矯正機關收容人納入全民健康保險 ─以RE-AIM架構為基礎之政策評估

Using the RE-AIM Model to Evaluate the Policy of Covering Inmates in the Correctional Institutions under the National Health Insurance

黃靖婷(Jing-Ting Huang)

指導教授 ： 陳孝平

國立中正大學/社會科學院/社會福利學系/碩士(2015年)

摘要

我國於1995年開辦的全民健康保險，當時未將犯罪矯正機關收容人與軍人納入體系中；自2001年軍人納保後，收容人成為全民納保的最後一哩路。然而，矯正機關的醫療照護，由於長期資源匱乏、缺乏專業醫師，且長期脫離主流的醫療體系，醫療品質甚為堪憂。直到2013年二代健保上路，將矯正機關收容人納入全民健保，才完成納保的最後一哩路，使健保真正達成「全民」覆蓋，且使台灣躋身為全世界少數達成「監所健康照護主流化」的國家之一。政策實施至今已近三年。因此，本研究值得就此項政策實施的成果詳予評估，以作為日後矯正醫療政策、精進之參考。

本研究以Glasgow 等人所發展的評估架構RE-AIM作為政策評估之架構與本研究方法，輔以文件分析、問卷調查法進行資料蒐集，針對收容人納入健保政策進行多面向、系統性的檢視，以綜合評估此制度達到的目標族群涵蓋程度（Reach）、政策介入效果（Effectiveness）、政策受採納程度（Adoption）、政策執行情形（Implementation）、以及收容人健康持續與政策運作存續性（Maintenance）。

研究結果顯示：在目標涵蓋程度方面，我國將收容人納入健保，使我國落實世界衛生組織所倡議的「健康監所」，洵為足以自豪的成就。矯正醫療並在「以健保制度為主、公醫制度為輔」的雙軌模式之下運作，建構矯正醫療安全網並確保每位收容人之醫療資源的適足；在政策介入效果方面，顯示收容人對納保相關議題普遍持正面的看法，然醫療設備的充實及改善以減少戒護外醫次數、解決多數矯正機關亟需的皮膚與牙齒問題實為當務之急；在政策採納方面，收容人納保相關規定與實務運作的記載，有助於提升矯正醫療服務作業之效能，並形成保護機制、就醫資料與健保資料庫的整合亦能確保收容人醫療連續性；在政策執行面，納保後診療科別更多元、診次亦有增加，然在就診人次方面卻大幅減少，主管機關即應留意自付費用對於部分收容人產生的就醫障礙，以免抵銷納保政策照顧收容人的美意；最後，在政策存續性方面，應留意收容人欠費問題不利於承作院所與矯正機關長期合作、永續經營的意願；收容人保費爭議問題，本研究建議可先從研擬相關排富條款開始，逐步排除經濟狀況較佳之收容人，以落實社會正義，消弭各界對於由國家全額支付收容人保費之歧見。

關鍵字

監所健康照護主流化 ； RE-AIM架構 ； 全民健保 ； 矯正機關收容人納保

並列摘要

When the National Health Insurance (NHI) was implemented in 1995 in Taiwan, men and women serving in the military and inmates serving time in the prison for longer than two months were not covered. Inmates became the only excluded group as the military was covered in 2001. Being isolated by the mainstream healthcare system and incapable of recruiting competent physicians, in-prison healthcare had been target for censure by human-rights groups for lacking necessary resources and quality standards. As a result of the reform concluded in 2011, the coverage of the NHI was extended to the inmates in the 49 prisons in this country, making NHI a genuinely universal program. This policy also pushed Taiwan into the rank of the few countries in the world that had accomplished “mainstreaming healthcare in prisons”. Three years into the implementation of this policy, it is about time to conduct a thorough review, and this study is poised to give such an evaluation on this policy.

This study drew on the evaluative framework of RE-AIM, developed by Glasgow, et al., and also applied document analysis, questionnaire surveys to give a comprehensive and multi-faceted evaluation of the policy in question.
As suggested by the name of the RE-AIM framework, the evaluation will cover five domains: reach, effectiveness, adoption, implementation, and maintenance.

This study found that, the inclusion of inmates is in line with the concept of “healthy prisons”, a core value advocated by the World Health Organization (WHO), in which Taiwan should take pride. Under this policy, inmates enjoy adequate medical resources through the NHI coverage; for a small number of inmates who failed to qualify for the coverage, a parallel system supported by the public funding is still in place for them. Inmates tended to be positive toward this new policy, and even gave a positive self-assessed health outcome for this policy. Escorted visits and hospitalization has increased substantially, largely because of the changed financial incentives, and more advanced medical devices and equipment should be installed in the prison to head off this skewed utilization trend. Some of the specialties, especially dental care and dermatological service, are still in serious shortage.

Since now inmates are an integral part of the insured of the NHI, the medical records and other information are collated with that of the rest of the insured people, making quality of care comparable and continuum of care possible, which enhanced effectiveness of in-prison healthcare. As a natural consequence, the specialties serving in prisons were diversified, and number of sessions increased. However, the newly added financial burden imposed by the copayment and registration fees might have constituted a barrier for access to in-prison care.
The competent authorities should see to it that this unpaid expenses thus entailed not become a factor that undermines the cordial cooperative relationship between the prison and the medical teams serving in it.

Since there is an undercurrent against paying the premium by the tax dollars, it is suggested that the authorities might consider to ask the wealth-to-do inmates to pay their own way, to defuse possible political upheavals, and ensure the stability of this policy.

並列關鍵字

RE-AIM ； National Health Insurance ； coverage for inmates ； Health insurance coverage for inmates ； Mainstreaming healthcare in prisons

參考文獻

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