scope of family dependent in Korea’s dependent system implies that its NHI can have a high potential of familialization. Meanwhile, the narrow scope and strict conditions for dependent entitlements in Taiwan can lead individuals to access the state’s welfare benefits independently of their familial relations, which implies a low familialization effect of Taiwan’s NHI. How to Calculate the Insurance Fee of Dependents Next, as another institutional feature of the two NHIs, this section will discuss how the insurance fee for the dependents is determined. The term “dependent” technically refers to the family members without economic abilities, thus the providers are responsible for those family members. The same principle applies to the NHI: the insured are responsible for paying the dependents’ insurance fees in both Korean and Taiwanese NHIs. This stems from the fact that both welfare systems are established on the familialistic model stressing the role of the head of a family in ensuring family members’ welfare. The issue of how much the insured have to pay for their dependents is a critical point because it can potentially limit the number of the dependents the insured can have. In Korea’s NHI, the insurance fee of employee insurance is calculated based on the insured’s earned income, the premium rate, and the contribution ratio.6 In this formula, as the premium rate and the contribution ratio are fixed by the NHI Act and evenly applied to all the insured, the insured’s earned income is the only factor that influences his/her insurance fee. That is to say, the number of dependents or their ages and properties do not impact the amount of insurance fees of the insured. As it is, Korea’s NHI does not impose the insurance fee of dependents on the insured individually. Spending for dependents’ medical benefits is pooled by controlling the premium rate as a whole, and hence all the insured pay for the speding for all dependents evenly. Meanwhile, the number of dependents in Taiwan’s NHI is a very important criterion in calculating the insurance fees of the insured. The insurance fee is decided by multiplying their “monthly income” by the

58  H.S. Wang

Fig. 3.3  Comparison of the premium calculation method in S. Korea and Taiwan’s NHIs

“premium rate,” the “contribution ratio,” and finally by the number of dependents including the insured themselves.7 It means that the insured have to pay the additional premiums in proportion to the number of dependents. Figure 3.3 compares the calculation methods of insurance fee in both systems. In sum, the Korean system does not take into consideration the number of dependents when calculating the insured’s premium. On the other hand, the insured’s premium is directly correlated with the number of dependents in the Taiwanese system. The calculation method itself may function as an incentive structure because the insurance fees are intrinsically bound up with the individuals’ economic interests. How individuals and families react to this given incentive structure at the micro level can affect the dependent ratios, that is, the familialization or de-familialization of the welfare regimes. For example, if the health insurance imposes the insurance fee proportional to the number of dependents, an individual insured cannot easily expand the dependent’s list. This is the Taiwanese case. Taiwan’s NHI policy creates a disincentive for the insured to expand their dependents’ list not only by recognizing a narrow scope of dependents but also by administering an insurance calculation method that imposes economic disadvantages upon the insured with many dependents. Thus, the Taiwanese insured may seek for an alternative to ensure medical security for their family members at a less cost. For example, before 1995 when a compulsory NHI was launched, the insured (of

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Civil Servant Insurance) intentionally would not apply for the dependent eligibility test for their family members who have less demand for medical services and let them buy less expensive private medical insurance. After 1995, some insured, those with high income in particular, intentionally omit some of their family members like old parents or adult children who have no stable income, and let those family members subscribe the NHI independently from family relationship. If they are registered as dependents, the insured should pay additional insurance fee based on high income. However, if they are insured individually and independently from the insured, they can enjoy the NHI with less insurance fees because they have no stable income. This explains why the dependent ratio of Taiwan’s NHI is relatively low; in the Taiwan’s welfare regime, more people access the state’s welfare benefit based on their individual citizenship rather than the familial membership, which shows a low familialization of its welfare regime. Contrary to the Taiwanese case, relatively generous institutional arrangements in S. Korea may offer individuals the economic incentives to increase the number of dependents. In Korea’s compulsory health insurance scheme, incomeless population have two options to be insured; one is to be an independent self-employed insured and paying the insurance fee for themselves, and the other is to be a dependent of an employee insured among his/her family members. Between the two options, a rational individual would prefer the second option, which is almost free both to dependents and the insured, to the first, which requires additional economic burden. Naturally, incomeless people would look for an employee insured among family members who would register them as dependents. The similar incentive can also operate to the insured. Regardless of the number of the dependents, the insured pay the constant amount of premium, fixed by their income. If they had family members without stable income, they would rather register those family members as their dependents than let them be insured independently. In the latter case, the insurance fee of those family members should be paid out of the insured’s pocket by cash anyway. Therefore, the rational insured would naturally have incentives to increase the number of their dependents, in some instances, even to include their distant relatives. In fact, such an individual decision of the insured could increase the freeriding dependents, and, in the aggregate sum, could cause the financial deficit of the NHI, which should be resolved by raising the insurance fee of all the insured as a whole. Also, the burden of increased insurance fee is evenly

60  H.S. Wang

distributed to all the insured. However, the insured, as an individualized actor with a bounded rationality and impartial information (Williamson 1988), cannot predict such an outcome. Hence, the insurance fee calculation method as well as social pooling in the Korea’s NHI program is equipped with the institutional arrangements that reinforce the insured’s and dependents’ incentives for increasing the number of dependents. Consequently, under the different methods of calculating insurance fees, the Korean insured will most likely have many dependents while the Taiwanese insured will minimize the number of dependents. This implies that the two countries’ dependent system can bring forth an opposite effect of familialization. Even though both of the welfare states establish the welfare institution based on family as a basic unit of its policy, their outcomes in familialization vary depending on the institutional features of each policy, in other words, the rules of games in encompassing family members. From Familialization Effect of Welfare States to Familiazation of Welfare Regimes Therefore, it can be concluded that the disparity in dependent ratios between the NHIs of S. Korea and Taiwan, which implies the different degree in familialization of the two welfare regimes, is resulted not from their different family realities in economic or demographical terms, but largely from the institutional factor built in their dependent systems. In Korea, a range of dependents can be expanded comparatively flexibly, along with the blood relationships. As long as the dependent applicants do not have stable income or lack the ability to sustain themselves, they can easily receive the dependent eligibility, regardless of their age or the degree of the familial lineage. In Taiwan, the family membership also determines the dependent eligibility, yet the scope of dependent itself is much narrower than that of Korea. Also, in order to be recognized as dependents, one must prove his or her economic inability and satisfy strict criteria like age and the degree of kinship. Another institutional characteristic that explains Taiwan’s low dependent ratio would be the insurance fee calculation method, which increases the economic burden of the insured in proportion to the number of dependents. On the other hand, in Korea, the insured pay the same amount of insurance fee regardless of the number of their dependents. This allows the insured in Korea to add dependents without any difficulty, while the insured in Taiwan tend to avoid such a choice of action due to economic pressure.

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Each NHI of S. Korea and Taiwan is equipped with a distinct incentive or disincentive structure, within which individuals and families calculate the cost and benefit that entry or exit from the dependent eligibility could entail. The welfare state of Taiwan has established the NHI with high potentials to lead families to act individually by raising the cost of familial eligibility, which results in the overall de-familialization of its welfare regime. Meanwhile, the welfare institution of S. Korea has high potentials to lead individuals to rely on the familial relationship in order to command the state’s welfare. The high dependent ratio of Korea’s NHI, browsed in the introduction, shows that these potentials of welfares state are fully realized, thereby resulting in the familialization of its welfare regime.

Evaluating the Familialization Effects Within the System I argue that the different dependent ratios of S. Korea’s and Taiwan’s NHIs can be more efficiently explained by the incentive or the disincentive structure built in the NHI institution itself, rather than by the demographic factors or socio-economic factors regarding families. However, as the argument was drawn from the cross-national comparison, there may be other systematic characteristics that can influence the phenomenon. That is to say, certain systematic characteristics related to the country, which the comparison fails to observe, may have created the difference. Therefore, it is required to evince that distinct institutional arrangements of the two insurance programs decisively influence the dependent ratios under the control of the systematic variable of the “countries”: the alleged familialization effects of the institutions should be evaluated separately and respectively within each national system. In order to clarify the inferred causal relationship between the dependent system’s potentials in familialization (familialization effects of the welfare state) and the dependent ratio (familialization of the overall welfare regime as outcome), the following part examines each NHI’s dependent ratio “within the system” (Skocpol and Somers 1980). Korea As stated above, Korea’s NHI is a dualized program between the employee insurance for those employed by a specific employer or a company and the self-employed insurance for farmers, professionals or the self-employed. The earlier discussion intentionally laid its

62  H.S. Wang

Employee

Self-Employed

4.00 3.50 3.00 2.50 2.00 1.50 1.00 0.50

1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

0.00

Fig. 3.4  Status of the dependent ratio of the employee and the self-employed insurance in S. Korea’s NHI

focus on the employee insurance alone in order to compare it with the Taiwanese case. This section will compare the different institutional features between the two subinsurances of the Korea’s NHI scheme, and thereby test the inferred influence of institutional features of NHI on the dependent ratio under the control of “countries” level factors. It will examine how different institutional designs of the two sub-insurances cause the different familialization of each insured group even though they do not show any definite difference in their family realities. Figure 3.4 summarizes the changing patterns in dependent ratios of the employee insurance and the self-employed insurance, from which we can notice that they display dissimilar patterns. As we already browsed through, the dependent ratio of the employee insurance shows a continuous increase until mid-1980s, and thereafter shows a gradual decrease, which is likely influenced by the rapid downsizing of family and increase

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in nuclear families. On the other hand, the dependent ratio of the selfemployed insurance demonstrates a disparate tendency. It starts with a relatively high ratio of 3.79 in 1981 when it started a test run, decreases as years go by, and significantly drops to 2.54 in the year of 1989, when the NHI was extended to nationwide. The dependent ratio has continued to decline and finally has fallen below the dependent ratio of the employee insurance since the mid-1990s. Inferred from this figure, it seems that the family realities of the two sub-insurance vary greatly. This can be interpreted as an outcome of the decrease in rural population because the self-employed insurance initially targeted the rural population, and later extended to the urban population. As the industrialization and urbanization expedited, the rural population, once occupied 60% of the whole population in the 1960s, drastically fell. Certainly, the hollowing-out of rural areas could have led the downsizing of families and correspondingly have affected the overall declining dependent ratio of the self-employed insurances. However, the hollowing-out of rural areas blew a more tremendous impact to the population itself than to families: the rural population as a whole had decreased rapidly. Since the late 1980s, the insured in urban areas had occupied the majority of self-employed insurance: to exemplify, in the 2000s, the proportion of urban insured reaches about 90%. Thus, it is misleading to conclude that the declining trend of the dependent ratio in vself-employed insurance is caused by the rural insured who occupy only 10% of the total insured: the phenomenon is originated from the urban insured who are not different from the employee insured. Then, why is the dependent ratio of self-employed insurance extraordinarily lower than that of the employee insurance? We can trace the cause from unique institutional features of the self-employed insurance, which entail a low familialization effect. Unlike the employee insurance, which allows the free rides of family dependents, the selfemployed insured have to pay the insurance fee in proportion to the number of household or of the family members. In detail, compared to the employee insured whose insurance fee is calculated only based on the insured’s income, the insurance fee of a self-employed insured takes into account the gender, age, economic ability, and property of every household member. For the self-employed insured, the insurance fees function similarly to a poll tax. In terms of the premium calculation method, the employee insurance fits well into the familialistic model, in which the entitlement of the insured is shared by all family members without additional cost. Meanwhile, the

64  H.S. Wang

self-employed insurance only partially fits into this model because its institutional design presupposes that every household member has a responsibility to contribute to the insurance and that a head of household just carries a role of collecting his or her dependents’ insurance fees or paying the fees on behalf of them as the representative of household. In this regard, the selfemployed insurance is, de facto, an individual insurance (Lee 2012). Therefore, under such institutional features of the self-employed insurance, being dependents of the self-employed insured is not an attractive or less costly option from the perspective of both dependents and the insured. This is one of the reasons behind the declining dependent ratio of self-employed insurance. Also, the other side of the coin of exit is entry: the existence of alternative, that is, the generous dependent system of employee insurance with a relatively less entry cost, could have accelerated the exodus from the self-employed insurance to the employee insurance. If the self-employed insured and their dependents could find the employee insured among families and relatives within the scope of kinship that the NHI Act designates, the whole household, including the self-employed insured and their dependents could be registered as dependents of the employee insurance without difficulty. It reaffirms the argument that the different dependent ratio can be explained by the incentive or the disincentive built in the NHI institution itself rather than by the demographic factor or socio-economic factors regarding families. One of the clear evidences is the contrasting reaction to the financial crisis in 1997 between the employee insured and the self-employed insured. In the employee insurance, which allows the free riding of the dependents by principle, the dependent ratio showed a temporary increase right after 1997 while the ratio of the self-employed insurance continued to decrease. This can be an indirect evidence showing that the population who temporarily lost their jobs due to the economic crisis chose to be dependents of the employee insured among family members, rather than being an independent self-employed insured. This explicitly shows that the changes in dependent ratio can be explained by the institutional features of the dependent system itself. It implies that institutions can affect families’ choice of action in respoding to the environmental changes. Taiwan Effects of the institutional arrangements also can be found in the Taiwan’s NHI. As stated above, Taiwan’s NHI divides the insured into

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Table 3.7  Status of the dependent ratio of Taiwan’s NHI by categories Total 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

0.71 0.75 0.76 0.75 0.74 0.73 0.74 0.72 0.71 0.68 0.66 0.65 0.62 0.61 0.59 0.56

Category 1

Category 2

Category 3

Category 4

Category 6

0.79 0.82 0.82 0.81 0.80 0.78 0.80 0.79 0.76 0.73 0.71 0.69 0.68 0.68 0.66 0.62

0.72 0.79 0.80 0.81 0.80 0.79 0.78 0.77 0.75 0.72 0.70 0.67 0.64 0.61 0.58 0.56

0.51 0.56 0.59 0.61 0.62 0.63 0.63 0.64 0.64 0.64 0.63 0.62 0.61 0.60 0.58 0.56

1.14 1.11 1.13 1.12 1.16 1.15 – – – – – – – – – –

0.64 0.68 0.69 0.69 0.67 0.66 0.64 0.62 0.63 0.61 0.59 0.57 0.55 0.52 0.50 0.49

Source The National Health Insurance Statistics, each year

six categories according to their employment status and occupations (see Table 3.2) and applies the different insurance calculation methods. Among these six groups, Category 4 does not have to pay insurance fees as it is fully supported by the government and Category 5 does not practice the dependent system. In the case of the insured of Categories 1, 2, and 3, their insurance fee is decided by multiplying their “monthly income” by the “premium rate,” the “contribution ratio,” and finally by the number of dependents including the insured themselves. The insurance fee of the insured of Category 6 is decided by the following formula: “Average Premium × Contribution Ratio × (1 + Average Number of Dependents)”. In sum, except for Category 4 and 5, the number of dependents affects the amount of insurance fee of all the insured in Taiwan’s NHI: the insured have to pay the insurance fee in proportion to the number of dependents. Table 3.7 shows the changing patterns of dependent ratios of five categories of Taiwan’s NHI, excluding Category 5 that does not practice the dependent system. Among five categories, the dependent ratio of Category 4 is extraordinarily high. Category 4 mainly includes the military personnel—both professional soldiers and volunteers—and their

66  H.S. Wang

families. Then, does it reflect that, compared to other occupational groups in Taiwan, the military group has an extraordinarily larger family size? The answer is no. Rather, the high dependent ratio of this group stems from the institutional arrangements of its dependent system. Insurance fees of Category 4 are 100% paid by the government. Therefore, the insured of this category can register their families as dependent without any additional economic burdens. It signifies that the extraordinarily high dependent ratio of Category 4 stems not from the distinct reality of military family but from the institutional arrangements of their dependent system: the incentive structure built in the system lowers individuals’ cost of accessing the state’s welfare by relying on the familial relations and raises the cost of commanding the individual entitlements. In sum, we can conclude that the different dependent ratios of S. Korea and Taiwan can be more efficiently explained by the incentive or the disincentive structure built in the institution itself rather than by the demographic or socio-economic factors. Korea’s NHI administers an institutional arrangement that reinforces the insured’s incentives to increase the number of dependents, while Taiwan’s NHI triggers the insured’s incentives to decrease the number of dependents. Institutional arrangements explain not only the national differences of dependent ratios of S. Korea and Taiwan but also the different dependent ratios among divided programs within each country. Due to such institutional arrangements and designs, in S. Korea, the self-employed insurance shows a lower dependent ratio than the employee insurance, and in Taiwan, Category 4 shows the highest dependent ratio compared to any other categories in the same NHI program. Such statistical examination implies that the dependent systems of S. Korea and Taiwan, in spite of their similar familialistic foundation, reveal the different familialization effects depending on each of the specific institutional arrangement and design. The Korea’s dependent system has a relatively high familialization effect that encompasses as many family members as possible into the state’s welfare institution. The Taiwan’s dependent system includes only a limited extent of family members into the state’s welfare institution, and leads families to seek their state welfare service independently of the familial relations, and therefore, has a limited familialization effect. In this regard, the different dependent ratios of the two NHIs, which show how much people rely on the familial relations to get entitled to the state’s welfare, are not the corollary of changing family realities or family tradition, but the

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outcomes of intervention of the welfare states with different degrees of familialization effects.

Conclusion: Divergence in Familialistic Welfare Institutions So far the chapter has investigated the detailed institutional differences of the two seemingly similar welfare programs in S. Korea and Taiwan. The results indicate that their NHIs share some characteristics of the conservative welfare regime in common, yet reveal different institutional arrangements regarding families. Their NHIs have different incentive structures, which entail the different responses from individuals and families, and finally demonstrate the varying degrees in familializing the welfare regime, in other words, maximizing one’s reliance on familial relations in fulfilling one’s welfare need. Such results allow us to raise the question on the existing literature, which exaggerates common features of familialism among East Asian countries. Some stress the persistent influence of Confucianism as the common cultural backgrounds of Taiwan and S. Korea. The extended family has been an essential part of the Chinese society, both as its cultural ideal and social reality. The traditional Chinese ideal of the family has been co-residence of parents with their married sons and their families in a large, joint-stem household unit (Freedman et al. 1978; Hahm 2003). Also, existing literature all point out that the families in Asian countries play a considerable role in offering welfare services. Nevertheless, most of them only adumbrate “families matter” as an independent factor deciding the welfare regime in the region, but do not articulate how different kinds and dimensions of families play certain roles in welfare regimes. Also, they do not articulate the mechanism that sustains such familial welfare functions in spite of the rapid modernization and industrialization threatening families. However, this chapter reveals that there exist fundamental differences in family norms embedded in the formal welfare institutions of S. Korea and Taiwan. The result implies that the East Asian societies, in spite of the shared Confucianism or the familialism as their cultural and traditional backbones, can develop distinct welfare institutions. Also, this chapter explains the variety of familialism inside the East Asian welfare regime, not as the cultural inheritance of the Confucian culture, but as the outcome of the familialization effect of social policies in S. Korea and

68  H.S. Wang

Taiwan. The argument can reject the outdated view on familialism that the household economy run automatically and autonomously alienated from outside institutions like state or market: we have never had such families in our history (Polanyi 1957). Then, the next question would be the reason why S. Korea and Taiwan have come to institutionalize the state welfare programs with the different familialization and de-familialization effects based upon distinct family norms and ideals. This will be the research topic for the next two chapters. Here, I should note that the term “de-familialization” used in this book should not be identified as the weakening or deconstructing of family or “anti-family” (Esping-Andersen 1999, 51). The concept is an operational indicator to estimate the extent to which the welfare state minimize one’s reliance on families: it does not mean the overall defamilialization or individualization, or the weakening family in a society at large. It is undeniable that the de-familialization effects of a specific social policy can generally influence families in a society. However, their influence cannot be easily judged: welfare institutions with high familialization effect can weaken families unintendedly (Polanyi 1957, 82–83), and de-familializing welfare institutions do not always lead to the decline of family’s role in caring its members. Likewise, a high de-familializing effect of the Taiwan’s NHI does not mean that the Taiwanese welfare state incurs the decline of the family’s role in welfare: Taiwanese families still take care of their members’ welfare in informal dimension. The point is that Taiwanese families just do not have the welfare state that matches with their family realities. The opposite can be applied to the Korean case: Korea’s NHI reveals a high familialization effect but it cannot properly reflect the changing reality of Korean families, either. It is the matter of coupling or de-coupling between families and state, and families in both countries do not retain the welfare states that can be properly coupled with their realities. Then, related question that can be raised would be why both Korea and Taiwanese families have established the welfare institutions far from their realities and have not tried to transform those institutions. This shall also be the topic of Chaps. 4 and 5. In finding the answer to the questions, next chapters will trace the historical development of each NHI in S. Korea and Taiwan. In the process, I will highlight the role of families not as dependent variable but as an independent variable. In this chapter, they have been treated as rational actors who calculate the economic incentive and disincentive

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under the given structure. In the following two chapters, they will be treated as political actors who actively try to change the incentive structure itself, and “create institutional changes,” though not a social revolution (Esping-Andersen 1999, 47).

Notes 1. See the Taiwanese National Health Insurance Act (全民健康保險法, http:// dohlaw.doh.gov.tw/Chi/FLAW/FLAWDAT0201.asp?lsid=FL014028, accessed on June 13, 2010) and the Korean National Health Insurance Act (國民健康保險法, http://www.nhic.or.kr/portal/site/eng/menuitem. d31a2a54ebe26a0644416433062310a0/, accessed on June 13, 2010). 2. The NHI in S. Korea has maintained the dependent system since 1963 when it was acted first. Meanwhile, in Taiwan, the dependent system existed only in the civil servants insurance which started in 1958. It was not until the launching of the NHI 1995 when the dependent system was adopted and extended into a universal social insurance. The historical development process of each NHI will be discussed in Chaps. 4 and 5. 3. The difference between the two notions was already mentioned roughly in Esping-Andersen’s work (1990, 47): in discussing the de-commodification of the welfare states, he also mentioned the de-commodification “potential” and its real outcomes were estimated through welfare mix in pension. 4. Especially, collateral families (brothers and sisters of the insured) have to meet the condition of cohabitation as well as income test, in which their total income in a year should be under 5 million Korean Won. 5. The dependent entitlement for collateral families such as children of brothers and sisters (niece and nephew) and parent’s brothers and sisters (uncles and aunts) was abolished in 2000. 6. In Korea, “monthly incomes” are reported by the employers to the NHI Corporation. “The premium rate” means the ratio of the amount of the insurance fee out of the whole income and it is set by the NHI bureaus or Corporation annually: it was 6.07% in 2015 (http://www.nhis.or.kr/ static/html/wbd/g/a/wbdga0404.html). 7.  In Taiwan, “monthly incomes” are based on the amounts reported by themselves to the bureaus. “The premium rate” is set by National Health Insurance Act, and has maintained 4.91% since April 1, 2010. The “contribution ratio” means the proportion of each among the insured, the government, and the employer takes respectively, and the contribution ratio of the insured are mainly 30 or 60% (http://www.nhi.gov.tw/English/webdata/webdata.aspx?menu=11&menu_id=591&WD_ID=591&webdata_ id=3153). The maximum number of dependents is of three even if the actual number of dependents is higher.

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References Aspalter, Christian. 2002. Democratization and Welfare State Development in Taiwan. England: Ashgate. Chang, Ming-cheng, 1987. Changing Familial Network and Social Welfare in Taiwan. In Conference on Economic Development and Social Welfare in Taiwan Vol. II , 459–482. Taipei, Taiwan: The Institute of Economics, Academia Sinica. Esping-Andersen, Gøsta. 1990. The Three Worlds of Welfare Capitalism. Princeton, NJ: Princeton University Press. ———. 1999. Social Foundations of Postindustrial Economies. New York: Oxford University Press. Freedman, Ronald, Baron Moots, Te-Hsiung Sun, and Mary Beth Weinberger. 1978. Household Composition and Extended Kinship in Taiwan. Population Studies 32 (1): 65–80. Greenhalgh, Susan. 1984. Networks and Their Nodes: Urban Society on Taiwan. China Quarterly 99: 529–552. Hahm, Chai Bong. 2003. Family Versus the Individual: The Politics of Marriage Laws in Korea. In Confucianism for the Modern World, ed. D. Bell and C.B. Hahm, 334–359. Cambridge: Cambridge University Press. Lee, Sang-Yi, Chang-Bae Chun, Yong-Gab Lee, and Nam KyuSeo. 2008. The National Health Insurance System as One Type of New Typology: The Case of South Korea and Taiwan. Health Policy 85 (1): 105–113. Lee, Yong-Gab. 2012. The Re-compositions of Family Members in the NHI. Health and Social Science 31: 22–54 (In Korean). Lee, Yong-Gab, Kyeong-ha Kim, Ji-yeong Park, Ui-heon Um, Chang-baeJeon, Sun-imHeo, and Mi-kyeongGu. 2005. Research on National Health Insurance Programs Abroad. Research Paper 2005-3, National Health Insurance Corporation (In Korean). Lin, Chen-Wei. 2002. The Policymaking Process for the Social Security System in Taiwan: The National Health Insurance and National Pension Program. The Developing Economies 40 (3): 327–358. Polanyi, Karl. 1957. The Great Transformation: The Political and Economic Origins of Our Time. Boston: Beacon Press. Skocpol, Theda, and Margaret Somers. 1980. The Uses of Comparative History in Macrosocial Inquiry. Comparative Studies in History Society 22: 174–197. Son, Annette H.K. 2001. Taiwan’s Path to National Health Insurance (1950– 1995). International Journal of Social Welfare 10 (1): 45–53. ———. 2003. The Extension of Entitlement to Health Insurance in South Korea and Taiwan: A Historical Institutional Approach. Economic and Industrial Democracy 24 (3): 455–478.

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Tchoe, Byongho. 1998. Integration of NHI in Taiwan and New Restructuring Debates. Health Welfare Forum 21: 88–99. Wang, Hye Suk. 2012. Familial Foundations of the State Welfare: A Comparative Approach to the Health Insurance Program in South Korea and Taiwan. PhD Thesis, Department of Sociology, Graduate School of Yonsei, Seoul, Korea (In Korean). Weinstein, Maxine, Te-Hsiung Sun, Ming-Cheng Chang, and Ronald Freedman. 1990. Household Composition, Extended Kinship, and Reproduction in Taiwan: 1965–1985. Population Studies: A Journal of Demography 44 (2): 217–239. Williamson, Oliver E. 1988. The Economics and Sociology of Organization: Promoting a Dialogue. In Industries, Firms and Jobs: Sociological and Economic Approaches, ed. G. Farkas and P. England, 159–185. New York: Plenum Press.

CHAPTER 4

Historical Development of NHI in S. Korea: Why not Equal Protection for Female Workers’ Families?

The earlier chapter compares the NHIs of S. Korea and Taiwan, which exemplify the familialistic nature of their welfare regimes. The result reveals the divergence in the (de-)familialization: the highly familialized welfare regime of S. Korea and the highly de-familialized welfare regime of Taiwan. Further, it interprets the gap in familialization of their welfare regimes not as an outcome of familial culture or the Confucian tradition, but as institutional designs built in the two NHI systems. The Korean system institutionalizes an incentive structure, which is designed to lower the cost of commanding the welfare entitlements relying on the familial relationship, thereby inducing individuals to act familialistically: the incentive structure built in the Taiwanese system lowers the cost of individual eligibility, thus induces even families to command their welfare benefits individually. The result implies that the familialization of one’s welfare, in other words, the extent of one’s reliance on family in securing one’s welfare need, is strongly influenced by the intervention of the welfare states and institutional features of their social policies. This interpretation could be condemned for its way of dealing with families. If we conceptualize the families as collective actors (Chang 2010), this perspective construes these actors as “rational fools” or institutional dopes who just react to the given incentive structure based on calculating the economic cost and benefit without considering any social norm. Otherwise, if we conceptualize families as one of social realms (Polanyi 1957), the interpretation reduces families to a substructure of a state or a market: thus, the choice of action or reaction by families is © The Author(s) 2017 H.S. Wang, Familial Foundations of the Welfare State, DOI 10.1007/978-3-319-58712-7_4

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the function of social policies or labor market, and families have no independent mechanism in operating welfare regimes. Both ways deny the possibility of families in playing the decisive role in forging the welfare regimes. However, this perspective is what underlies the earlier debates on the welfare states in the political economy and the feminist political philosophy. In the inter-causal triad of state, market, and family, both camps pay attention to the determinant role of the welfare state in de-familializing and de-commodifying one’s welfare. Both of them advocate that the intervention of the welfare state through social policies can minimize one’s reliance on family and market. In their analytical frame, family is conceived as a dependent variable whose role as welfare provider could be determined by the contents or the degree of intervention of welfare states, not vice versa. Moreover, Esping-Andersen situates social classes as the political agents that can build the welfare state with high potentials of defamilialization and de-commodification. In his analysis on the inter-causal triad of welfare mix, families are set as passive clients of the welfare state. In order to overcome limits of earlier approaches as well as Chap. 3 of this book in dealing with families, this chapter and Chap. 5 approach families as independent institutions as well as actors, and thereby highlight their roles in making or reshaping the welfare regime from a historical perspective. In Chap. 3, families are treated as passive actors who calculate the economic incentive and disincentive under the given structure. This chapter and Chap. 5, they are treated as political actors who actively try to change the incentive structure built in the welfare states and to “create institutional changes,” though not a social revolution (Esping-Andersen 1999, 47). From this perspective, the next two chapters will trace the historical process in the development of each NHI in S. Korea and in Taiwan. As Chap. 3 compares S. Korea and Taiwan, Chap. 4 and 5 compares the initial and the later periods of NHI within each country. In the process, applying the aforementioned two meanings of cultures, the two chapters will examine what interests and motives families have had in claiming the familializing or de-familializing welfare states and how families have tried to realize them in the welfare politics. Chapter 3 demonstrates that the NHI of S. Korea stipulates more generous conditions for entitlements to family dependents than that of Taiwan, even though both of them belong to the conservative welfare regime with a similar familialistic frame of social insurances, in which entitlements are decided not by individual citizenship but by familial

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membership and relationship. The generosity of the Korean dependent system is measured with the two dimensions: the broad scope of family dependents and exemption from insurance fee for dependents. The family ideal envisaged in the NHI of S. Korea is closer to the traditional norm of extended families, both in family structure and in principle of collective rights. As a result of comparison, the NHI of S. Korea reveals a higher familialization effect. Interestingly, Korea’s NHI did not have such a generous dependent system from the start. When it was launched in 1977, it confined dependent entitlements only to the male insured’s spouse, parents and children, demonstrating “patrilineal stem” family or typical “male breadwinner model.” This early model is very close to the familial model of the present Taiwanese NHI. However, such a narrow definition, through several decades of revisions, has shifted from patrilineal to bilineal and from stem to collateral, and finally reached today’s “gender-equity extended” family. Then, who are the main actors and what is their reason behind such a dramatic expansion of dependent eligibility of the Korean NHI? To answer this question, this chapter pays attention to motives and interests of the family, which had been the hidden actors in the existing welfare state. The chapter examines the historical process of how the familialistic institution has been institutionalized by families as political actors and what were their interests and motives in building such an institution. However, in the realm of welfare politics, even though some groups had strong interests in the familialistic institution, their interests could not be automatically institutionalized into social policies. As the institutionalization process, in other words, the policy making process entails the negotiation and political struggle against those who oppose the policies, the group in favor of familialistic policies had to confront with the opposing groups. Moreover, in the early period of welfare institution building in East Asia, the state is the powerful actor in welfare politics. Therefore, even though this chapter aims to pay attention to families, it is inevitable to consider the role of a state, its perception of families, and, above all, the state’s interests and policy aims in establishing the familialistic welfare state, which could have had unexpected repercussion on the welfare politics. Therefore, this chapter examines the historical process of the familialistic institution building and its transformation, from the viewpoint of the three main interests groups: the first is one group of the insured (including their families) who were for the familialistic institution, the second is the other group of the insured against it, and the third is the

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state. What were their interests in building the familialistic institutions, and how did their conflict or consonance end?

Development of NHI and Expansion of Dependent Eligibility From Patrilineal Stem Families to Gender-Equity Extended Families S. Korea’s first NHI act was legislated in 1963. The period around 1963 was a historical watershed for social policy alignment. The Park Chung Hee Regime, after seizing power through a coup, declared the realization of the welfare state and the banishment of poverty as the government’s ultimate goal (Davis 2004). The Park regime established more than ten innovative programs for basic social welfare, of which the first NHI was one. However, this act provided that the NHI should be made available on a voluntary basis. During this period, only 11 companies administered the health insurance for their employees. Hence, it remained virtually ineffective, covering only a meager portion of the population until 1977 when the insurance was converted to a compulsory program (Son 1998, 17). In December 1976, the Park regime amended the NHI Act, which stipulated that companies with more than 500 workers were obliged to have their employees covered by the NHI beginning in July 1977. It was the starting of the compulsory NHI for employees. Since then, the scope of compulsory clause had gradually expanded to small and medium sized companies. In the late 1980s, as the insurance included the rural population, i. e., farming and fishing village residents (1988) and the selfemployed in cities (1989), the NHI scheme developed to cover de facto the whole population, as affirmed in Fig. 4.1. Considering the fact that the development of the welfare state requires the corresponding development of bureaucracy and administrative capacity, it is astonishing that Korea’s NHI was able to encompass the whole population in such a short period. In its early expansion, the Korean NHI owes its success to its dependent system. As seen in Fig. 4.1, the dependent system made an important contribution to the quantitative expansion of the NHI. Especially, in the two periods that showed the most drastic quantitative explosion of the NHI coverage population, that is, 1979 (increased 102.0% year-on-year) and

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50,000 45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000

= Total Population,

= dependents,

2009

2007

2005

2003

2001

1999

1997

1995

1993

1991

1989

1987

1985

1983

1981

1979

1977

0

= insured

Fig. 4.1  Status of the insured and the dependents of the NHI of S. Korea (unit: 1000 persons). Source 2010 National Health Insurance Statistical Yearbook

1987–1989 (increased 34.7–36.8% compared to 1986), the main reason for the expansion was the active participation by the dependents. In 1979, which showed the most noticeable expansion of covered population, two events occurred: one was the inclusion of public servants and private school teachers in the NHI program and the other was the expansion of compulsory clause to companies with more than 300 workers. During this period, the newly covered population was 4,076,807 persons in total, and among them, the number of the insured was 1,063,670 (26.1%) and that of dependents was 3,063,670 (75.2%). The statistics shows that dependents outnumbered the insured by three times. The main drive for the expansion in the second period 1987~1989 was the implementation of self-employed insurance in rural areas in 1988, which produced 6,427,177 persons of newly covered population. Among this number of covered population, householders were 1,627,072 (25.3%) and dependents were 4,800,105 (74.7%). In the very next year 1989, with the administration of self-employed insurance in urban

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areas, the newly entered population reached to 12,455,867, including 3,672,484 householders (29.5%) and 8,783,383 dependents (70.5%). Even though the two events took place at a different time targeting the different social groups, they reveal a common feature. In fact, throughout the entire history of the NHI including the two periods, dependents have always outnumbered the insured, and the proportion of dependents to the whole coverage population always has taken the absolute majority. This implies that dependent system was the main driving force for the expansion and inclusion mechanism in Korea’s NHI. The statistics only addresses the quantitative dimension of the NHI development. In its qualitative dimension, one of the most drastic expansions can be found other than in its dependent system. The first act defined the beneficiary as “the insured” and “the insured’s dependent family,” yet did not specify the particular regulations for the scope of dependents or the process for acquiring dependent’s eligibility. Consequently, the first NHI remained as a program just for the insured (KFMIS 1997). The revised act in 1976 stipulated the scope of dependents as the insured’s “spouse, lineal ascendants, and lineal descendants who mainly supported by the insured.” This stipulation limited the scope of dependent to lineal families among relatives through blood and only to spouse among relatives by marriage. It adopted the lineal stem family ideal and applied the narrow term in defining legitimate dependents. Since then, the term “dependent” had gradually included further range of kinship. Conventionally, the development process of the dependent system can be divided into two periods (Cho 2002): the expansion period from the first implementation of the NHI in 1977– 1995 when the last expansion of dependent system was passed, and the retrenchment period after the integration since 1998. This section mainly explores the first 30 years of the expansion process, focusing on changes in definitions and scope of dependents. First, in 1981, this regulation was revised to include “lineal ascendants” of spouse of female insured, that is, husband’s parents. This revision underlay the traditional responsibility of wives in supporting their husbands’ parents. Next, in 1982, parents of single female insured were included under the condition of co-habitation. The 1985 revision further recognized parents of wife as (husband’s) dependents. This revision also institutionalized the familial responsibility of husbands in supporting wives’ parents, which seemed to deviate from the custom of patriarchy but still stayed within the bounds of traditional familial norms of the filial

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piety. In this way, the law was revised and extended the entitlement of dependents to lineal ascendants (parents) of male and female or husband and wife. Figure 4.2 visualizes the process of expanding the dependent entitlements for parents on both sides in this period. Since the late 1980s, the dependent eligibility had been broadened to encompass the collateral families. The revised act in 1987 granted the dependent eligibility to lineal descendant’s spouse (children’s and grandchildren’s spouses) and, more importantly, brothers/sisters supported by the insured. Moreover, in 1989, parents with a certain amount of incomes or property and unmarried brothers/sisters under 20 without stable incomes were also included. In 1990, as the earlier regulation on co-habitation was eased, parents and unmarried brothers/sisters could be registered as dependents even if they did not live with the insured. Finally, in 1995, the scope was extended to “stepparents, stepchildren, birth parents, biological children, mother’s grandparents, daughter’s children, and collateral kin within third degree (uncles, aunts, nephews, nieces and so on).” To sum up the overall changes from 1963 to 1995, the dependent system of S. Korea’s NHI, starting with the frame of patrilineal stem family, expanded its eligibility to the females’ families and collateral kin, and reached today’s “gender-equal and partially extended family.” The Kim Dae-jung government, which was launched during the turmoil of 1997 financial crisis, initiated the restructuring of NHI and abolished the dependent eligibility to some collateral families such as children of

Fig. 4.2  Expansion process of parents’ dependent entitlements

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brothers and sisters (nieces and nephews) and parent’s brothers/sisters (uncles and aunts) in 2000. However, the familialistic frame of the dependent system remains intact and the Korean NHI still confers the dependent entitlement to an extraordinarily broad range of family relations, as summarized in Fig. 3.2 of Chap. 3. Until today, the majority of the population are still covered not by individual citizenship but by the family membership. Then, what is the main driving force, which had led the continuous expansion of the dependent eligibility since 1977? As the dependent system is intrinsically related to families, its changes could reflect the transformation and adoption of Korean families to the industrialization and urbanization. However, Table 4.1 indicates that there is a certain gap between the family model reflected in the dependent system and the reality of the Korean families. According to the statistics in 1975, around when the NHI was about to launch as a compulsory scheme, the proportion of patrilineal stem family on which the first NHI was based was only about 11.4%. Meanwhile, nuclear families already occupied 70.7% in 1975 and reached 79.8% in 1995 when the last and most generous expansion of dependent took place. It is clear that the dependent scope has expanded against the overall changing pattern toward the nuclear family. To solve the puzzle concerning the gap between expanding dependent eligibility and declining family size and structure, it is necessary to examine who have been the main actors claiming the expansion and for what. Based on evidence collected from newspaper articles from 1977 to 1995, the following section scrutinizes how the insured responded to the dependent system of the state launched in 1977. First, it will take a view of the voices of the insured groups who claimed the expansion of the dependent entitlement to include a broader scope of kinship. At the same time, considering the risk of generalizing the institutional changes by a partial voice of a particular group, it also pays attention to the voices of the insured groups who were against the expansion and tried to de-familialize the dependent system. Hence, it will try to take a balanced approach to the contested views on the familialization of the welfare system. Plus, considering the nature of NHI as social policies implemented by the state (O’Connor 2006) and the authoritarian characters of the Korean developmental state (Wong 2004; Woo 2004), it will scrutinize the state’s interest behind the expansion and its role in the process.

6367 7470 8751 10,167 11,133 11,928 12,491

1975 1980 1985 1990 1995 2000 2005

5.0 6.4 7.8 9.3 12.6 14.8 18.1

55.6 56.5 57.8 58.0 58.6 57.8 53.7

10.1 10.0 9.7 8.7 8.6 9.4 11.0

0.5 0.6 0.8 0.9 1.1 1.2 1.2

Parents with married child(ren)

A father or mother with unmarried child(ren)

Married couple

Married couple with unmarried child(ren)

Stem family

Nuclear family

10.9 10.4 9.9 9.3 8.0 6.8 5.7

Grandparents, parents with unmarried child(ren)

Source Korea Statistics (National Statistics Bureau), Population and Housing Census Report, 2010. Note: * exclude “nonfamily households,” in which unrelated persons lived together and one-person household.

General household* (thousand)

Year

Table 4.1  Types of households in S. Korea

17.9 16.1 14.0 13.8 11.2 10.1 10.4

Others

5.0 4.5 4.1 3.7 3.3 3.1 2.9

Average persons of a household (person)

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Expansion of Dependent Entitlement and Recognition Struggles of Families Why not Equal Rights for Female Workers? The first NHI act was legislated in 1963 and revised to a compulsory program in 1977, following the first act without any correction of regulations. The first act, which was already outdated and unable to correspond to the changing reality of families in 1963, was put into an action in 1977 without any consideration of accelerated social changes within 14 years. The period between 1963 and 1977 marked the era of rapid industrialization of S. Korea, and social changes regarding women and families were more remarkable. In the early stage of industrialization in the 1960s and the 1970s, the increased demand for labor was mobilized from cheap female labor and the proportion of female labor was extraordinarily high in the labor-intensive industries (Koo 2001).1 The proportion of the female insured of NHI reflects this trend. As shown in Table 4.2, the number reached 37.2%, marking the highest in 1980, and had gradually decreased afterwards. However, the first NHI conferred the dependent eligibility based on the traditional “patrilineal stem family.”2 This family model of the then NHI is appreciated to have been influenced by the Family Law of the old Civil Law around 1963 when the NHI was launched (Lee 2007). According to the law, the scope of relatives are “patrilineal relatives within eighth degree of consanguinity, matrilineal relatives within fourth degree of consanguinity, husband’s patrilineal relatives within eighth degree of consanguinity, husband’s matrilineal relatives within fourth degree of consanguinity, and the wife’s parents and their spouses (in the Table 4.2  Status of the insured of the NHI (employee insurance) by gender (unit: person) Year

Female

Male

1980 1985 1990 1995 2000

733,538 1,220,728 1,600,513 1,573,475 1,591,651

1,237,651 2,687,237 3,697,057 4,203,055 4,299,353

Source Lee 2007, 15

Proportion of female (%) 37.2 31.2 30.2 27.2 27.0

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case of remarriage).” Thus, the old Civil Law found its family ideal in the extended family encompassing the direct and the collateral line. And the stipulation is centered to patrilineal relatives based on the patriarchy. Therefore, it applied the strict discrimination against the matrilineal family in comparison with the patrilineal family, and against the wife’s family in comparison with the husband’s family (Lee 2008). It also established the primogeniture, with male offspring having a precedence over females as well as the first son over others. Under this system, the first son succeeds the family and supports his parents, while the second or other sons and daughters move out of the family and set up branch families (Lee 1997). The dependent eligibility of the NHI based on this narrow and outdated family norm posed several problems right after its implementation. For example, the first son could register his parents as dependents even if he had omitted the obligatory, if perfunctory, screening procedure. On the other hand, in order to register parents as dependents, the second son had to submit documented evidences and the daughter had to live together with their parents. Due to the patrilineal regulation, most of the female insured who left their home and worked in cities could not grant the dependent eligibility to their parents or other family members (brothers and sisters) who lived in the rural hometowns. Moreover, these female workers belonged to the age group of the least demand for medical services. Also, they could not benefit much from the NHI due to their working hours even when they encountered disease or injuries. Nevertheless, as the NHI was converted to the compulsory one, their insurance fees were deduced automatically from their salaries every month. Thus, the NHI was considered to be ineffective for female insured and their families. Naturally, the first resistance to the NHI, that is, the demand for the expansion of dependent eligibility arose from the female insured, especially unmarried female breadwinners who supported their parents and siblings. Right after the compulsory NHI launched in 1977, the female insured started to file complaints about the dependent regulation to the NHI corporation, and the mass media featured this problem as the most pressing issue that the government should solve.3 Afterwards, professionals and academia also asserted that considering the Korea’s family norm and realty it would be proper to extend the scope of dependents to include brothers and sisters.4 Above all, the female insured as breadwinners, mainly unmarried female workers, actively raised complaints and

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claimed to recognize the dependent eligibility of their parents and siblings who lived separately. In the case of Miss L who left her hometown in 1980 and has worked in K industrial complex, she supports her two little siblings’ educational expenses in less viable living situations. The health insurance fee is deducted from her salary every month. However, due to the dependents regulation, her siblings cannot benefit from the insurance even when they get sick. Her parents in the rural hometown also cannot obtain dependent eligibility because they do not live together. Therefore, only her name appears on the health insurance card. She herself rarely goes to the hospital. To Miss L, the insurance fee merely refers to “the third tax.”5 Among the total insured, the proportion of unmarried female workers whose siblings cannot benefit from the insurance, in other words, who just contribute to but cannot benefit from the health insurance occupy about 48 percent.… First of all, for unmarried female workers, the scope of dependent should be extended to include “siblings in the same family who are supported by the insured.” … without such remedial actions, the less benefiting insured cannot but consider the insurance fee as the second tax considering their poor salaries.6

As shown in the above articles, the female insured criticized the unfairness of the system: they considered it economically unfair that their families could not be recognized as dependents despite paying the same amount of insurance fees based on their salaries with the male insured whose families enjoyed the benefits as dependents. Moreover, their dissatisfaction with the system is about the discrimination against their families rather than themselves. According to their claims, what hindered the female insured and their family members from fully and properly enjoying their accrued rights is the patrilineal family ideal enshrined in the NHI Act. The female insured pinpointed that the economic discrimination against them stemmed from the social and cultural nonrecognition for female breadwinner’s family. They alleged that the dependent system made an unjust distinction between “male insured and female insured,” and recognized only the household of male breadwinner as normal. This official and institutionalized distinction was applied not only to the female insured themselves but also to their families. The familial boundary of the ideal male breadwinner model—parents, female spouse, and children mainly supported by husband—definitely differed from the unmarried female worker’s

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family—parents and siblings. Nevertheless, the act did not recognize their family dependents, thereby stigmatizing them as abonoral families. Their voices are in consonance with Honneth’s second form of recognition struggle. In this type of struggle, the main agent is a person or a specific group who are structurally excluded from the possession of certain rights in a society, as exemplified by the denial of rights or by social ostracism, which would imply that he or she is not recognized as a full-fledged member of a community, equally endowed with moral rights (Honneth 1996: 133). Therefore, this form of struggle relies on the general and universal feature that makes him or her a legally capable subject equal to other male workers. The resistance of the female insured shares the main characteristics of the recognition struggle for rights. Based on their labor rights equal to make workers, they insist that they and their family should be equally endowed with welfare rights that are guaranteed to male workers and their family. In this way, they demanded the institutional recognition of their families even though their family situation might be dissimilar to that of male workers. Their claims can be interpreted as claiming material benefits of NHI, that is, providing their family members with the medical service and benefits at the minimum cost which, otherwise, should be paid out of their pockets. In this regard, their struggle could be interpreted as an economic one for equitable distribution of scarce resources (Fraser 1997). However, material interests are closely related with moral and normative ones (Kymlicka 2002, 328): “the negation or forfeit of specific rights and the objective inequalities in the distribution of material opportunities” can lead individuals to experience feelings of being disrespected and treated with injustice or disdain (Honneth 1996, 161). Since relations of social esteem are indirectly coupled with patterns of income distribution, economic confrontations are also constitutive for this form of struggle for recognition (Honneth 1996, 127). In particular, “when the social esteem for a person or group is so obviously correlated to the level of control over certain goods, only the acquisition of those goods can lead to the corresponding recognition” (Honneth 1996, 166). In the then Korean society, the NHI eligibility was the material goods so obviously correlated with the social esteem. In the early NHI scheme, only the specific social groups, especially those who were important in enhancing the state’s legitimacy and promoting the industrialization, were given priority in their eligibilities (Kim 2002). In this selective system, the state prioritized the civil servants, military, and workers in

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the strategic industrial sectors and their families, which was only 10% of the then total population. In this context, to the female insured and their families, the NHI eligibility did not only mean the material utilities of particular medical services, but also the symbolized social status and prestige as industrial warriors that contribute to the national development and deserved the corresponding protection from the state. It implies that their struggle can be interpreted as demanding the third form of recognition for social esteem. Contrary to the second form based on the equality, the third form of recognition relies on certain personal traits or particular characteristics (their own accomplishments and forms of life) that distinguish a person or a specific group from others and show a person or a specific group to be especially valuable (Honneth 1996, 113, 126). The following quote is worthy of note as it reveals another dimension in the struggle of the female insured, which makes their struggle differentiated from the Western cases of distributive struggle. I tried to register my mother who lives together as a dependent. First, I assumed that she could be my husband’s dependent believing an old Korean saying, “a son-in-law is another son.” However, the regulation denied the eligibility of parents-in-law. So, I decided to register her as my dependent. The NHI act rejected my request again, and the reason was that my brother is expected to support her. It is that irresponsible son that has made me support her for more than 10 years. Nevertheless, the regulation says that a daughter can’t be a legitimate child to fulfill a filial piety.7

Here, she stresses the primary affectional relationship between her and her mother who share the financial interdependence and affectional attachment and interprets the dependent system as an institutional obstacle to the recognition of their intimate relationships. She decries that even though she has lived with her mother and supported her for a long time instead of son, the system does not recognize her and her mother as a legitimate family only because she is a daughter. To the female insured, this kind of denial is interpreted as disrespect, which implies that a daughter is not a capable subject equal to son. In the patrilineal system, daughters have been considered as inferior to sons and economically dependent on male breadwinner. In this context, the NHI entitlement was the symbolic goods that could reevaluate and elevate their degraded identity and recognize her as legitimate child as well as breadwinner of

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family. It shows that her struggle is oriented to or based on the first type of recognition for the intimacy in primary relationships. Nevertheless, her recognition struggle is somewhat different from the first form of recognitiosn struggle. Theoretically, one pursues the first type of recognition from his/her significant other, who is usually the interaction partner in his/her primary or intimate relationship. However, in the article, she demands the recognition not of a significant other but of the institution or the state’s legal system, which could be the specificity of the recognition struggle of S. Korea. This difference is stemmed from the institutional features of S. Korea’s NHI, which was designed for the familialization: the familial membership determines the eligibility in the state welfare institutions, thus the intervention of the welfare state intensifies an individual’s reliance on family. Thus, the nature of welfare state forges the specificity of recognition struggle in the welfare politics. In sum, what the female workers struggled for was the recognition as legitimate and respectable citizens and industrial workers who contributed to the national development as well as responsible breadwinners who supported their family. In their struggles, under the influence of the familialistic welfare regime of S. Korea, demands for three forms of recognition for intimacy, rights for distribution, and social esteem are intertwined to constitute the welfare politics of S. Korea. Also, the moral dimension of recognition struggle does not mean that this type of struggle always stems from purely moral and normative motivation: neither a normative nor a material motive solely constructs the whole process of struggles; the two motives act together and reinforce each other during the process. The previous quote also demonstrates how the two meaning of culture is operating in the recognition struggle. In the news article, she sets up a series of cultural codes specifying sacred and profane elements (Smith 1991), in which the most fundamental binary opposition is the distinction between “an irresponsible son and a filial daughter” and “the unreasonable NHI and the family norm of filial piety.” To resist the patrilineal norm of the dependent system and thereby legitimizing her right as daughter, she utilized the alternative norm of filial duty of children from the tool-kits of traditional norms inscribed in the Confucianism. The struggle for recognition intrinsically entails the cultural struggle in which different groups attempt by means of symbolic force to raise the value of their personal traits and specific abilities associated with their way of life. In order to acquire the recognition, social groups should succeed in publicly interpreting their own abilities and traits

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Fig. 4.3  The interplay of two forms of culture in shaping the NHI in S. Korea Source Chan 2009, 296

within value system (Honneth 1996, 126–127). Within this value system of Korea, the female insured pick up the filial piety of children as a tool to circumvent and resist the patrilineal norm. It shows that the female insured are embedded in the value system as the first meaning of culture in that their struggle originates from their motives for family recognition. At the same time, they choose an alternative norm from this value system and utilize it to construct the strategy of struggles to circumvent the institutional and cultural obstacles to the recognition. The interplay of two forms of culture in shaping and changing the NHI in S. Korea is visualized in Fig. 4.3. Logically, the female insured partially envisaged a gender-equity or “universal breadwinner model” (Fraser 2000, 3–4).8 What they criticized was not the familial model itself but the patriarchal family model unfavorable to women: they wanted the breadwinner’s right and status equal to the male workers. In fact, they resisted against not the familial norm per se but the specific norm of “patrilineal family.” As a result, the initial institutional arrangement of the familialistic program was reinforced. While women’s welfare movement in the West demanded the universal eligibility based on citizenship and struggled to detach themselves from familial responsibility, that is, the strong orientation towards “de-familialization” (Esping-Andersen 1999), the female insured in S. Korea further intensified “familialization” of the welfare system in their pursuit.

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The female insured resisted to the specific family norm of “patrilineal family,” but they were not free from the deeply rooted cultural influence of familialism. To the female insured, familialism established a cognitive frame for their perception and choice of action. In addition, their family reality also led them to consider the familial frame as rational or takenfor-granted. Considering the socioeconomic condition at that time, the de-familializing or individual model based on the equal citizenship was, in fact, less feasible or even unimaginable. Ironically, the female insured as a whole always took a marginalized and limited position in these debates. The generalized dichotomy between the male insured and the female insured confined the concept of “female” to only a certain group of “unmarried female workers.” It implies that married or jobless women remained marginal in this struggle. Also, claims of these female insured were never fundamentally far from the traditional ideal of a family. In the context of the Korean society, the gender-fair or the universal breadwinner model assumed the role of the female in supporting their parents and siblings (mainly brothers) before marriage and supporting the husband’s family after marriage.9 In this regard, they could not be free from structural constraints imposed by familialism as the first meaning of culture. Reproduction of Familial Strategies: Families’ Free Riding In 1988, the self-employed insurance was luanched for the residents in rural areas and extended to self-employed people in urban areas (in 1989). As it included the two socials groups who had not been covered by the employee insurance, the NHI developed into the insurance for the whole population. Ironically, this development triggered a transition in natures of welfare politics. After the health insurance administered nationwide in 1988, the expansion of dependent scope mattered not only to a specific group of female workers, but also to all the insured, in other words, de facto all the population, be it a male or a female, be it employee or self-employed, or be it rural or urban. The event brought about the increase in participants in welfare politics surrounding the expansion of dependent eligibility. More fundamentally, institutional differences between the existing employee insurance and the newly starting self-employed insurance ignited the struggle around unfair eligibility between lineal and collateral families.

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As with the administration of the self-employed insurance in 1988, the NHI in S. Korea settled as a divided system between “the employee” and “the self-employed.” Under this institutional setting, the population, which had not been covered by the employee insurance, now could be insured through the self-employed insured. At the time and still today, the employee insurance and the selfemployed insurance use different methods to calculate the insurance fee. As browsed in Chap. 3, the employee insurance fee is determined mainly by the monthly income of the insured only, and the number of dependents does not affect the fee. Meanwhile, the self-employed insurance fee considers the income level, property, age or economic ability of a householder (the insured) as well as all dependents. That is to say, the more dependents, the larger insurance fee. Different institutional arrangements instill distinct economic incentives: the employee insured have the incentive to increase the number of dependents as much as possible and the self-employed insured have the opposite incentive to register the least number of dependents. Especially, those who are not eligible for employee insurance tend to look for relatives who can enroll them as dependents rather than to be insured independently. In turn, the employees insured have no additional burden in increasing dependents and, therefore, tend to register as many dependents as possible within the regulation. The combination of these incentives of the two sides, the insured and dependents, is likely to motivate them to support expanding the scope of dependents beyond the regulation. The insured, based on various background in gender, occupation, employment status, locality, and family realities, claimed the recognition of more families as legitimate dependents of the insurance, which led the quantitative expansion of the total covered population. As a result, the scope of the dependent was extended to include the employee insured’s stepparents, stepchildren, birth parents, biological children, mother’s grandparents, daughter’s children, and collateral kin within three degrees such as uncles, aunts, nephews, nieces, and so on (in 1995). This period showed a different expansion pattern from the earlier period: firstly, the method through which the scope of dependents determined changed from “positive list” to “negative list” method, which granted dependent eligibility to almost all kinds of kinship except those with stable incomes. Secondly, the main claims of the insured aimed to extend the scope of dependents from the lineal families to “collateral” or extended families.

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On the other hand, the resistance in the earlier period mainly was concerned with its “patriarchal family” norms. Despite the changes in natures and actors of struggles, welfare politics surrounding the NHI followed the pattern of a family recognition struggle shaped by the female insured in the early period. However, it does not mean that all the actors enter the multidimensional recognitions struggles like the female insured of the early period. In most news articles in this period, their struggle remained in the economic level: the insured and family demanded further benefits to a broader range of kinship, which highlights the economic incentive for free-riding of the insured and dependents as the rational actors. However, it is misleading to infer from the relative scarcity or absence of evidences that only economic incentive motivated their claims for expansion. One of the males insured insisted that maternity benefits, which at the time was offered only to the spouse of the insured, should be given to his daughter-in-law as well.10 In this claim, the traditional family composed of at least three generations living together under the same roof is envisaged as the legitimate family ideal, based on which he insisted that even married adult children and their spouses should be recognized as his dependents.11 Also, he relied on other traditional family value of parental responsibility in claiming that “economic and social responsibilities for children’s parenting and delivery primarily lied with parents.” Thus, the insured’s discourses on the expansion of the dependent system—its scope and benefits—typically show the struggle for family recognition. In his claim, it is difficult to isolate these two motives and identify which one was more dominant. He could have adhered to the traditional family norm, or he could have intended to save the medical cost by utilizing the dependent system: the two motives are often intertwined and even the actors themselves do not understand their real motives or interests behind their actions. Moreover, even when they pursue purely economic interests, in order to legitimize their claims, they cover their economic motives with moral and cultural camouflage based on family norms and familial discourses. Notably, their repertoires resemble those of the female insured in the early period in that they also combined the demands for legal rights and claims for social recognition of intimacy in their primary relations. They might have been influenced from the female insured in the early period, or they might have strategically adopted their struggle strategy as policy learnings. The insured also mobilize moral resources of family norms

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from culture to legitimize their claims for expansion, thereby reproducing the earlier family’s recognition struggle and strengthening the familial path of NHI.

Familialism in Counter Discourses The evidences suggested above show that the main actor who initiated the expansion of dependent scope was the female insured who resisted the cultural and institutional hindrances to their recognition as responsible breadwinners, legitimate and respectable citizens, and industrial workers who had contributed to the national development. Later, their repertoire strategies of the female insured in the early period, with the nationwide implementation of NHI, were utilized and reproduced by the all insured, which resulted in the further expansion of dependent entitlement. However, it is misleading to conclude that their discourses have dominated the welfare politics around the dependent system. Those who could benefit from the familial institution and those who could not existed simultaneously. In fact, familial claims for expanding the dependent scope are not the only claim that we can witness in the history of the NHI of S. Korea. Contrary to these claims, some raised claims for reforming the existing system that allowed families’ free-riding, and insisted that the insurance fee had to be calculated according to the number of dependents, that is, the de facto abolition of familialistic system. It means that voices towards de-familializing or individualizing the system and limiting the scope of dependent have existed and had participated in the welfare politics around the dependent system since its early period. Interestingly, the state was one of these actors. In 1983, as the population grew to forty million, the then Minister of Health and Society, as a special statement, proclaimed that the health insurance fee would be adjusted to be differentiated according to the number of dependents in order to “reform the traditional preference for many children and, especially, sons.”12 With this measure, the different imposition of insurance fees based on the number of children was actually discussed, though not realized in the end.13 Nevertheless, a stronger resistance to the NHI was from the insured groups. Indeed, in the late 1980s, some insured started to insist that insurance fee should be calculated according to the number and incomes of dependents.14 Especially, the insured who had less dependents

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assumed that they were losing out compared to the insured with more dependents, or that they were paying more insurance fee instead of the insured with more dependents. Above all, the households with multiple income-earning members were the strongest dissident group. As the NHI compels the employees with stable salary to be the independent insured, regardless of their gender, age, and status in family, and obliges them to pay the insurance fee, the families with multiple income sources have to pay more insurance fees. As reflecting this dissatisfaction, the complaint, which has been raised most frequently for 30 years of the NHI history was about the double payment of NHI fee in dual earner households (Lee 2008). Particularly, complaints and claims about the unfairness of double payment of two-income couples have been raised ceaselessly since the early stage of the NHI. The main contents of their claims can be condensed as, even though they are “one family,” a husband and wife are enrolled as the insured “individually” and, therefore, they have to pay the insurance fee “separately”: they are paying “the insurance fee twice,” which is “irrational” and “unfair.”15 Their logic is that they are “one family” and, therefore, it is fair that only one person as a representative of family pays the fee no matter how many income sources they have. Additionally, they criticized the state’ segregious bureaucratic expediency and inefficient adherence to administrative process and rules without consideration on the insured’s convenience. Clearly, their claims are closely related to economic interests in minimizing their insurance fees. Nevertheless, they combine their economic claims with moral claims for legitimacy and recognition of one family. The following news article epitomizes how they utilize the familial norms to legitimize the claims for material interests and thereby cover up the economic nature of their claims. The female insured in the following news article exposes the dissatisfaction of married couples who both are employed and, therefore, respectively pay the insurance fee. Insurance fee itself is quite a burden … but more embarrassing is that I am not enlisted as dependent on my husband’s insurance card. To others’ eyes, it may look like that my husband is a bachelor with children. On my insurance card, there is no dependent enlisted. Therefore, it may look like I am unmarried. It makes my husband or mother–in-law hesitate to bring children to hospital themselves, and also makes me feel ashamed to visit the maternity clinic.16

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The female insured in the article complains that, as the NHI compels a husband and wife to be the independent insured, and, hence, hinders them to be recognized socially and institutionally as one family and makes them abnormal and divided family. Their dissatisfaction is stemmed not only from the economic burdens of doubled insurance fees but also the social and legal nonrecognition of her identity of wife. She also claims her economic interest under the cloak of family recognition struggle. It is an irony that, among the female insured, the married women were one of the dissidents to the gender-equity family model. What she insists literally in the above article is that her family should be recognized as one family: in other words, wives, regardless of their status in the labor market, should be the dependents of their husbands without paying the insurance fees. The family ideal that underlays her argument is nothing other than the patrilineal family or the male breadwinner model, which was denounced by the unmarried female insured. It shows that the expansion of the dependent system was not a harmoniously orchestrated process without any conflict or tension: the female insured had widely divergent opinions on the dependent system and the family ideals according to their family realities. Nevertheless, those against the familialistic system also had to rely on the same familialistic discourses in order to enhance and reinforce the legitimacy of their claims. It explicitly reveals that all the insured utilized the familialism as a strategic tool to pursue their material interests. Even though they clashed on the specific family norms that they pursued, they played on the common battlefield of familialism.

Why Did the State Accept Their Claims? Evidences show that there existed the two insured groups with opposing interests in the expansion of dependents and both groups expressed their voices actively. However, the gradual expansion of dependent scope meant that the unmarried female insured’s demands were accepted and they received the corresponding recognition from the state and society. Then, why did the state accept the female insured’s demands for expansion while rejecting the other insured’s? The Productive Regime of the Developmental State First of all, the development of the welfare state cannot be understood in the isolation from the development of the interlocking production

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regime (Huber and Stephens 2001, 85). Considering the industrial policy of the Korean developmental state in the 1970s, the state had to protect the female labor force, which functioned as the main base for the development of labor-intensive industries (Shin and Chang 2003). Especially, in the late 1960s when a lack of low-wage female labor force occurred in some industries (Koo 2001), the state needed to encourage women’s participation in economic activities for the continuous supply of cheap labor force. At the same time, encouraging women’s economic activities was related to the birth control policy, that is, politics of population. The state intended to control both labor force and the population growth by encouraging women’s participation in the labor market. This demonstrates two intended goals: one is to decrease the fertility rate by inducing women of reproductive age to labor market through gender-equity institutions, and the other is to symbolically undermine a strong tradition of son preference of Koreans, which presumably expedited the high fertility rate. Indeed, in the mid-1980s, the government stated that the inclusion of the male insured’s parents-in-law as dependents aimed to “eradicate a son preference, which has been the chronic obstacle to population control policy and to dissolve worries about post-retirement life of those who have no sons.”17 Ironically, with the same aim of population control, the state intended to limit the dependent system. As mentioned earlier, in 1983, as the population grew to 40 million, the government tried to readjust the NHI fee according to the number of dependents in order to “reform the traditional preference for many children and, especially, sons,” in other words, control the population increase. Such capricious and whimsical turns of policies imply that the state had no definite principle or aim in operating social policies including the dependent system and considered the social policy not as independent policy with its own goal but a tool to serve the goal of other policies. They also evince major features of “productivist welfare regime” that pursues the economic development in priority and subordinates the social policy to economic objectives (Holliday 2000; Woo 2004; Kwon 2004). Additionally, considering the reproduction of future labor force, the motherhood of female workers had to be protected by the patriarchal state. At that time, as the female workers increased, major mass media spotlighted female workers’ health conditions and working environments repeatedly.18 News articles represented their concerns through discourses

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on the protection of motherhood by the paternalistic state, such as an expression of worry that “if health and delivery-nursing function of future (or present) mothers are deteriorated, they are more likely to bear physically and mentally inferior children.”19 In addition, they outcried that pre-modern familial customs dominated the state welfare institutions and asserted that the government should arrange legal institutions for protecting the female workers in the inferior environment.20 In this situation, the state could not ignore the demand of the female workers for welfare, medical welfare in particular. Industrial concerns also influenced the financing mode of the NHI. The Korean developmental state intended to minimize the cost of social welfare and appropriate the curtailed cost for economic development (Lew 2013, 44). For this aim, the NHI dictated 50% of contribution between employer and employees equally. In terms of fiscal logics, the government was stipulated as mere administrator of NHI program and the fund (Kwon 1997, 51), which means that the state did not have to bear any financial burden.21 Under this financing mode, the state had no definite incentive or disincentive to oppose the expansion of dependent’s scope. Any possible increase or decrease in the number of dependents and fiscal deficits that it could entail were not the government’s serious concern. Instead, by accepting their claim, the state could embrace female workers and their families into the beneficiary groups supported by the state, and enhance its political legitimacy without any cost. Therefore, although the female insured required the state to revise the patrilineal family norms, the state could not but accept their demands. Moreover, they did neither claim a fundamental revision of the state’s official familialistic frame nor resist the traditional ideal of a family. From the perspective of fiscal concerns, the female insured, mainly unmarried workers, had no or few dependents and had less opportunity to utilize the medical benefits due to their relatively young age: naturally, the expenditure for their insurance benefits was lower than that for the male insured who had relatively more dependents (Lee 2007, 19). It meant that the female insured contributed more to the insurance finance but benefitted less. Consequently, the NHI funds of companies that employed more female workers were fiscally healthier and more stable.22 In this vein, the female insured were important contributors to the NHI finance. This is why the state rejected the claims that double-income households or the married female insured should be exempted from the insurance fees. The state unlimitedly recognized those without income as

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dependents with the reason that they were one family, but never allowed the eligibility to those with stable income, that is, those who could contribute to the insurance finance. At last, in the whole period of expansion, the state’s first priority was fiscal balance, not a family. Under the reign of the productivist regime, the state remained as a passive fiscal state in the realm of welfare policies: it just intended to escape the financial burden by sustaining the fiscal balance of the NHI. The Fiscal Logic of the Welfare State Industrial policy concerns of the Korean government in 1970s implies that the Korean developmental state coincided with major features of “productivist welfare regime” that pursued the economic development in priority and subordinated the social policy to economic objectives (Holliday 2000; Kwon 2004). As the developmental state in the 1970s had shifted to a more democratic regime since the 1980s (Choi 2012), the old welfare regime, which had related the welfare policies directly to labor force or population control and just focused on the fiscal balance, gradually faded away. However, more fundamental features of the productivist welfare regime, imprinted on the frame of NHI, have remained constantly regardless of political regime changes, which sustained the fiscal logic of the Korean welfare state and strengthened its development trajectory. Above all, the launching of the self-employed NHI in 1988 ignited the fiscal logic of the welfare state: it transformed the government from the former passive actor who had only responded to the insured into the active actor with definite incentives in the expansion of dependent scope. The NHI, when it launched in 1977, covered only the employee. Hence, the population who were not employed, mainly rural population, lived in the blind spot of the medical welfare system. As the industrialization advanced and the life standard improved, those who were excluded from the health welfare started to raise their demands for medical security and forced the government to include them in the realm of NHI. To cope with their demands, the government promised to launch “the self-employed NHI,” a separate insurance scheme for rural residents and those who had no stable employer in 1988. However, unlike the employee insurance in which employees and their employers equally contribute 50% of the insurance revenue, the self-employed had no employer who should contribute to the fund

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matching with them. The anticipated budget deficit of self-employed insurance in the near future fell on the government. Moreover, in the face of the national election, the then ruling party already promised to use the government general revenue in order to contribute to the 50% of the self-employed insurance fund, which meant the insurance finance was destined to be an additional burden to the government. Meanwhile, the new insurance targeted mainly rural residents whose demands for health benefits were ever increasing due to aging population, which made the financial stability bleaker. At last, the separated fund and operation between “healthy” employee insurance and “poor” self-employed insurance and the financial pressure of the latter strongly motivated the state to extend the dependent system of the employee insurance (Lee 2008, 54). In 1989, only 1 year after the implementation of the self-employed insurance, the government eased the regulation for dependents entitlement and allowed the parents with income or asset and unmarried brothers and sisters without income to be dependents of the employee insurance. Again, in 1995, the government included nephews or nieces, and daughter’s children as well as collateral kin within third degree (uncles and aunts) in dependents categories, and intended to induce the population covered by the self-employed insurance to employee insurance by extending the scope of dependents to the maximum. All these actions intended to convert the self-employed insured in rural areas, who were anticipated to rely on the government’s finance, into dependents of employee insurance by extending the scope of dependents (Wang 2015). No matter what had led the state to promote such policies, among industrial policies, fiscal logics, or pressures from mass media, the state also pursued its interest by utilizing familial and moral camouflage as strategic tools. As stated above, the operation of the self-employed insurance in 1988 enhanced the state’s economic and fiscal interest in expansion of dependent scope. The pursuit of this interest, however, was not represented naively in economic discourse, but expressed in a moral and normative form. For example, as the government eased the regulation for dependent eligibility, it announced that “increasing car accidents, various incidents or accidents, industrial disaster are producing cases in which people cannot benefit the NHI like orphans” and “the revision intends to solve such problems.”23 Likewise, introducing the system which allowed the full-grown children in a city to pay the insurance fee of their parents living in the countrysides, the government expressed this new system would “open wide

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the window for filial piety.”24 Originally, this system intended to compensate for the poor performance in collecting insurance fees in rural areas by encouraging children to pay their parents’ insurance fees, but the government promoted it as helping families in rural areas. Here, by stressing traditional norms such as “filial piety” or “mutual help,” the state tried to instill in people the idea of family-centered welfare, in which children are responsible for their parents’ welfare, and consequently, familialize the duty of the individual’s welfare as well as shift the state’s role as welfare provider onto family.25 Every year, the NHI Corporation has honored “healthy families” with a commendation.26 Here, “health family” refers to “the household of which the insured as well as dependents have never visited hospitals, medical offices, pharmacies, or oriental medical clinics and have never had their insurance fees in arrears for the recent 2 years.” Symbolically, it means physically healthy families, but, substantially, it means the households that contribute to the insurance finance: it is an exemplar case that tints the state’s fiscal logics with familial discourse. Be it economic or moral, familialism built a cognitive frame of various actors related to the NHI—the insured, dependents, and the state. The intersection of their interests, especially between the unmarried female insured and the state in the 1970s, led to the quantitative development of NHI and the reinforcement of its initial familialistic frame. However, related to limits of the familialization orientation of female insured, the government, or mass media, social policies for women were conceived as benevolent “favors” by the paternalistic state for social minorities. Such a conceptualization was far from “rights” which female workers had advocated, but a “security without entitlement” (Goodman et al. 1998, 10).

Conclusion: Recognition Struggles in Institutional Changes This chapter examines the historical process of how the dependent system of NHI had expanded, from the initial patrilineal stem family model to the today’s gender-equityextended family model. With regard to this, it tries to trace the historical origin of our time’s welfare system. The findings imply that the establishment of welfare institutions cannot be explained solely from the state’s fiscal logic (O’Connor 2006), the authoritarian regime’s pursuit of political legitimacy and social control (Kwon 2004; Woo 2004), or the blind adherence to the tradition (Lew 2013).

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It was a consequence made by various actors mobilizing the complex net of culture in which economic, normative, or moral motives are interwoven together. Especially, the unmarried female insured’s recognition struggles in the early period, in consonance with the state’s fiscal interest in the later period, were reproduced and strengthened, and finally shaped the specific features of the welfare regime of S. Korea. The intersection of their material, normative, and moral motives led to the quantitative development of NHI and the reinforcement of its initial familialistic foundation. Also, as the strategic mobilization of familialism, be it economic or moral, has shaped the familial nature of the welfare politics for 40 years, familialism has built a cognitive frame of various actors related to the NHI—the state, the insured, and dependents. This institutional inertia still sustains the familial frame of the NHI despite the drastic restructuring process on the NHI after the crisis in 1997, resisting appeal for the individualization and de-familialization of the NHI. Also, it investigates the institutional changes from the perspective of two meanings of culture —one as shared norms and values and the other as strategic tools. From the first meaning of culture, regardless of whether they agreed or resisted to the given dependent scope, motives of all the insured were fundamentally same: to provide their family members with the maximum medical service and benefits at the minimum cost. In this regard, culture of the familialism shaped actors’ cognitive and interpretative frame for rationality. At the same time, from the second meaning of culture, each actor chose different tools from the toolkit of familialism to achieve their aims: the female insured chose the filial piety and responsibility as daughter, double-income households stressed the collective identity of one family, and the state also relied on the mutual help among family members. Williamson’s analytical frame, suggested in Chap. 2, can help us understand how the two meanings of culture operate or influence the institutional changes and actors involved in these changes. Figure 4.3 specifies the relationship between the institution and actors in the changing process of dependent system of the NHI. Culture of familialism (L1) shapes actors’ cognitive and interpretative frame and criteria for rationality. Under the influence of familialism, families can have their own family ideals and norms according to their realities and situations. However, the stronger influence of industrial strategies and family cultures made the patrilineal family model to be chosen as an official family norm of the state (L2), and, in turn, shaped the NHI and its dependent system

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with specific incentive structures and structural limits in lower level (L3). Actors, with internalized cognitive frame and incentive structure, participated in the political process of institutional changes of the NHI (L4) and try to maximize their interests. Regardless of whether they agreed or resisted to the expansion of dependent scope, they shared the same motive of familialism: to provide all the family members with the maximum medical service and benefits at the minimum cost. However, the specific institutional arrangements in the L3, that is, the familialistic method of premium calculation and the scope of dependent offered institutional obstacles to some actors and opportunities to others. Actors, some in order to utilize the opportunity and others to circumvent the obstacle, strategically mobilize and utilize family norms that are favorable to them. Of course, these norms are nothing new but are chosen and mobilized from the existing cultures and tradition. This political process can lead to the transformation of the existing institution (t0→t1 in L3) (Fig. 4.4). The concept of recognition struggles is useful in explaining the expansion process of the Korea’s NHI. Nevertheless, the process and the way that it is unfolded in S. Korea are distinct from those of the Western. The recognition struggle of the female insured and their families in S.

Fig. 4.4  Causal model between institution and actor

102  H.S. Wang

Korea, like in the West, processed in a way that they attached a legitimate meaning to their familial identities by utilizing cultural resources, in order to acquire the rights denied by the modern nation-state. In the process, however, they utilized both the modern identity (labor and welfare rights) and traditional identity (family) simultaneously. In this vein, the Korean case shows how the “pre-modern” identity of family in the “private” and “informal” sector is adopted and recognized as the eligibility for the “modern” welfare institution in the “public” and “formal” sector. In other word, Korea’s case shows how the identity in the private realm and the politics in the public realm are interwoven to constitute the specific features of welfare politics in S. Korea.27

Notes









1. As of June 1976, 40% of the total number of employed was female, and in the service sector 54% was female. Especially, in local industrial complexes and Masan Free Export Zone, the proportion of female workers was 70% and 76% respectively, which were significantly higher (“Protection of female workers,”Chosun Daily, May 26, 1977). This trend continued to the late 1970s, and the employment rate of women increased continuously (“Increasing rate of female employment exceeds that of male employment,” Seoul Gyeongje, November 29, 1978). 2. The then dependent system has the important implication, especially in terms of class and gender (Lee 2007). The regulation on dependent eligibility in 1977 reflected family values of “male” workers of “middle class,” therefore it posed certain disadvantages to “female” workers of “lower” class. 3. See “Including brothers and sisters as dependents, currently impossible for fiscal reasons,” Bogeon, September 22, 1977. “NHI inspection: need the black solutions such as expansion of dependent scope,” Chosun Daily, October 28, 1977. 4.  See “Current situation and challenges of NHI,” HyeondaiGyeongje, November 19, 1977. 5. See “Scope of compulsory workplaces and dependents eligibility should be extended,”Chosun Daily, July 7, 1980. 6.  See “NHI inspection: need the black solutions such as expansion of dependent scope,” Chosun Daily, October 28, 1977. 7. “Regret for NHI,” BogeonShinmun, February 9, 1984. 8. Fraser (2000, 3–4) suggests two orientations of feminism in Western post-industrial welfare state: “the universal breadwinner model” and “the caregiver parity model.” The former, as a vision implicit in the most US feminists and liberals, aims to foster gender equity by promoting

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women’s employment. The centerpiece of this model is state provision of employment-enabling series such as child care. The latter model, mainly a vision of most Western European feminists of social democrats, aims to promote gender equality by supporting carework in informal sectors. This model compensates informal domestic labor, such as delivery or nursing, with caregiver allowance which is enough to support children and equal to paid labor. Moreover, the role of caregiver determines the eligibility of major social insurance such as pension, health, unemployment, disability and so on. These two contrasting strategies reflect the dilemma surrounding “equality” and “difference.” 9. Moreover, not like the female insured, female dependents (mainly wife) remained the object of the institution. For example, claims for dependent entitlement for parents of the female dependents (wife) were voiced not by female dependents themselves, but by the male insured, that is, husband. Only one case could be found that female dependent demanded her parents’ eligibility (Pusan Daily, July 6, 1995). It’s because dependent rights of female spouse’s parents are inherently derived from son-in-law as male breadwinner and 70% of the total insured at those times was male. 10.  DaejeonMaeil, May 31, 1992; DaejeonIlbo, September 8, 1993. 11. Maternity benefits for spouse of dependent started from July 1994. 12. “Three children, more tax and health insurance fee,” and “Son preference, stronger in rural and lower educated people,” Chosun Daily, July 28, 1983; MaeilKyeongje, July 27, 1983; HankookIlbo, July 28, 1983; Seoul Daily, July 28, 1983. 13.  BokeonShinmun, August 1, 1983; Joong-Ang Daily, November 25, 1983. In addition, in 1994 the Ministry of labor considered exempting the insurance fee of wife, in the case of double income couples, to alleviate the manpower shortage of small and medium-sized enterprises and to spur employment of housewives (Kyeonghyang Daily, August 13, 1994; Kyeong’inMaeil, August 16, 1995). 14. “Employee insurance fee should be differentiated to numbers of family and income,” Gangwon Daily, March 15, 1989. 15. Gang’wonIlbo, October 18, 1988; YeongnamIlbo, April 20, 1989; MaeilShinmun, November 18, 1989; Hankyeorek, January 31, 1994; Seoul Shinmun, July 7, 1983. 16.  Hankyoreh, January 31, 1994. 17.  Chosun Daily, July 8, 1984; “Promise dependent eligibility to female’s parents: easing the son preference is a key of population policy,” Kyoenghyang Daily, July 12, 1984. 18. “Environment Improvement for Female Workers,” Dong’a Daily, January 9, 1978; “Nutritional Status of Bus Conductress,” Dong’a Daily, October 11, 1978.

104  H.S. Wang 19. “Protection of female workers,” Chosun Daily, May 26, 1977. 20.  “More welfare facilities for female workers,” Hankuk Daily, October 26, 1978; “Increasing rate of female employment exceeds that of male employment,” Seoul Kyeongje, November 27, 1978. 21. Until today, the government mainly has taken a role of program manager or administrator, not finance contributor. 22. “NHI inspection: need solutions such as expansion of dependent scope,” Chosun Daily, October 28, 1977. 23. See “NHI, Expanding the Scope of Dependent: Including Step-parents,” Chosun Daily, November 29, 1995. 24. See “Insurance Fee, opening wide the window for filial piety: the automatic payment system, starting from next month,” UihyeopShinbo, May 27, 1996: Jung’angKyeongje, September 27, 1989. 25.  As another example, the government implemented the “movement for sending filial piety pension” which let children living in cities could pay the pension payment of parents living in rural areas (Pusan Ilbo, July 5, 1995). 26. “Reward of 2.3 billion to 7.4 thousands of healthy families, 1.3% of the employee insured,” YeonhaoTongshin, May 9, 1995. 27.  Most studies on the recognition politics mainly focus on the public sphere regarding the sovereign state or the nation state, and citizenship. However, it is obvious that the recognition politics operate in both the public and private spheres (Taylor 1994: 37).

References Chan, Cheris Shun-ching. 2009. Creating a Market in the Presence of Cultural Resistance: The Case of Life Insurance in China. Theory and Society 38: 271–305. Chang, Kyung-sup. 2010. South Korea under Compressed Modernity: Familial Political Economy in Transition. London; New York: Routledge. Cho, Won-Tak. 2002. Changes on Dependents Scope of the NHI and Its Implication in Policies. Health and Welfare 5: 63–76 (In Korean). Choi, Young Jun. 2012. End of the Era of Productivist Welfare Capitalism? Diverging Welfare Regimes in East Asia. Asian Journal of Social Science 40 (3): 275–294. Davis, Diane. 2004. Discipline and Development: Middle Class and Prosperity in East Asia and Latin America. Cambridge: Cambridge University Press. Esping-Andersen, Gosta. 1999. Social Foundations of Postindustrial Economies. New York: Oxford University Press. Fraser, Nancy. 1997. Justice Interruptus: Critical Reflections on the Post-socialist Condition. New York: Routledge.

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Fraser, Nancy. 2000. After the Family Wage: A Postindustrial Thought Experiment. In Gender and Citizenship in Transition, ed. B. Hobson, 1–32. New York: Routledge. Goodman, Roger, Gordon White, and Huck-Ju Kwon (eds.). 1998. The East Asian Welfare Model: Welfare Orientalism and the State. London: Routledge. Holliday, Ian. 2000. Productivist Welfare Capitalism: Social Policy in East Asia. Political Studies 48: 706–723. Honneth, Axel. 1996. The Struggle for Recognition: The Moral Grammar of Social Conflicts. Cambridge, MA: MIT Press. Huber, Evelyne, and John D. Stephens. 2001. Development and Crisis of the Welfare State: Parties and Policies in Global Markets. Chicago: The University of Chicago Press. Kim, Young Bum. 2002. The Origins and Institutional Characteristics of Social Insurance in South Korea: An Analysis on Health Insurance and National Pension. Economy and Society 55: 8–34 (In Korean). KFMIS (The Korean Federation of Medical Insurance Societies). 1997. The 30 Year History of the Korean National Health Insurance. Seoul: The Korean Federation of Medical Insurance Societies (In Korean). Koo, Hagen. 2001. Korean Workers: The Culture and Politics of Class Formation. Ithaca: Cornell University Press. Kwon, Huck-ju. 1997. Beyond European Welfare Regimes: Comparative Perspectives on East Asian Welfare Systems, Journal of Social Policy 26(4): 467–484. Kwon, Huck-ju. 2004. Transforming the Developmental Welfare States in East Asia. Houndmills, Basingstoke: Palgrave Macmillan: UNRISD. Kymlicka, Will. 2002. Contemporary Political Philosophy: An Introduction. New York: Oxford University Press. Lee, Kwang-kyu. 1997. Korean Family and Kinship. Seoul: Jipmoondang. Lee, Mee-sook. 2007. Investigating the 30 Years History of the National Health Insurance From Women’s Perspective. Health and Social Science 22: 5–35 (In Korean). Lee, Mee-sook. 2008. Family Norms Implied in the National Health Insurance and the Changes of Beneficiary System. Korean Journal of Sociology 42 (6): 38–67 (In Korean). Lew, Seok-Choon. 2013. The Korean Economic Developmental Path: Confucian Tradition, Affective Network. New York: Palgrave Macmillan. O’Connor, James. 2006. The Fiscal Crisis of the State. In The Welfare State Reader, ed. C. Pierson and F.G. Castles, 62–65. Cambridge, UK: Polity Press. Polanyi, Karl. 1957. The Great Transformation: The Political and Economic Origins of Our Time. Boston: Beacon Press. Shin, Jang-Sup, and Ha-Joon Chang. 2003. Restructuring Korea Inc. London and New York: Routledge Curzon.

106  H.S. Wang Smith, Philip. 1991. Codes and Conflict: Toward a Theory of War as Ritual. Theory and Society 20 (1): 103–138. Son, Annette H.K. 1998. The Construction of the Medical Insurance System in the Republic of Korea, 1963–1989. Scandinavian Journal of Social Welfare 7: 17–26. Taylor, Charles. 1994. The Politics of Recognition. In Multiculturalism: Examining the Politics of Recognition, ed. C. Taylor and A. Gutman, 25–73. Princeton: Princeton University Press. Wang, Hye Suk. 2015. Familialisation Effects of the State Welfare: Focused on the National Health Insurances in S. Korea and Taiwan. Asia Pacific Journal of Social Work and Development 25 (1): 29–41. Wong, Joseph. 2004. Healthy Democracies. Ithaca, New York: Cornell University Press. Woo, Myungsook. 2004. The Politics of Social Welfare Policy in South Korea: Growth and Citizenship. Lanham: UPA.

CHAPTER 5

Historical Development of NHI in Taiwan: De-familialization Path of Welfare Politics

The Chinese family ideal of the Confucian tradition is based on the model of extended families in which multigenerations live under the same roof. However, this ideal had disappeared in the Mainland China long ago since the one-child policy, a part of population control and family planning policy of the Communist Party, was introduced in the late 1970s. Meanwhile, in Taiwan, the family customs and tradition, such as ancestor worshiping rituals and familial gatherings, have been maintained relatively well so that Taiwan is considered a more legitimate successor of the Chinese family tradition. Compared to Korean families, Taiwanese families reveal more varieties in structure and size; from stem to neo-extended families. Nevertheless, as examined in Chap. 3, the NHI of Taiwan adopts the stem and nuclear family model, which is, in fact, not far from the Western family norm. Especially, seen from its method of imposing the insurance fee for dependents, Taiwan’s NHI adopts the individualistic principle that considers family as a mere aggregate of individuals rather than one unit of totality sharing collectivist rights. Considering the variety of family realities that Taiwanese families show, it is a puzzle that they have built such a de-familialized welfare institution based on a narrow and individualistic family model. Then, in Taiwan, by which process has such a narrow family ideal been institutionalized into the basic family model of its NHI? Before the universal NHI was launched in 1995, the social insurances of Taiwan had developed through the divided path between the © The Author(s) 2017 H.S. Wang, Familial Foundations of the Welfare State, DOI 10.1007/978-3-319-58712-7_5

107

108  H.S. Wang

Fig. 5.1  Social insurance scheme of Taiwan (before 1995)

government employees (military, civil servants, and teachers) and the nongovernment employees (in the private sector), as roughly visualized in Fig. 5.1, Among them, the “Civil Servant Insurance” and the “Labor Insurance” had been the two pillars of the Taiwan’s welfare programs, which occupied about 91% of the total government expenditure for social insurances (Wu 1987, 433; Cheng 1987). Both the programs were established as comprehensive insurance programs protecting the insured against major risks that they could face in their life courses such as illness, disability, retirement (pension), and death. Both programs were established as representative social insurances of Taiwan almost at the same time and were set up as comprehensive insurances to protect the insured against various risks. However, they revealed the differentiated characteristics in some dimensions. First, in terms of the population coverage, there is a great gap between their proportions. As of 1994 in Table 5.1, the Civil Servant related insurances covered only about 8.5% of the total population1 while the Labor Insurance covered about 40% of the total population, which had the most insured under its scheme.2 Secondly, their developmental paths are also drastically different: the Labor Insurance gradually expanded its entitlement to include a wider range of occupational groups into one universal insurance scheme, while the Civil Servant Insurance had established the separate and fragmented insurances, of which benefits and targeted groups varied under the public

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Table 5.1  Status of population coverages of the Civil Servant related insurances and the Labor Insurance in Taiwan (unit: %) Year

Civil Servant related insurances

Labor Insurance

1961 1966 1971 1976 1981 1986 1991 1994

1.9 1.9 2.1 2.3 2.5 4.0 5.4 8.5

4.4 4.9 6.6 10.3 15.3 24.2 35.3 40.1

Sources Bureau of Labor Insurance, Each Year; Department of Government Employees’ Insurance, Central Trust of China, 1999

insurance scheme (See Fig. 5.1). Moreover, it is noteworthy that the expansion of Civil Servant related insurances had accompanied the establishment of the subservient but separate programs for family dependents of the Civil Servant insured. It shows that, between the two programs, only the Civil Servant Insurance had the dependent system for the insured’s family, while the Labor Insurance was an individualistic insurance only for the insured, that is, employees. Therefore, from a historical perspective, this chapter traces the historical origin of the today’s dependent system and its family ideal back to the initial frame of the Civil Servant Insurance in the 1950s. The focus is laid on its relevance to the family realities of the then civil servants who were the new immigrant group from the Mainland China and the logic of the conservative welfare state in protecting the political supporting group. Plus, the latter part of this chapter examines the historical process of how the initial frame, once designed only for the civil servants group, had influenced the later discussion on extending the Labor Insurance and finally had been adopted into the universal and compulsory NHI for the whole population in 1995. Also, regarding the low familialization effect of Taiwan’s NHI, this chapter questions the reason that the Taiwanese families did not resist the welfare institution which did not correspond to their family reality. Or, how could their resistance, if any, be effectively nullified in the welfare politics, especially in the stage of the universal welfare institution building, which was synchronized with the democratization?

110  H.S. Wang

The Initial Frame of the Social Insurance Scheme in Taiwan (1958–1982): Divided Programs Between the Civil Servant Insurance and the Labor Insurance Introduction of the Civil Servant Insurance and the Dependent System The familialistic frame of social insurance was first introduced in the Civil Servant Insurance. This insurance started as a comprehensive welfare program protecting civil servants against the major life course risks such as illness, disability, retirement, and death. It even provided family benefits like funeral expenses and nursery allowance. It was not only a favor to the employees of the public sector serving the nation but also the KMT government’s reward to the loyalty of its support group. As a form of privileges, the insurance with generous benefits intended to make the status of the civil servant distinguished from other occupations. These privileges are highlighted in the existence of the dependent system. According to the first draft of the Civil Servant Insurance Act, submitted to the Executive Yuan in February 9th, 1951, the Article 1 defined the policyholder of insurance as “civil servants and their family members” ( ). Also, the Article 11 of the draft, proposed in January 1958, defined the dependents as “spouse and lineal relatives of civil servants.” The first Act shows that the initial frame intended to include the civil servants as well as their families under the scheme. It means that the familialistic frame of Taiwan’s social insurance scheme preceded S. Korea’s. Nevertheless, this Act exhibited some problems. First, the Act did not articulate the definition of families that could be entitled as dependents and the conditions for entitlement such as dependent’s economic status or cohabitation. Therefore, the dependent entitlement could be applied unconditionally to lineal relatives on paternal and maternal sides. Secondly, unlike the civil servants who should be compulsorily insured, their dependents could be insured on a voluntary basis. Hence, some warned of the difficulty in the fiscal control because the number of the total insured could be arbitrarily changed: there were many anticipated abuses, for example, only highrisk dependents like old parents or children could be insured, which would cause the fiscal setback (Guo 1980, 266). Even before the execution of the insurance, there were many voices criticizing the feasibility of the insurance. Above all, the real problem was that the government had no serious or strong will to launch the insurance for civil servants’ families. Even

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though the Civil Servant Insurance Act in 1958 stipulated that the insurance for civil servant’s family would be put into practice by legislating a separate and independent act, the government had delayed its execution under the pretext of fiscal difficulty. In the absence of any social pressure or any sign of organized collective action among civil servants to demand the implementation of the insurance for their families, the dependent system for civil servant’s family remained virtually ineffective for more than 20 years. However, in the 1970s, the KMT Government faced an internal and external political crisis and felt the necessity to mobilize the political support through extending social policies. During this period, various social policies were enacted or reformed, and among them, the delayed execution of the insurance for civil servant’s family was passed as the first. On 29 January 1974, the government revised the Civil Servant Dependent Health Insurance Act to articulate the scope of families and changed its earlier voluntary subscription to a compulsory one. As a result, in 1982, the revised “Civil Servant Dependent Health Insurance” ( ) started its step as a separate and independent social insurance program. The act stipulated the insured of the Civil Servant Dependent Health Insurance as the “spouse, parents, and children under 20 of the Civil Servant insured. Among the unmarried children over 20, it allowed the entitlement only to those who were students, jobless, declared incompetent, or those who could not maintain themselves because of disability” (the Civil Servant Dependent Health Insurance Act, Article 2). It limited the dependent entitlement only to parents and children among lineal families and only spouse among relatives by marriage. Though allowing some exceptions, children were expected to be independent of parents once they reached adulthood. This stipulation is the first official appearance of narrowly defined lineal and stem family ideal in the formal welfare institution of Taiwan. Additionally, the insurance fees for dependents are based on the poll tax system, calculating the individual fees of each dependent, which was set around 3–5% of the average salary of civil servants. The act did not require additional fees if the number of dependents exceeds five. The poll tax system on a compulsory basis was introduced in order to prevent the possible abuses of the insurance. As a result, a seemingly familialistic frame like the Korean NHI, but a virtually individualistic frame, in which a family is considered as an aggregate sum of individuals and each family member bears the responsibility in paying their own insurance fee, appeared in the initial frame of the NHI of Taiwan.

112  H.S. Wang

For Whom was the Civil Servant Insurance? With the introduction of the Civil Servant Dependent Health Insurance, the narrow family model and individualistic family ideal had been established as the official family model of the state’s welfare institution in the early period. Can we interpret this family model as reflecting the family reality of the civil servants at that time, including other employees of the governmental sector? To answer this question, first, this section examines who were the employees of the governmental sector and tries to understand their family realities based on their social, economic, historical, and especially ethnic backgrounds. Taiwan is a multicultural society composed of immigrants from the mainland China as well as the surrounding regions like the Southeast Asia for several centuries. The divergent “ethnicity” of immigrants is determined by their original residences and immigration periods. The major categories of ethnicity in Taiwan are three: the aboriginal Taiwanese ( ), the Taiwanese ( ), and the Mainlanders ( ). The first category of the aboriginal Taiwanese refers to immigrants from the Southeast Asian regions before 15,000 years. The second, the Taiwanese refers to one of the Han Chinese ( ) subgroups who immigrated from the Mainland China (mainly, provincial areas of Guangdong or Fujian) to Taiwan island after the fall of Ming Dynasty from the early seventeenth century to nineteenth century. The Taiwanese ) and Hakka ( ), accordcan be subcategorized into Minnan ( ing to their original residences. Finally, the “Mainlanders” refers to the immigrants group who moved to Taiwan following the KMT government and Chiang Kai-shek after the defeat of Civil war in 1949. The number of these immigrants is composed of three hundred thousand soldiers; if their families are counted, it will exceed one million (Roy 2003; Rubinstein 1999). In the Taiwanese society of today, this categorization of ethnicity is officially abolished. As the Family Registration Law was revised in 1992, the national census does not survey the data on ethnic groups (Wang 2008, 150). Moreover, the advent of urbanization and industrialization has made the social mobility of various ethnic groups inevitable, and the accompanied new social stratification mechanism has made ethnic identities blur. In addition, each ethnic group assimilated into each other’s culture and languages: more strictly speaking, at least culturally, other ethnic groups had been assimilated into the Han

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culture and language of the Mainlanders through the formal education system of the KMT government (Scott and Tiun 2007). Now, only the two categories of Mainlanders and Taiwanese are used only unofficially. However, these ethnic categories still hold the validity and important implications in social, political, economic, and cultural dimensions in the Taiwanese society. Let alone the importance of ethnicity in the Taiwanese society in 1950s. In 1949, the KMT government withdrew to Taiwan island with one million of military force and civilians after the defeat in the civil war, of which the volume is roughly estimated as 15% of the then population of Taiwan. Of those were the bureaucrats of the central government, legislators, officials of inspection, military personnel, and elites in culture and education sectors. It means that the whole upper political apparatus of the Republic of China moved to one Province of Taiwan (Wang 2008, 166). Even after the immigration, they had consolidated their status as the ruling elites in the Taiwanese society. Election institution helped intensify their status. Under the martial law, the KMT government suspended the legislative election and let them sustain their position and exert their authority until the KMT government recovered the Mainland. It was not until the late 1970s that the election resumed though limited to the local election, in the level of county ( ) and city ( ) government (Wei 2008, 106). Especially, the legislators whose role is making the law and formal institutions were critical. Under the martial law, they were guaranteed of the semi-permanent status and authority in making the laws and institutions that could reflect and protect interests of the Mainlanders. Additionally, in the administration’s personnel policy after the retreat to Taiwan, the bureaucratic agencies of the KMT government employed mainly the Mainlanders, and hindered the entry of the Taiwanese in the government sector. Accordingly, it avoided employing the Taiwanese when recruiting civil servants or any position in the Government (Wang 2008, 92–95). In addition, in order to gain the international recognition as the sole legitimate and authentic government representing China against the Communist party in the Mainland, the KMT government had stuck to the Chinese culture education under the cloak of promot)” and through ing the “Chinese Cultural Renaissance ( cultural policies recognized only the Mandarin as the standard language and oppressed the local language of Taiwan. Hence, the Mainlanders could occupy and monopolize the absolute superiority in cultural sphere

114  H.S. Wang

under the control of the central government (Wang 2008, 166–167). As a result, at least in the governmental sectors, institutions that favored the Mainlanders over the Taiwanese had been established and sustained. The Mainlanders’ political and cultural homogeneity imbued by the state are also derived from their similar identity and culture in several dimensions: occupational commonality (concentrated in the military personnel, civil servants, employees of education sector), political consciousness and loyalty to the Republic of China, KMT, and Chiang Kai-shek, memory of battles against the Japanese and the Communist, a strong will to recover the Mainland, and a nostalgia for the hometown and families. Those commonalities had been established in a relatively short period of compressed experiences. In fact, except for these commonalities, each of them belonged to different ethnic groups according to which part of the mainland China they came from. It is the identity as idiosyncratic ruling class, guaranteed status by the state, which made them share one homogeneous collective consciousness. In addition, under the ethnic frame of conflicts between the “Taiwanese (the ruled) vs. the Mainlanders (state/ military/ruler),” they had been gradually constituted into one ethnicity of the “Mainlanders.” Nevertheless, the Mainlander’s political and cultural dominance could not be extended to the economy. Even though not a few large capitalists also immigrated to Taiwan, they had difficulty in sustaining their status. The main reason is that they could not speak Taiwanese local language (Shin and Chang 2003; Scott and Tiun 2007), which obstructed them to adapt to the Taiwan economy and to enter the private market sector. As a result, even after the 1960s when the Taiwan economy took off, most of the Mainlanders remained in their initial positions in the army, bureaucracy, or education. This situation had further intensified the ethnic division between the Mainlander’s monopoly in politics and the Taiwanese’s monopoly in the economy (Shin and Chang 2003). Such an ethnic segregation in politics and economy led another ethnic segregation in social security schemes operated by the state. The Mainlanders, relatively a larger portion of employees of the government sector, subscribed to the civil servant related insurances, meanwhile the Taiwanese, mostly in private sector, be it an employee or an employer, was covered by the labor insurance. In addition, combined with different welfare benefits of the two insurances, the segregated system between the civil servant insurance and the labor insurance constituted the conflict structure of political, economic, and ethnic identities, which ensured

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the privileged status of mainlanders. Therefore, in Taiwan, the civil servant related insurances signified not only better material benefits, but also the privileged status in the labor market as public employees, the political status as ruling class, and ethnically the newly immigrated Mainlanders. In sum, political structure—separation and segregation in the labor market—differentiated welfare benefits overlapped and therefore symbol. The Fig. 5.2 summarizes the dualized system between the civil servant and the labor insurance as its core of ethnic identity. The family realities of the two ethnic groups were also differentiated to each other. It is true that the Mainlanders and the Taiwanese are the descendants of Han ( ) ethnic, but, even among subgroups of Han ethnic, various family traditions and norms coexist. As most of the Mainlanders who immigrated following the KMT government and Chinag Kai-shek after the defeat in the Civil war in 1949 were young single male soldiers, vigorous and high spirited, ready to dedicate themselves to the KMT. According to the data, the male Mainlander reveals a higher rate of getting married to other ethnic females than the male of other ethnic groups; it shows the gender imbalance of the Mainlanders (Wang 1994). Additionally, in their immigration patterns, they could not but immigrate single-handed or just with their spouse and children in the form of nuclear family. They rarely brought their parents or other siblings who had established their livelihoods in the mainland. Such a large-family immigration can be only witnessed in the core personnel or the stalwarts of the KMT government, whose families could have been in danger of prosecution

Mainlander

Ethnic

Taiwanese

Political elites

Politics

The governed

Employees in government sector Civil Servants Insurance

Economy

Welfare

Employees in Non-government sector Labor Insurance

Fig. 5.2  Ethnic segregation between the civil servants insurance and labor insurance

116  H.S. Wang

of the Communist party. Moreover, they considered their immigration to Taiwan as temporary, and believed that they would go back to the mainland before long. Therefore, the immigration on a large scale of the extended families is rarely witnessed. As evincing this immigration pattern, the family survey data in the 1960s and the 1970s show that the Mainlanders’ family structure is very simple and small-sized nuclear family. About 55–60% of the Taiwanese family is nuclear family, more than 80% of the Mainlanders families live in a nuclear family. Especially, Table 5.2 shows among the Taiwanese, most of the married sons live with their parents, meanwhile only a few Mainlanders live with their parents after marriage. The interesting point is the reason why the Mainlanders do not live with their parents; it is simply because their parents are not available to live together. In 1973, 76.7% of the Taiwanese family responded that their parents were “not available,” which means that their parents had passed away or stayed in the mainland China so that they could not live together. Meanwhile, the average family size of the Taiwanese is larger than that of the Mainlanders, and most of the Taiwanese families are extended family but varied and complicated in the family structure (Greenhalgh 1984, 537). Among the Taiwanese, the nuclear family is the absolute majority, but the proportion of the stem family, in which one of the married children supports old parents, is higher than that of the Mainlanders. It means that the family ideal of the Chinese tradition is preserved well in the Taiwanese Table 5.2  Status of the Taiwan’s family structure by ethnicity (unit: %) Total

Nuclear Parents living With other siblings Alone N.A. Stem Joint-stem Total N

Taiwanese

Mainlander

1973

1980

1985

1973

1980

1985

1973

1980

1985

60.0

60.6

62.2

55.0

58.2

60.9

83.8

81.3

75.8

15.8 19.9 24.3 33.1 6.4 100.0 5543

18.5 24.2 17.9 32.7 5.9 100.0 3816

23.1 27.2 11.9 32.3 5.0 100.0 3101

18.7 23.0 13.3 36.7 7.7 100.0 4598

21.0 26.2 7.0 34.4 6.6 100.0 3153

24.3 27.4 9.2 33.0 5.4 100.0 2733

1.8 5.4 76.7 15.7 0.3 100.0 931

5.1 12.6 63.6 17.8 0.9 100.0 428

9.1 25.1 41.6 22.6 1.6 100.0 243

Source Weinstein et al. 1990, 223

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families who had immigrated from the Mainland more than several 100 years ago: the recently immigrated Mainlanders, due to the unexpected political immigration, could not but constitute the nuclear families. The family model of the Civil Servant Insurance is very close to the nuclear family of the Mainlanders in the early period when the insurance was launched. Then, it could be inferred that the distinct family reality of the Mainlanders could be reflected in the public welfare institutions, and crystalized into the basic principle of overall family policies. In other words, can we interpret the stem family model and the individualistic frame of the Civil Servant Insurance and the insurance for their families as reflecting the family reality of the civil servants group, most of whom are the newly immigrated Mainlanders? Family Reality vs. Fiscal Logic The independent insurance only for the civil servants, which also protected their families with generous and superior benefits, is one of the privileges for the civil servants, that is, employees of the government. As in the conservative welfare regime, the particularly privileged welfare provision is offered for the civil servant groups, in order to tie the loyalties of the individual directly to the monarchy or the central state authority (Esping-Andersen 1990, 24). Plus, considering the historical and political context of Taiwan, the KMT government was more desperate for the loyalties of the civil servants; as an alien government without local base of support, the Mainlanders were the only political supporting groups the KMT government could rely on. To the KMT government, the support of civil servants had a greater importance in enhancing its political legitimacy and controlling the Taiwanese society. In return for their loyalties, the KMT government had to provide them with the welfare benefits, which should be benevolent enough to consolidate their support and privileged enough to differentiate and distinguish the superior status of the Mainlanders to the Taiwanese. If the privileged welfare were benevolent “favors” by the paternalistic state with aims to consolidate and broaden the base of support (Goodman et al. 1998, 10), it would be better to include not only the civil servants but also their families. Nevertheless, the Civil Servant Insurance limited the scope of family dependents only to the narrow nuclear family. Then, can we interpret the

118  H.S. Wang

narrow scope of dependent entitlement as the outcome of the distinct family reality of the Mainlanders? To probe for the reason why the Civil Servant Insurance started based on a narrow family ideal with a low de-familialization effects, first it should be proved that the civil servants and their families did not show any resistance or dissatisfaction about the dependent entitlement based on a narrow scope of family and the insurance fee calculation based on a poll tax system: it implies that they considered such institutional features of the insurance as rational or taken-for-granted. At the same time, it should also be confirmed that the government intended to offer the benevolent welfare to the civil servants and their families by expanding the dependent entitlement to include a broader scope of families, but their intention was constrained by the distinct family reality of the Mainlanders. It would evince that the state’s intention to build the familialistic insurance was not realized because of the distinct family reality of the Mainlanders. However, major concerns of the government witnessed in the legislation and execution process of the insurance are the fiscal logic and administrative concerns. From the initial stage of the insurance building, the government had approached the welfare from a very practical and utilitarian stance, which often caused the conflict of interests between the government and the civil servants. Their conflict of interests first appeared in the discussion on the insurance fee calculation for dependents. The government proclaimed the insurance for the civil servant’s families in 1958. However, the government considered the simultaneous implementation of the Civil Servant Insurance and the insurance for their families would inevitably cause the financial deficit. For this reason, the government had delayed the execution of the insurance for the civil servant’s families until 1982. However, as the political crisis emerged in the 1970s, the KMT government launched the insurance for the civil servant’s families in an attempt to appeal to the traditional supporting group. Nevertheless, with the financial pressure at hand, the government intended to secure the additional budget by deciding the insurance fee calculation method on a basis of the poll tax system. To the then government, it was the only alternative to mobilize the political support and save the welfare expenditure. The implementation of the national insurance for the civil servants and their families was an expression of the government’s concern for them, but it was just nominal because the government would not contribute to their insurance fund.

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Under the system, the insurance fees are calculated on the basis of the number of family members, and a head of household as wage earner has a responsibility to pay the insurance fees on behalf of every dependent, which meant the more dependents, the more insurance fees. To exemplify the case of a civil servant family of four, according to the Act, a house head had to pay 10–15% of his/her salary as the insurance fee. This method alarmed a significant burden, especially to households with many family members because such households with many dependents had to bear not only a higher cost of living but also a higher insurance fee. The civil servants group decried that this principle of the insurance violated the redistribution functions of social policies as well as the collectivity spirit of mutual help and shared responsibility. In order to serve the purpose of mutual help of social policies, they insisted that the insurance fee should be calculated regardless of the number of dependents, and a flat rate should be applied to all households.3 The resistance of the civil servants against the insurance fee calculation method demonstrates that the poll tax system was not taken for granted among the Mainlanders. The dominance of administrative concern had appeared more explicitly in the gradual expansion process of family dependents. In 1982 when the insurance was launched, the entitlement was not applied to all family dependents simultaneously; it started with spouses (in 1982), and later applied to parents (in 1989) and finally to children (in 1991). The insurance encompassed parents as dependents in prior to children, which could be interpreted that the filial piety of the Confucianism had influenced this sequence as it considered the health benefits of the aged group first. However, in practice, the priority given to parents was because of the administrative concerns. As examined in the earlier data, only a small proportion of the Mainlanders lived with parents. Therefore, the then government anticipated that the number of parents would be smaller than that of children, which guaranteed the early expansion of the insurance (Guo 1980). This administrative measure invoked the strong resistance from the civil servants. Especially, the civil servant group showed the strong dissatisfaction about the policy that dependent entitlement was applied to spouses in prior to parents or children. They criticized that the policy clearly violated the public sentiment because the original purpose of social policies is to take care of those in need (the old and the weak) with the strength of collective community. They harshly blamed the fact that parents were not given a priority based on a moral and normative ground that the policy

120  H.S. Wang

violated the human nature.4 They insisted that the dependent entitlement should be first applied to parents other than spouse or children. However, their outcries could not be evaluated entirely from a moral perspective based on the traditional family norms. The economic interests were also implicated in their argument: spouses of civil servants were likely to have a job, which endowed their spouses with the entitlement for the Labor Insurance or other occupational insurances. Meanwhile, to children or parents, the Civil Servant Dependent Health Insurance was the only social insurance, to which they could apply. The last issue with which the civil servants and the government were in conflicts was that the Civil Servant Dependent Health Insurance was established as a separate insurance independent from the Civil Servant Insurance. The civil servants group and their families criticized that most of the social insurances in Taiwan such as Labor Insurance, the Civil Servant Insurance, the Military Insurance, the Private School Teachers Insurance did not include the insured’s family as beneficiary, in contrast to social insurances of other countries that encompassed not only the insured but also their family. They criticized that the principle of the Civil Servant Dependent Health Insurance violated the universal nature of social insurances seriously as well as “run counter to against the idea of the Chinese people who always consider families a high priority.”5 Their argument reflects the logic that, as one unit, family members are entitled to sharing a derivative right of their family members. Then can we interpret the claims of civil servants as advocating the legitimacy of familialistic norms? It is a complicate task to articulate and separate the two motives- material and normative- within their familial discourses around the dependent eligibility because of their intertwined characteristics. The data below render an inference of the mixed nature of their discourses. In 1977, in preparing for the execution of the Civil Servant Dependent Health Insurance, the government conducted a survey in order to estimate the number of insured. The survey of 371,974 civil servants estimated that 1,321,832 of civil servant family members were anticipated to get insured when the Civil Servant Dependent Health Insurance would be launched. The number was composed of 133,315 fathers, 169,900 mother, 69,639 husbands, 213,223 wives, 394,383 sons, and 341,372 daughters (Guo 1980, 62). According to the survey, the dependent ratio of the insurance was 3.55, as high as the Korean case. However, as the government released the details such as implementation schedules and financing plans and the insurance fee calculation method

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was set as a poll tax system, the actual number of insured fell behind the previous forecast of 3.55. Table 5.3 summarizes the number of the insured of the Civil Servant Insurance and of the Civil Servant Dependent Health Insurance. According to the table, in 1982 when Civil Servant Dependent Health Insurance was implemented and first applied only to spouses, the dependent ratio ranged relatively low around 0.36–0.40. In 1989 when it included parent as dependent, the ratio increased just to 0.7. Finally, when it included children as dependents in 1991, the dependent ratio increased to 1.7. This ratio was only the half of the previously forecasted number of 3.55, even lower than the dependent ratio of the Korean NHI of the same year (2.12 in 1992). More specifically, among 280,000 spouses, 300,000 parents, and 740,000 children who were expected to be insured in 1977 survey, 180,000 spouses (64% of the original estimate), 200,000 parents (66% of the original estimate), and 560,000 children (75% of the original estimate) were actually insured as dependents. These figures mean that a third of family dependents exited the dependent system. They also affirm that the familiar discourses of civil servants and their families feature a nature of strategic tool to enhance and strengthen the legitimacy of their claims for material benefits. Like the Korean case, their struggle for family recognition was an economic struggle under the veneer of familial norms. The historical records show that in the early period of welfare institution building process, the civil servants groups and their families resisted the individualistic model whatever their motive and interests were. Then, why did their resistance end without any profit? Also, why did the Mainlander families accept the institutional frame despite resistance as well as despite their political status and capacity as civil servants that they could utilize as leverage in the negotiation with the government? First, in relation to the government, the civil servant group was taking part in the state ruling coalition. The KMT government with the loyalty of civil servants for granted would not invest much in securing their political support. Moreover, even though the civil servants were one of privileged groups with high political status in the Taiwanese society, as seen in Table 5.4, they were numerically a minority group, occupying only 2% of the whole Taiwanese population, which posited the constraints in organizing a resistance to have an influential power on the government’s social policy. In this situation, the more welfare benefits the civil servant claimed for, the more negative response they got from the society at large. Only

122  H.S. Wang

the civil servants had the state-run insurance for their family, which distinguished their status of privileged social elite class: their voice for demanding the reform of the insurance for families was considered as cliquish elitism and as group selfishness. Mass media at that time blamed the government for implementing the Civil Servant Dependent Family Health Insurance prior to the health insurance for rural population (farmers and fishermen) and working class as it evinced the state’s priority in protecting the civil servants.6 Facing the structural constraints in putting forward their resistance to the institution, the civil servant group had to adjust their interests and adapt themselves to the given institution. Finally, in 1982, the Table 5.3  Dependent ratio of the civil servant group Year

Civil Servant Insurance The number of insured

Civil Servant Dependent Health Insurance The number of insured

Dependent ratio

1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994

443,783 452,881 468,577 475,663 483,473 489,772 496,175 515,387 536,775 549,615 560,127 572,122 581,047

176,030 176,937 179,573 180,360 180,739 179,688 176,749 385,632 390,239 388,012 950,307 976,771 982,642

0.40 0.39 0.38 0.38 0.37 0.37 0.36 0.75 0.73 0.71 1.70 1.71 1.69

Table 5.4 Status of coverage of the Civil Servant related insurances and Labor Insurance to the population (unit: %)

Year 1961 1966 1971 1976 1981 1986 1991 1994

Civil Servant related insurance 1.9 1.9 2.1 2.3 2.5 4.0 5.4 8.5

Labor Insurance 4.4 4.9 6.6 10.3 15.3 24.2 35.3 40.1

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elementary frame of the Civil Servant Dependent Health Insurance was settled down under the initiative of the government, and was implemented without any serious revision. Further, it laid the overall foundation for any social policy for families which were established afterwards. For example, the Civil Servant Dependent Health Insurance was expanded gradually to the other occupational group who enjoyed the similar status with civil servants, that is, the employee of the public sector, such as the Military Insurance and the Private School Teachers Insurance. These following insurances took the individualistic frame of the poll tax system as its insurance fee calculation method. If we just focus our attention on the superficial characteristics of the two phenomenon, the stem family ideal and individualistic family norm, which the civil servant related insurances exhibit, and the low dependent ratio could be interpreted as outcomes of the family reality of the civil servant group who had experienced a recent immigration and, accordingly, the downsized structure. However, the historical details do not support their relevance or the seemingly causal relationship. In the micro process of political actors, the civil servant group advocated the familialism. However, what they pursued in the welfare politics surrounding the dependent system was material interests regarding the maximum welfare benefits to family members with a minimum cost rather than the legitimacy of any family norm or tradition with a coherent reference. What they wanted to realize through establishing the welfare institution was not the institutionalization of family ideal or norms they considered desirable or taken for granted: they wanted to institutionalize the economic structure which could maximize and guarantee the material interests of individual member of family. If the welfare institution, which the welfare politics had brought about, could not guarantee the maximization of their material interest, they would not hesitate to exit the institution in pursuit of those interests. As a result, the individualistic frame of the poll tax system created the incentive structure in which the Taiwanese families could choose the de-familialization rationally from the perspective of all family members. This established the path of the de-familialization of social policies; the familial discourses retreated to the back stage of the welfare politics in the history of welfare development in Taiwan. Why, in the late 1970s, was the familialistic institutional framing coincided with the political crisis of the KMT government? It could be interpreted as a “serendipity” of historical sequences (Davis 2004). If the

124  H.S. Wang

welfare institution building process had proceeded after or with the democratization, it could have ended with a different result. If the civil servant group had raised the same voice for resistance after or with the democratization that had enhanced their administrative and political autonomy from the KMT government, the KMT government could not have simply ignored their demands.7 The political environmental changes could have led the civil servant group to raise a strong voice for the institutional reforms rather than staying with the passive loyalty or exiting the given institution (Hirschman 1970). It could have been likely that the civil servant group could have succeeded in achieving the familialistic system. However, in this period, the civil servant group’s ambiguous status between the government and the society postulated the structural constraints in their further resistance to the state. At last, under the initiative of the government, the fiscally stable frame based on the individualistic dependent system was settled down. It was the momentum for the social insurances of Taiwan to be equipped with its individualistic nature, and therefore to establish the de-familialization path of social policies in Taiwan.

From the Labor Insurance to the NHI (1991–1995): Failure of Familialistic Reform The Taiwanese insurance scheme had been built on the two pillars of the Civil Servant Insurance and Labor Insurance. As seen in Table 5.2, the Labor Insurance was the only health insurance for working class, mainly Taiwanese, with the largest number of the insured. The two insurances provided their insured with widely varied levels of benefits. The first gap between the two insurances was the existence of a dependent system. The civil servants had the national insurance for their families operated by the government as the privilege only allowed for the civil servants. Meanwhile, the Labor Insurance covered only the individual insured: only the workers could be qualified as the insured and their family dependents could not enjoy the insurance eligibility. It means that the family of the working class was placed in a blind spot and medical costs for these dependents had to be paid out of the pockets of the insured. Indeed, it was the only way for workers’ families to be employees of their own in order to get the benefits from any national insurance. In some cases, in order to receive the insurance benefits, jobless children or parents forged an identity of employee through trade unions and registered the Labor Insurance.

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The gap between the two insurances is also enlisted within the levels of medical benefits. Even when the Civil Servant Insurance started in 1958, it provided the insured with medical benefits for outpatients and inpatient. Meanwhile, the first Labor Insurance had no medical benefits; it was not until 1956 that the medical benefits for inpatients were introduced, not yet for the outpatients. The government delayed the full-fledged implementation of medical benefits by arguing that it would increase the insurance fees, which would intensify the financial distress of both employees and employers. It also worried that the implementation of medical benefits would increase the medical demands but the medical facilities of that time could not meet the increased demands. The aims, which the authoritarian government intended to achieve through social policies, were not providing actual benefits but encompassing as many populations as possible into the realm of social insurances to control them (An 1993). Moreover, the KMT government offered welfare benefits disproportionate to the extent to which each social group had importance in consolidating the regime. The disproportionate benefits between the two insurances had established the discriminating perception between the Civil Servant Insurance and the Labor Insurance. The disproportionate benefits between the two insurances, combined with the existing segregation between the two ethnic groups in the ethnic, economic (occupational), and political dimension, offered not only symbolic but also substantial and material foundation to build the perception that the Labor Insurance is inferior to the Civil Servant Insurance. However, as the democratization and election competition was intensified, the KMT government faced the crisis in its political legitimacy and had to reinforce its traditional support, that is, the civil servants of the government sector as well as extend its base of political support to the Taiwanese and the labor class. To this aim, the KMT government intended to improve benefits of the Labor Insurance. The insured of the Labor Insurance, that is, the labor class, at the same time, the Taiwanese, also started to voice their dissatisfaction about the benefits of Labor Insurance inferior to those of the Civil Servants Insurance. At the same time, the democratization on the move, rendered them to achieve the enhanced political capacity, based on which they could organize the political movement to pursue better welfare benefits as well as the insurance for their families. As mentioned earlier, a narrow family model embedded in the dependent system of the civil servant related insurances in the early period did not match with the family reality of the Mainlanders, let alone the Taiwanese. Then, the puzzle is how such a narrow family model farther from the reality

126  H.S. Wang

could be adopted as a basic family model of the universal NHI which was launched in 1995? To fill the gap between the dependent system of the Civil Servant Insurance in 1958 and that of the NHI in 1995, the following section scrutinizes how the family dependents issues were dealt with in the Labor Insurance, the largest single insurance for the Taiwanese, in the 1980s and the early 1990s. It will offer the clues to understand how their policy discourses regarding families were influenced by the early discussion and, in turn, influenced the following welfare politics surrounding the NHI. Labor Insurance for Families? Since the late 1980s, in the situation of intensified democratization and electoral competition, the government pledged the implementation of the health insurance for working classes’ families to mobilize their political supports. Actually, the two related agencies of the government, the Labor Committee and the Economic Planning and Development Committee, had prepared plans to legislate the health insurance for workers’ families. The government considered this policy not as welfare policy but as labor market policy. Therefore, the Labor Committee, which was in charge of the Labor Insurance administration, and the Economic Planning and Development Committee co-led the legislative process. As a result, the Labor Committee heralded the launching of the insurance in 1991.8 According to the proposal submitted at that time, the act offered an additional provision about worker’s family health insurance on the previous Labor Insurance Act, which stipulated the family dependent as spouse, parent, and children of the insured. This specification inherited the immediate family model of the existing Civil Servant Dependent Health Insurance. A high official of the government anticipated that the new insurance would cover 7.2 million worker’s family dependents.9 Given that the Taiwan’s population at that time was about 20 million, it was a genuinely innovative policy. As of 1991, the civil servant related insurances covered 1 million, and the Labor Insurance covered 7 million of the population. Therefore, if the new insurance had been implemented as planned, 15.2 million people in total, that is, the 75% of the total population were expected to enjoy the health benefits, which could have been recorded as the greatest progress in the history of the welfare development in Taiwan. However, the enforcement of the Act was delayed as its premium calculation method of the insured triggered the hassle. The Labor Committee

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announced that it would choose one between the two options regarding the insurance fee calculation and the fund raising.10 The first plan ( , family) was a kind of a collective calculation method, which set the insurance fee at a fixed rate on a basis of income regardless of the number of family dependents. It was similar to the insurance fee calculation method of the NHI of S. Korea. In this system, the insurance fee is paid by the insured and the employer by 50%. The second ( , household) method was represented as a poll tax system, which calculated the insurance fees in proportion to the number of family dependents. In this system, the insurance fee should be paid by the insured and the employer by 20 and 80%, respectively. Finally, 8 months later, the Labor Committee and the Economic Planning and Development Committee announced the first draft of Act based on the first plan that adopted the familialistic frame. Also, it determined that the insurance fee for family dependents were to be equally contributed by employers and workers by 50% respectively. The government tried to find a justification for this decision by emphasizing that Japan’s insurance also followed the same model based on a unit of family, not counting the number of household members.11 Additionally, the government argued that in the Japanese model the employer and the employee contributed equally to the fund, which would be fairer. The Japanese insurance system, in which the government and the society at large considered to be more advanced, was utilized as a tool to guarantee the legitimacy and equity of the new insurance under suspicion of its possibility and fairness. However, suddenly a month later, the Labor Committee converted the draft to the individualistic frame of the second plan, which was collecting the insurance fee by a poll tax system, without revision on the equal contribution between the employer and the employee. The Committee argued that the second plan would be consistent with the spirit of the beneficiary burden, ensure equal rights and duties and fair contribution, and avoid the discontent of the workers without family dependents.12 Above all, the most important reason for this policy reversal was the opposition of workers, particularly the workers whose family had a small number of members. The representative of workers who participated in the Labor Committee presented survey data conducted on 350,000 workers. In these data, 67% of respondents said that the family unit calculation method was unfair. Based on the survey, the committee insisted that the insurance should be revised to an individualistic one.13 This

128  H.S. Wang

period is different from that period when the Civil Servant Insurance was established; not the authoritarian government but the labor class played an important role in designing the insurance with enhanced political capacity and its interest was strongly reflected in the insurance. The problem is that the labor class did not want the familialistic frame. Meanwhile, against the Labor Committee, the Economic Planning and Development Committee supported the original plan of familialistic frame, stressing that this approach was more consistent with the principle of societal mutual aid and redistribution principles, and refuted the actuarial fairness was neither important nor proper as a principle of social insurance. Additionally, the Economic Planning and Development Committee criticized that the second plan stipulated the employer in charge 80% of insurance fee for employee’s family dependents, which could let employers avoid hiring an employee with many family dependents.14 Employers also supported the first plan: however it was not because they supported the family norm that the first plan manifested but because there would be less burden (50%) on them regarding the insurance fee of family dependents. Many employers expressed negative opinions on the second plan, worrying that the employees with more family members would be handicapped in the labor market and be in danger in securing their job.15 It was a thinly veild threat to push the government to lower the burden of the employer holding the livelihood of large families as hostage. After all, these debates were centered on the issue of the elementary basis of the insurance fee, between the family unit and the household unit. The Economic Planning and Development Committee and employer group supported the more familialistic first plan. Meanwhile, the Labor Committee and employees group supported the second plan of poll tax. Both parties failed to react an agreement and the dispute had continued until 1993. However, this debate was absorbed into a larger process of integrating health insurances and the launching of the universal health insurance, i.e., the NHI in 1995. The Inauguration of the NHI The preparation to introduce the universal health insurance scheme had been already put into an action since the mid-1980s under the initiative of the KMT government (Lin 2002; Wong 2004). In 1984, the Economic Planning and Development Committee under the Executive Yuan established a taskforce team to realign the social welfare policies,

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and in 1986 submitted a “Comprehensive Plan of National Welfare System,” which advised to integrate the existing fragmented social insurance programs and inaugurate the universal health insurance by 2000. In 1988, the Committee proclaimed that it would push ahead with its plan to advance the NHI in 1995 instead of the originally proposed 2000. Soon, it invited the academic professionals to organize the national health insurance planning taskforce team, which submitted the first draft of the NHI (policy guideline) to the Department of Health, the Executive Yuan in 1990. After the first stage of policy planning of the NHI, which had been under the governance of the Economic Planning and Development Committee, the authority in the detailed design of the NHI was taken by the Department of Health, under the Executive Yuan. The Department of Health took the responsibility for the second stage of planning the implementation and practical administration of the NHI. To this purpose, the Department of Health organized its own taskforce team, composed of various kinds of professionals such as the medical professionals and legislators so that the number of its members was extended to 32. The policy planning in this stage was dominated by “professional and technocrats” (Lin 2003). Especially the opinions of scholars were influential. The policy experts who cooperated with planning the NHI had an orientation that emphasized a strong, efficient technological rationality. These policy experts were not placed under the restraints of practical administration of policies, so that they could avoid the “status quo bias” of policy bureaucrats. This made a fundamentally ground-breaking plan, completely different from the past, appear in the new NHI. Especially, the frame manufactured by them, intended to restructure the previously fragmented structure into the centralized organization. It signified that the Taiwan’s social insurance departed from its historical path of development, which it had followed for about a half century, heading for a new path of integrated insurance: the departure from the old conservative welfare state. However, judged from the perspective of the dependent system, the new NHI proposal did not signify the discontinuity with the past path. There was a wide consensus that the new NHI should integrate the existing occupationally fragmented and, thereby administratively costly and inefficient insurances scheme. However, concerning the detailed administration of the NHI, there were several debates. Major issues can be summarized into three: the scope of integration, the proportion of government’s contribution to the NHI

130  H.S. Wang

fund, and the calculation methods for the insurance fees for dependents (Lin 2003). Regarding the third issue, from the early period, the two contested opinions were in conflicts on whether additional insurance fees should be imposed on dependents or not. The first one was the “family” method, which imposed the total insurance fee on the basis of household without counting the number of family dependents—imposing the insurance only on one person of the family, mainly a head of household, on behalf of his/her family. The second one was the “household” method, which imposed the insurance fee on each member of the family: it succeeded the earlier discussion of the Labor Insurance. The previous dispute, which had unfolded in reforming the Labor Insurance around the issue of how to calculate the insurance fees of family dependents, reappeared in the welfare politics in the building process of a universal health insurance system, which would be newly introduced soon, and finally set the basic framework of the new NHI. At first, both taskforce teams of the Economic Planning and Development Committee and the Department of Health agreed that the dependents should be exempt from the insurance fees. However, soon, the taskforce team of the Department of Health reversed its opinion and insisted that insurance fees also should be imposed on dependents based on a poll tax system for the excuse of fiscal soundness. The Department of Health argued that in the present population structure, one-person households already occupied the high proportion of the whole population, and that they would not regard the first plan as fair.16 The reversal of the opinion of the Department of Health provoked the strong resistance from the Labor Committee, which decried that “the Department of Health supports the plan that will hamper the principle of mutual help and produce the discrimination within the labor market; and the employees with many dependents will hesitate to subscribe to the insurance.”17,18 The dispute between the Labor Committee’s family plan and the Department of Health’s household plan was put to an end by the intervention of the government (Lin 2002): the Executive Yuan decided the “household” method, which imposed the insurance fee on the insured as well as dependents and put the insured as responsible for paying the total insurance fees imposed on their household according to the number of dependents. This was the moment when the long and tedious dispute since the civil servant insurance came to an end.

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Curiously, most of the employees and their families considered the government’s decision as reasonable and accepted it without any tangible resistance. Families with many dependents, who once had strongly resisted the same “household” plan 10 years before, did not appeal their voices this time. Here, it is worth mentioning three reasons. First, through the integration of the Labor Insurance and the civil servants related insurances and the implementation of the universal NHI, the Labor Insured were able to get a substantial benefit of the dependent system. The existing Labor Insurance did not offer the medical benefits to the dependent of the insured: if the NHI was implemented, then their families could be entitled to get access to health benefits, not through informal or illegal routes. This signified that their demand for insurance for their families was accepted at last. In addition, to the Labor Insured who had experienced their demands for health insurance for their family being ended in vain just a few years ago, the key was the implementation of insurance per se rather than its detailed rules. Secondly, their satisfaction with a new NHI partially came from the symbolic and psychological benefits which the unified NHI would bring forth. Under the existing public insurance scheme of Taiwan, a myriad of social insurances had developed in an extremely segmented and smallscaled way, which raised the administrative cost in operating the program as well as managing each insurance fund and hence. Neither the Labor Insurance nor the Farmers’ Insurance was free from these problems: they had been on the verge of fiscal crisis. The Labor Insurance had already displayed the potential danger in its fiscal aspect since it was drafted (Lin 2003, 61–62). The comprehensive insurance scheme of the Labor Insurance had caused a fiscal problem because under its accounting system the cash benefits and medical benefits could not be caculated separately, which later became an indirect cause for a fiscal crisis of the insurance. Moreover, the government's policy for lowering insurance fee (low-cost policy) to allure the political support had greatly increased the actual expenditure and retirement benefits since the late 1980s and had caused the steady increase in costs for the medical treatment causing the financial burden for the government. This soon provoked numerous criticisms and the fiscal crisis of the Labor Insurance appeared on headlines of the major mass media. This again created a negative atmosphere in Taiwan, and inclined

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people to avoid the Labor Insurance. On the other hand, the Civil Servant Insurance had formed the image of an ideal insurance system that seized both equity and efficiency with a good financial standing. These perceptions were in fact produced in a relation with the hierarchical and positional status of the laborers and government officials. The insured of other social insurances expected that if the Labor Insurance and the Farmers’ Insurance were to be incorporated into the Civil Servant Insurance, the unified insurance would solve the problem that the earlier fragmented insurances had in managing the fund and administration as well as provide them with superior benefits that the civil servants had enjoyed. Therefore, the plan did not face any serious resistance from the working class and farmers, the two representatives of Taiwanese social groups, which were equipped with the most potentials of organizing the collective movements (Lin 2003, 61).19 In turn, it also had intensified the policy preference in the Civil Servant Insurance as desirable social insurance. Finally, the institution, once designed and operated only for 10% of the Taiwan population two decades ago based on a very narrow family ideal, was adopted as the institution for the whole population of Taiwan without any appreciable resistance. As a result, the development path of the two insurances, which originated from signifying the differentiated economic status between the Taiwanese and the Mainlanders in the 1950s, were conjoined with discriminated perception on social status of occupational groups in the following two decades, imprinted the different policy preferences between the two insurances, and finally influenced strongly the building process of the NHI in the 1990s. The experience of earlier institutions had crafted the cognitive frame of social actors in a specific way. Moreover, the earlier policy making processes regarding the Civil Servant Dependent Health Insurance and the Labor Insurance had established a kind of the institutional “taken-for-grantedness” (Lin 2003). In 1991, in the midst of the debate on introducing the dependent system to the Labor Insurance, the Department of Health proclaimed the basic principle that the financing mode of a new NHI would be set as a poll tax system, following the precedents of the Civil Servant Insurance and the Labor Insurance.20 The proclaim notified that all the social insurances of Taiwan in future would base its principle on a poll tax system.

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Table 5.5  Status of number of dependents of the NHI of Taiwan (in 1995) (unit: 1000) Number of dependents

0

1

2

3

4

5

Over 6

Total

Number of the insured %

6951 67.03

1052 10.15

1146 11.05

805 7.76

308 2.97

79 0.77

28 0.27

10,369 100.0

Table 5.6  Average size of Taiwanese families (unit: %) 1

2

3

4

5

6–9

1956 – – – – – – 1966 – – – – – – 1970 – – – – – – 1975 – – – – – – 1980 – – – – – – 1990 13.4 12.7 14.6 21.5 18.6 17.5 2000 21.5 17.2 17.6 20.3 12.0 10.4 2010 22.0 22.0 20.9 19.1 8.7 7.3*

Over 10

Average number of people per household (person)

– – – – – 1.7 0.9 –

5.7 5.9 5.5 5.3 4.8 4.0 3.3 3.0

Source Statistical Data in 1956–1980 is from Summaries of Population and Housing Census in TaiwanFukien Area: Statistical Data in 1990–2010 is from Directorate General of Budget, Accounting and Statistics Executive Yuan, R. O. C., 2010. Social Indicators.

Interestingly, in the Taiwan’s welfare politics around the Labor Insurance and the NHI, unlike in Korea, the voices for extending the scope of family are not witnessed. The dissatisfaction with the dependent system is mainly focused on the calculation method, and the narrow scope of the family dependent is rarely criticized. This is derived from the institutional features of the calculation method of insurance fee. As explained in Chap. 3, the poll tax nature of the insurance fee does not create an incentive to extend the number of dependents, even though the system allows a broader scope of relatives to be entitled as dependents. Rather, the insured worried that the extension of the scope of dependent entitlement would increase the insurance fee as a whole. It implies that the institutional features of the insurance also strongly influenced the nature of welfare politics and its de-familialization path.

134  H.S. Wang

More importantly, as the universal NHI started after the industrialization and urbanization in the mid-1990s, it had to face the resistance from urbanized nuclear families who occupied the majority of the whole households. This time, the employee changed their opinions and supported the individualistic plan that calculated the insurance fee based on the number of dependents. Here, the sequence of the timing of industrialization matters: the NHI launched after the completion of first stage of industrialization and urbanization, and therefore, the major client of the NHI was mostly families who experienced the downsizing, nuclearization or atomization. It means that the familialistic frame was not welcome by urban nuclear families and one-person households that occupied the absolute majority of working class. As shown in Table 5.5, in 1995 when the NHI was implemented, 67% of the total insured was the single insured without dependents. Of course, in some dimension, the dependent system is equipped with advantages to large families. If the number of dependents exceeds three, the NHI does not require the insured to pay additional fees. Such a rule intended to alleviate the economic burdens of large families. However, families who could benefit from the familialistic frame, in other words, those with more than four dependents, occupied only 4%. Meanwhile, the majority of the insured, roughly 88% of the insured with less than two dependents, considered the familialistic frame as irrational or incongruent with their interests. They worried that if the governments were to adopt the familialistic system, it would let them pay more on behalf of the large families with more dependents, and they would lose out. As Table 5.6 demonstrates, the transformation of Taiwanese families into the nuclear family and the downsizing of families have altered the incentive structure of families. Families who once voiced for the familialization of the health insurances just 10 years ago, voiced for the de-familialization of the NHI. As a result, the initial frame of the individualistic nuclear family model was firmly sustained and ever reinforced, not by the government’s fiscal logic but by the voluntary choice of families themselves. It implies that the Taiwanese families rationally chose their own way of de-familializaing their welfare regime.

5  HISTORICAL DEVELOPMENT OF NHI IN TAIWAN … 

135

Notes

1. The “Civil Servants related insurances” refers to six insurances for the civil servants and their families and four insurances for private school teachers and their families, excluding social insurances for employees in the nongovernment sector in Fig. 5.1. 2. The Farmers’ Insurance established in 1985 only offered the medical benefits not like the Civil Servant Insurance or the Labor Insurance which were designed as a comprehensive insurance, so that it is of an entirely different nature to be compared with the two insurances. Additionally, the number of the insured of the Fishermen’s Insurance and Students’ Insurance is too small to be paralleled with other insurances. 3.  , January 16, 1982. 4.  , January 16, 1982. 5.  , January 16, 1982. 6.  , January 16, 1982. 7. In Taiwan, the democratization had the authoritarian nature of the state, and had brought changes in the relation between the state and the civil society as well as the relation between the state and the bureaucrats (Ku 2002, 163–165). The separation of party and government and politicians and bureaucrats enabled the civil servants’ autonomous bureaucratic control of administration. 8.  , April 15, 1989. 9.  , December 23, 1989. 10.  , April 15, 1989. 11.  , December 23, 1989. 12.  , January 19, 1990. 13.  , January 11, 1990. 14.  , January 19, 1990. 15.  , January 22, 1990. 16.  , April 23, 1993. 17.  , May 23, 1993. 18. Interestingly, the Labor Committee in the earlier disputes on the reforming of the Labor Insurance supported the poll tax system. Now, in the similar dispute on the NHI, it reversed its earlier opinion and resisted the poll tax system. Its abrupt reversal of opinions should be evaluated from the perspective of power structure and struggle within the government agencies. The implementation of the unified insurance, NHI, implied that the medical benefits-related administration, which had been one of the most important functions of the Labor Insurance, would be transferred from the Labor Committee to the independent NHI Administration

136  H.S. Wang under the Department of Health. It anticipated the shrink of authority and power of the Labor Committee. In fact, in the process of planning the NHI, the Labor Committee and the Ministry of Health collided over every issues. 19. The KMT regime let all the employees, except but the civil servants and teachers, subscribe to the Labor Insurance, regardless of their occupations. Also the government made a rule that employees as well as self-employed and employers should subscribe to the NHI through occupational associations (labor unions). In result, the Labor Insurance unexpectedly constructed a cross-class social group based on broad social background. Such a cross-class composition of the insured group was invented by the authoritarian government in order to hinder the development of class interests and class consciousness of each class (EspingAndersen 1990). Therefore, in the formative years of the NHI, classes had limited capacity in organizing their resistance or dissatisfaction into a collective movement against the government’s plan. 20.  , September 19, 1991.

References An, Jae Shin. 1993. A Comparative Research on Social Insurance Systems of S. Korea and Taiwan: Focused on the 1960s and the 1970s. M.A. Thesis, Department of Social Welfare, Yonsei University (In Korean). Cheng, Peter Wen-hui. 1987. Financing Social Insurance in Taiwan. In Conference on Economic Development and Social Welfare in Taiwan, vol. II, 525–548 (465–525). Taipei: The Institute of Economics, Academia Sinica. Davis, Diane. 2004. Discipline and Development: Middle Class and Prosperity in East Asia and Latin America. Cambridge: Cambridge University Press. Esping-Andersen, Gosta. 1990. The Three Worlds of Welfare Capitalism. Princeton, NJ: Princeton University Press. Goodman, Roger, Gordon White, and Huck-Ju Kwon (eds.). 1998. The East Asian Welfare Model: Welfare Orientalism and the State. London: Routledge. Greenhalgh, Susan. 1984. Networks and Their Nodes: Urban Society on Taiwan. China Quarterly 99: 529–552. Guo, Yinsheng. 1980. Introduction for the Civil Servant’s Insurance Law. Taipei: Taiwan Xuesheng Shuju (In Chinese). Hirschman, Albert O. 1970. Exit, Voice, and Loyalty: Responses to Decline in Firms, Organizations, and States. Cambridge, MA: Harvard University Press. Ku, Yeun-wen. 2002. Towards a Taiwanese Welfare State: Demographic Change, Politics and Social Policy. In Discovering the Welfare States in East Asia, 143– 167. Westport: Praeger.

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Lin, Chen-Wei. 2002. The Policymaking Process for the Social Security System in Taiwan: The National Health Insurance and National Pension Program. The Developing Economies 40 (3): 327–358. Lin, Kuo-ming. 2003. Path Dependence and the Institutional Formation of Taiwan’s National Health Insurance Plan. Taiwanese Sociology 5: 1–71 (In Chinese). Roy, Denny. 2003. Taiwan: a Political History. Ithaca and London: Cornell University Press. Rubinstein, Murray A. (ed.). 1999. Taiwan: A New History. New York: M. E. Sharpe. Scott, Mandy and Hak-khiam Tiun. 2007. Mandarin-Only to Mandarin-Plus: Taiwan. Language Policy 6: 53–72. Shin, Jang-Sup, and Ha-Joon Chang. 2003. Restructuring Korea Inc. London and New York: Routledge Curzon. Wang, Pu-chang. 1994. A Research on the Causes and Structure of Marital Relationship of Han Ethnic Group in Taiwan after Independence. Ethnographic Research 76: 43–96. Wang, Pu-chang. 2008. Identities in Conflict: Ethnic imagination in Contemporary Taiwan. Seoul: Nanam Publishing (Translated in Korean). Wei, Lungta. 2008. The Transformation of the Imagined Subject: A Historical Sociological Investigation of the Political Discourses in the 1970s-1990s. M.A. Thesis, Department of Sociology, the National Taiwan University (In Chinese). Weinstein, Maxine, Te-Hsiung Sun, Ming-Cheng Chang, and Ronald Freedman. 1990. Household Composition, Extended Kinship, and Reproduction in Taiwan: 1965–1985. Population Studies: A Journal of Demography 44 (2): 217–239. Wong, Joseph. 2004. Healthy Democracies: Welfare Politics in Taiwan and South Korea. Cornell: Cornell University Press. Wu, Chung-lih. 1987. Economic Aspects of Health Insurance in the Republic of China: A Demand-Side Analysis with a Proposal of National Health Insurance. In Conference on Economic Development and Social Welfare in Taiwan, vol. II, 431–464. Taipei: The Institute of Economics, Academia Sinica.

CHAPTER 6

Conclusion

The miraculous growth of East Asian countries has resulted in the flux of studies on the East Asian developmental model and its effectiveness and feasibility (Amsden 1989; Chang 2006). However, most of these studies solely focused on the production mechanism of the East Asian developmental state model, ignored the redistributive dimension of the model and concluded that the redistribution mechanism or the welfare function did not exist in the region. Worse still, the dynamics of the model were blamed for hampering the welfare development in the region (Kwon 1997; Hong 1999; Woo 2004). Especially, the Confucian bias for the free market orientation (Bell 2003), which was once heaped as the source of East Asian miracle (World Bank 1993), seemed to convince the claim that welfare is “an-Asian” (Chau and Yu 2005, 22–23). However, as the welfare development also has proceeded in East Asian countries, more and more scholars started to discuss the newly established welfare regime in the region. They share an ambitious project to establish “an Asian” welfare regime, which can be differentiated from the West. However, they were too ambitious. They exaggerated the cultural and historical homogeneity, especially the familial characters of the welfare regimes in the region, and affirmed those characteristics as the Confucian legacy, which once was blamed as an obstacle to welfare development. In this regard, this book intended to gear toward the opposite direction. It paid attention to the diversity of welfare regimes inside the East Asia, and tried to account for the origin of this diversity not from the inherited tradition but from welfare politics. © The Author(s) 2017 H.S. Wang, Familial Foundations of the Welfare State, DOI 10.1007/978-3-319-58712-7_6

139

140  H.S. Wang L1

Familialism in Confucian tradition

Patrilineal L2

stem family norm t0

L3

t1

Welfare institutions

Institutional Changes

(dependent system)

(expansion) Circumventing or Resisting

L4

Strategic mobilization of cultures

Interests and norms of actors

Fig. 6.1  Interaction between institution and actor and institutional changes

This book reexamined the expansion of the NHI and the institutional changes of its dependent system. The results indicate that the historical changes of the dependent system in S. Korea and Taiwan cannot be explained solely from the state’s fiscal logic, the authoritarian regime’s pursuit of political legitimacy and social control through the mobilization of family ideology, or the blind adherence to the tradition. It was the consequence made by various actors who pursued different interests through strategic action. And this book highlighted normative and economic motives of these strategic actors in the light of the recognition struggles. This research also tried to address how historical legacies, institutional arrangements of welfare system, and diversity of family realities affect the welfare politics by constructing the individual’s interest and rationality and offering constraints and opportunities to their choice of actions. In this regard, it explored the interaction between institutions and actors, which occured in the processes of welfare politics. Figure 6.1 specifies

6 CONCLUSION 

141

how the multilayered interaction between institutions and actors led to the institutional changes of the NHI over time (Williamson 2000). In the initial period (t0), both of S. Korea and Taiwan shared the strong influence or taken-for-grantedness of familialism (L1). In fact, the influence of familialism has been witnessed throughout the whole periods of welfare politics in S. Korea and Taiwan, be it individuals or the states. Regardless of whether they agreed or resisted to the familialistic welfare institutions, motives of all the insured were fundamentally the same: to provide all the family members with the maximum medical service and benefits at the minimum cost. It affirms that familialism in L1 shaped actors’ cognitive and interpretative frame for rationality. Nevertheless, individuals could have their own family ideals and norms according to their different realities and situations. Male laborers and female laborers in S. Korea and the Mainlanders and the Taiwanese in Taiwan experienced the idiosyncratic family realities and thereby had different family interests. In the second level of “institutional environment” (L2), formal institutions such as the executive, legislative, judicial, and bureaucratic functions of government as well as the distribution of powers were established to institutionalize familisliatic values and norms of L1. In this level, the state deliberately fostered a certain kind of family ideal for its economic and political needs. What dominated the Korean government in the initial stage of institution building was economic concerns: the government had to pool all the resources for the economic development and curtail the costs for welfare. For this aim, the Korean government established the formal institutions based on the patrilineal family norm which stressed that a male head of family should take care of its members. In Taiwan, the institution building process was dominated by the state’s political aims; it intended to consolidate the solidarity of ruling coalition by mobilizing the political supports from the Mainlanders. Therefore, it established a series of economic and political institutions which favored the family reality of the Mainlanders who had a patrilineal stem family because of the recent immigration from China to Taiwan. As a result, under the stronger influence of familialism, S. Korea and Taiwan had established the institution environments based on a patrilieal family norms, despite the fact that their authoritarian states pursued different aims. However, this fact made a divergence in the “organizational governance” in L3, that is, the dependent system. They institutionalized the different methods of collecting the insurance fees according to

142  H.S. Wang

the aims that they pursued through the NHIs. S. Korea’s developmental state had established the dependent system for the workers in the strategic industries. However, in order to avoid the financial contribution, it put the fiscal responsibility for dependents on the insured and the employers as a whole. Meanwhile, Taiwan government had to launch the dependent system in order to cope with the political crisis even though it had to take a fiscal burden. Nevertheless, it tried to minimize its burden by introducing the poll tax system. In both cases, the NHIs were subordiate to economic or political policies. Families, with the internalized cognitive frame of familialism (L1) and incentive structure (L3), participated in the resource allocation process (L4) and tried to maximize their interests. However, their choices of actions are never automatically determined by the institutional constraints, but they depend on the contextual and “ad hoc” invention by the strategic actors. Some in order to utilize the opportunity and others to circumvent the obstacle, strategically mobilized and utilized family norms that are favorable to them. Of course, these norms are nothing new but were chosen and mobilized from the exiting cultures and tradition (L1). In this process, certain norms are strategically mobilized from the existing institutional frameworks in the name of tradition and some new norms are created and invented. These processes unintentionally involved the change or maintenance of the existing institutions (t0 → t1 in L3). In Korea, the insured demanded the extension of dependents for familial and economic reasons, because according to the given institutional arrangement, it was more rational to have as many dependents as possible. And this led to the development of NHI system as well as reinforced the familialistic development path of welfare institutions. Meanwhile, in Taiwan, under the given dependents system, it was more rational and less costly to have less dependents than to resist or try to change the institution. That’s why the institutional changes did not occur in Taiwan and the initial institutions (t0) remained without substantial change. It resulted in the scale-down of ideal family norms and the de-familialization of NHI. It should not be misunderstood as saying that Taiwanese society, in general, is de-familialized. Taiwanese families just retreated from the welfare politics and decided to de-familialize their welfare state in order to maximize their family interests.

6 CONCLUSION 

143

As such, this research attempts to take balanced consideration on historical legacies, institutional arrangements of the welfare system, and diversity of family realities. Tradition matters only when “through practices it can be constantly reconstructed and mobilized” (Ringmar 2005). And in the very momentum of reconstruction and mobilization of tradition, how political actors respond to and interact with these three institutional factors is critical in shaping the actual arrangements of certain welfare institutions. In addition, their economic and moral motives also influence their mode of interaction with these institutions. In the Korea’s case, not only concerns for economic costs regarding the insurance fees but also feelings of disrespect and negation, which the female insured experienced through the patrilineal NHI in the early period (L3), led them to put forward their rights and their families’ rights. Like other social movements, the outcome of recognition struggles cannot be solely determined by participant’s motives and organizational capacity. It is also influenced by the institutional settings surrounding the struggles. In the context of rapid industrialization (L2), their claims offered the strong moral motivation for expanding the dependent system to a more gender-equity institution to the state that had to subsume the female workers, 37% of the total labor force at that time, as well as uphold the familialism and protect the maternity for political reasons. It shows how the economic struggle of a specific group surrounding insurance fees and medical benefits could transform itself to the moral struggle for recognition of generalized identity of women and family. In the late 1980s when the recognition struggle around the dependent eligibility expanded beyond the female insured’s matter to all the insured’s interests, the institutional arrangement of the dependent system tightly combined the moral and economic motives, which propelled the further expansion of the dependent system. The Korean case shows how the “pre-modern” identity of family in the “private” and “informal” sector and the “modern” identity of worker or citizens in the “public” and “formal” sector are interwoven to constitute the specific features of welfare politics in S. Korea. In contrast, Taiwanese case evinces that the two identities are detached from each other in the welfare politics. In both cases, the key was the unique institutional arrangements of their NHIs that strongly coupled the two identities in Korea while de-coupled them in Taiwan.

144  H.S. Wang

Future of Familialistic Welfare Regimes Based on the findings, this book argues that both Korea and Taiwan have institutionalized the NHIs alienated from their family realities, which can be the intended or unintended results of historical and political paths of each NHI. Then, what is the present situation and problem which each NHI faces? Families in Korea have the welfare institution which is too broader and more inclusive than their realities. That’s why Koreans are dissatisfied with their NHI and skeptical about its fiscal sustainability, claiming that the scope of family dependents should be limited only to immediate family.1 It means that the insured who have less dependents assume that they are losing out compared to the insured with more dependents, or that they are paying more insurance fee instead of the insured with more dependents.2 Especially, it became an important issue of welfare politics with the East Asian financial crisis in 1997, which unveiled the weakness of the existing Korean welfare system. To cope with the crisis, the newly launched DJ government introduced the new social policies like employment insurance and initiated the restructuring process on existing programs which lost their validity. The NHI, one of the oldest welfare programs of Korea, was the main target. Restructuring the NHI was implemented on the two principles, “equity” and “efficiency,” which underlay the overall social policies of DJ government (Mishra et al. 2004). Related to the second issue, one of the suggested solutions to maintain the fiscal health was to reform the ineffective “dependent system,” which allowed the eligibility to unrealistically broad range of kinship without paying the insurance fees (Cho 2002). According to the critics, as the dependent system is too generous for family dependents, even those who afford to pay the insurance fees can be registered as dependents, which aggravates the NHI fund. After two decades of discussion, in 2017, the reform bill to abolish the dependent entitlement of brothers and sisters of the insured passed the National Assembly. By this refome bill, 250,000 to 260,000 of dependents who have enjoyed the free ride of the NHI are expected to lose the dependent entitlement and have to subscribe to the NHI on their own.3 Taiwanese families also have the welfare institution alienated from their reality. The family dependents in their NHI are too narrowly determined to encompass their more complicated family realities. However, since 1995 when its NHI was launched, the Taiwanese society had not

6 CONCLUSION 

145

had such a serious momentum like S. Korea to reconsider the NHI system because Taiwanese economy could stay relatively intact despite the East Asian financial crisis. However, the critical moment came from another dimension. It experienced the demographical changes of a low birth rate and the aging population earlier than the Korean society, which called for the fundamental restructuring of their welfare systems. Like the Korean society, family issue also rose as one of the main issues of the NHI reform bill in 2010 and the bill intended to exempt dependents’ insurance fees like Korean NHI, though it failed. It was claimed that Taiwanese NHI failed to support families in need by offering a heavier burden to families with more members. At the same time, however, there existed a strong voice against familializaing the NHI. Some insured harshly blamed the reform bill as the introduction of “single tax” because it intended to militate in favor of a household with many family members while punishing small-sized households like married couples without children and one-person households. Such problems and dissatisfaction raised by the insured themselves imply both of the two NHIs, overfamilialized one and under-familialized one, need a fundamental reform to reflect their family realities properly. It also affirms that the on-going welfare politics of the two societies are not free from the familialistic path, which the past welfare development had paved: they have repeated moving back and forth between familialization and de-familialization like a pendulum. Moreover, the rapid demographical changes, as summarized as “the low birth rate and fastaging society,” and the emergence of diverse forms of family have made the family issue one of the major concerns of welfare politics. However, family policies without enough consideration on changing family realities, just focused on political or fiscal concerns and therefore alienated from families, cannot produce any tangible benefits on families but cause only the social costs. As a result, it is family that has to take in all theses costs: family has to live with a deficit spending of the state’s social policies or exit the realm of welfare state to the welfare market.

Notes 1. United Daily News, December 21, 2010 (http://city.udn.com/62960/ 4358777). 2. “Employee insurance fee should be differentiated to numbers of family and income,” Gangwon Daily, March 15, 1989.

146  H.S. Wang 3. Joong-Ang Daily, February 27, 2001; Seoul Gyeongje, April 20, 2001; Dong’a-Daily, June 19, 2001; Hankook Daily, March 22, 2017.

References Amsden, Alice H. 1989. Asia’s Next Giant: South Korea and Late Industrialization. New York: Oxford University Press. Bell, A. Daniel. 2003. Confucian Constraints on Property Rights. In Confucianism for the Modern World, ed. D. Bell and C.B. Hahm Chai Bong, 218–235. Cambridge: Cambridge University Press. Chang, Ha-Joon. 2006. The East Asian Development Experience: The Miracle, the Crisis and the Future. London: Zed Books. Chau, Ruby C.M., and WaiKam Yu. 2005. Is Welfare UnAsian? In East Asian Welfare Regimes in Transition: From Confucianism to Globalisation, ed. A. Walker and C. Wong, 21–45. Bristol, UK: Polity Press. Cho, Won-Tak. 2002. Changes on Dependents Scope of the NHI and Its Implication in Policies. Health and Welfare 5: 63–76 (In Korean). Hong, Kyung-Zoon. 1999. Social Welfare Regime in Korea. Seoul: Nanam (In Korean). Kwon, Huck-ju. 1997. Beyond European Welfare Regimes: Comparative Perspectives on East Asian Welfare Systems. Journal of Social Policy 26 (4): 467–484. Mishra, Ramesh, Stein Kuhnle, Neil Gilbert, and Kyungbae Chung (eds.). 2004. Modernizing the Korean Welfare State: Towards the Productive Welfare Model. New Brunswick: Transaction Publishers. Ringmar, Erik. 2005. Surviving Capitalism: How We Learned to Live with the Market and Remained Almost Human. London: Anthem Books. Williamson, Oliver E. 2000. The New Institutional Economics: Taking Stock, Looking Ahead. Journal of Economic Literature 38 (4): 595–613. Woo, Myungsook. 2004. The Politics of Social Welfare Policy in South Korea: Growth and Citizenship. Lanham: UPA. World Bank. 1993. East Asian Miracle: Economic Growth and Public Policy. Washington, DC: World Bank and Oxford University Press.

References

Chambers, Deborah. 2001. Representing the Family. London: Sage. Chan, Hou-sheng. 1987. Perspective of the Social Security System in Taiwan. In Conference on Economic Development and Social Welfare in Taiwan, vol. II, 105–122. Taipei: The Institute of Economics, Academia Sinica. Cheng, Tun-jen. 1990. Political Regimes and Development Strategies: South Korea and Taiwan. In Manufacturing Miracles: Paths of Industrialization in Latin America and East Asia, ed. G. Gereffi and D.L.Wyman. Princeton, NJ: Princeton University Press. Chau, Ruby C.M., and Yu. WaiKam. 2005. Is Welfare UnAsian? In East Asian Welfare Regimes in Transition: From Confucianism to Globalisation, ed. A. Walker and C. Wong, 21–45. Bristol, UK: Polity Press. Chibber, Vivek. 2003. Locked in Place: State-Building a Late Industrialization in India. Princeton: Princeton University Press. Chu, Yun-han. 1992. Crafting Democracy in Taiwan. Taipei, Taiwan: Institute for National Policy Research. Cornford, James, Susan Baines, and Rob Wilson. 2013. Representing the Family: How Does the State ‘Think Family’? Policy and Politics 41 (1): 1–19. Croissant, Aurel. 2004. Changing Welfare Regimes in East and Southeast Asia: Crisis, Change and Challenge. Social Policy and Administration 38 (5): ­504–524. DiMaggio, Paul. 1997. Culture and Cognition. Annual Review of Sociology 23: 263–287. Hattori, Tamio. 2007. Economic Sociology of Development. Seoul: Jeontonggwa Hyundai (In Korean). Kim, Byung-Kook, and Ezra F. Vogel (eds.). 2011. The Park Chung Hee Era: The Transformation of South Korea. Cambridge: Harvard University Press. © The Editor(s) (if applicable) and The Author(s) 2017 H.S. Wang, Familial Foundations of the Welfare State, DOI 10.1007/978-3-319-58712-7

147

148  References Korea Statistics (National Statistics Bureau). 2010. Population and Housing Census Report. Seoul: National Statistics Bureau (In Korean). Kuk, Min-ho. 1999. State-initiated Industrialization in East Asia and Confucianism. Gwangju: Jeonnam University Press (In Korean). Lew, Seok-Choon. 2007. Power Structure and Recent Political Development in Korea. Asian Profile 35 (2, April): 85–99. Lin, Kuo-ming. 1997. From Authoritarianism to Statism: The Politics of National Health Insurance in Taiwan. Ph.D. Thesis, Department of Sociology, Yale University. Lin, Wan-yi. 1990. Social Welfare Development in Taiwan: An Integrated Theoretical Explanation. UC Berkeley: Ph. D. diss. Lin, Wan-yi. 1994. Welfare States: Comparative Historical Perspective. Taipei: Juliu Publishing (In Chinese). Lin, Wan-yi, and Kuo-ming Lin. 2004. Taiwan’s Social Welfare Movements. Taipei: Juliu Publishing (In Chinese). Ma, Kyoung-Hee. 2004. Study on the Breadwinner Assumption in Korean Social Insurance. Feminism Research 4 (1): 9–53 (In Korean). Mau, Steffen. 2003. The Moral Economy of Welfare States: Britain and Germany. Abingdon: Routledge. Midlarsky, Manus I. 1997. Inequality, Democracy, and Economic Development. Cambridge: Cambridge University Press. North, Douglass C. 1990. Institutions, Institutional Change and Economic Performance. Cambridge: Cambridge University Press. Pfau-Effinger, Birgit. 2005. Culture and Welfare State Policies: Reflections on a Complex interrelation. Journal of Social Policy 34 (1): 3–20. van, Wim, Michael Opielka, and Birgit Pfau-Effinger. 2008. Culture and Welfare State: Values and Social Policy in Comparative Perspectives. Cheltenham, UK: Edward Elgar. Wang, Pu-chang. 1994. A Research on the Causes and Structure of Marital Relationship of Han Ethnic Group in Taiwan after Independence. Ethnographic Research (Academia Sinica) 76: 43–96.

Index

A Aging, 98, 145 B Birth rate, 50, 145 C Chan, Cheris Shun-ching, 26 Chiang Kai-shek, 112, 114, 115 Citizenship, 35, 37 Civil Servant Dependent Health Insurance, 111, 112 Civil Servants’ Insurance, 12, 42, 85, 108, 110 Communist party, 107, 113, 116 Confucianism, 4, 5, 25, 28, 67, 87, 119, 139, 140 Confucian welfare state, 26 Culture, 5, 6, 9, 28 cultural codes, 87 institutionalization of culture, 29 the first meaning of culture, 32 two meanings of culture, 100

D De-commodification, 21, 27, 42 De-familialization, 20–21, 27, 50, 61, 88, 100, 107, 117, 124.. See also familialization Democratization, 109 Dependent, 11, 36, 44, 45 category of dependent, 48, 112 dependent eligibility, 44, 47, 75, 90, 98, 120 dependent ratio, 48, 51, 58, 61, 64, 123 dependent system, 47 scope of dependent, 54, 58, 78, 98, 117 E Eligibility, 22, 25, 44 Employee health insurance (S. Korea), 41, 53 Esping-Andersen, 19, 42, 68 Ethnicity, 112 ethnic segregation, 114, 125

© The Editor(s) (if applicable) and The Author(s) 2017 H.S. Wang, Familial Foundations of the Welfare State, DOI 10.1007/978-3-319-58712-7

149

150  Index F Familialism, 2, 4, 5, 15, 23, 26, 41, 68, 92, 94, 123, 141 familialism of East Asia, 23 Familialization, 5, 15, 48, 51.. See also de-familialization effect of familialization, 15, 41, 51, 60 Family, 8 collateral family, 55 down-sizing of family, 63, 134 extended family, 67, 83, 99, 116 familial membership, 45, 48, 59, 74 family wage, 22 gender-equity family, 15, 75, 76, 94 lineal family, 90 matrilineal family, 83 nuclearization of family, 50, 54, 55, 57, 62 patrilineal family, 33, 83, 88, 94, 96, 100, 141 scope of family, 53, 75, 117 stem family, 78, 99, 111 Farmers’ Health Insurance (Taiwan), 42, 111 Fertility, 95 Filial piety, 78, 86, 88 Financial crisis, 15, 64, 144 Fiscal logic, 96–98 Fraser, Nancy, 26, 85 G Garfinkel, Harold, 9 Germany, 47, 54 Granovetter, Mark S., 6, 33 H Han Chinese, 112 Historical institutionalism, 6, 23 Honneth, Axel, 10, 15, 34, 85

Household, 119, 127 household economy, 26, 28 I Identity, 10, 34, 94, 115, 124, 143 politics of identity, 34 Institutions institutional changes, 9, 29, 31 institutional environment, 31, 141 Insurance fee, 47, 84, 107, 118 calculation of insurance fee, 57, 84, 92, 111, 117 category of insured, 48 insured, 66 Integration of the National Health Insurance, 12, 78, 129, 131 Intimacy, 36, 87 J Japan, 25, 28, 127 Jones, Catherine, 28 K Kuomintang (KMT), 110–114 L Labor insurance (Taiwan), 12, 42, 108, 114 Love, 34 M Mainlanders, 16, 112–113, 125 Male bread-winner model, 22, 75, 84 Multiculturalism, 35

Index

N National Health Insurance (NHI), 1, 11–12, 41 New institutional economics, 31 O Old-age Social Assistance Programs (Taiwan), 42 One-person household, 130, 134 P Poll tax, 63, 111, 117, 120, 123, 127 Primogeniture, 83 Private/public sphere, 35 R Rationality, 8, 32, 60, 100 Recognition, 34, 113 politics of recognition, 34 recognition struggles, 33, 35, 82, 99–101, 140, 143 three patterns of recognition, 34 Rights, 34, 75, 84, 91 S Scandinavia, 23, 29, 45 Self-employed health insurance (S. Korea), 43, 59, 61–63 Solidarity, 28 Son preference, 95, 103 State, 3, 61, 64, 85

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authoritarian state, 3, 80, 135, 141 developmental state, 3, 15, 80, 95–97, 139 patriarchal state, 88 Stratification gendered stratification, 22, 50 social stratification, 43 Swidler, Ann, 8, 9, 29, 30 T Taiwanese, 7, 107, 112 Tool-kits, 30, 32, 34, 87 U Unemployment Insurance (Taiwan), 42 W Welfare regime conservative welfare regime, 23, 42, 47, 53, 67, 74 definition of welfare regime, 5 East Asian welfare regime, 3, 10, 15, 25, 67 liberal welfare regime, 25 productivist welfare regime, 95, 97 social democratic welfare regime, 21, 25 Williamson, Oliver E., 31–32, 100, 141