Thursday, August 13, 2009

Health Care in Israel

I got a bit of flak for writing about the American health care issue, which must have raised my appetite for more. How else to explain my decision to talk about health care in Israel?

I'm aware - believe me, I'm aware - that Israel is smaller than the US. Why, the whole country has less of a population than the larger American cities, its geographical size is smaller than some of the American metropolises, and I'm not even talking about Houston which is slowly swallowing all of southern Texas. (Which raises the interesting question why Israel so fascinates most of the world, while Houston merely gobbles up the surrounding plain. You'd think we were a superpower). I also recognize that America has three or four separate layers of government while all we've got is one, and even that one is rather inept. So I'm not saying what works in Israel might work in the US. Probably not. This post is merely to be informative, and you needn't jump down my throat.

Israel has a social security system (bituach leumi) which serves as a safety net for various things. If you can't work for a while because of health matters it kicks in. If you're permanently disabled. If you're called up to reserve duty but would like to keep on getting your salary. if you've got children under 18 it pays you a monthly stipend. It even ensures a minimal pension once you've reached 65 0r 67 (women or men) though no one could live off it. And it offers many additional useful things. In return, every adult after military service must pay a tax of a few percent, depending on income, and employers also chip in; if you're a student or unemployed you still have to pay something like $50 a month.

It's nice to have, bituach leumi, it doesn't abolish poverty or anything of the sort, and all Israeli citizens have it. Even the Arabs of East Jerusalem who are somewhere between citizens and permanent residents have it- a word about them later.

About 15 years ago we also got universal heath care, though for many of us the difference from our prior condition was not dramatic. The universal tax for this is similar to the social security one, which means that the middle class pays about 5% for each, totaling 10% beyond income tax. Or more accurately, before income tax, since everyone pays, while some 50% of workers don't pay income tax.

In return for the tax, everyone must be a member of one of three Kupot Holim, which are exactly like HMOs but different. You choose which one you wish to join, and every six months there's a period when people are allowed to switch. The kupot are not allowed to turn you down. There aren't major differences between them by now (there were back when the law was first passed); each has slightly different nuances of service, and some have better infrastructure in different parts of the country. (The one we're in apparently offers fewer doctors outside of Jerusalem, I'm told). You more or less choose your doctors from a list; many doctors are on all lists. Medications are available for a small fee, which means expensive ones are essentially free. Each visit to a specialist (not a GP) is taxed at 18 NIS, or about $5. The types of lab tests and procedures you're likely to need in a normal state of health short of catastrophic ailments are mostly covered; sometimes you need to haggle a bit with the system, but at an acceptable level.

All of this is determined by the government. There's a committee of specialists which determines what the universal coverage is, and updates it annually; the government then has the final say. Some years there's a public outcry because some expensive new medicine isn't yet on the list; in most cases it then will be sooner or later because politicians like happy voters. The universal coverage is called Sal Briut - the basket of health. We're as good as anyone with euphemisms.

The sal briut isn't bad, but it's far from perfect. So each Kupa offers supplementary plans, which cover additional stuff. These plans aren't very expensive, though if you want the full monty and have a largish family it does accumulate. Middle class folks, so far as I can tell, all have the full supplements. Once you do, you really are covered to a reasonable extent, even in case of catastrophes. There can be waiting lines but not anything a Briton wouldn't find an improvement to their NHS. If you activate the supplemental coverage even those can go away, unless you want a specific procedure with a specific surgeon who only works 32 hours a day and can't fit you in right now - but you could go to a different specialist.

I've accompanied a family member through cancer treatment a few years back (she's fine, thank God), and the Kupa did make a mild hassle about this medicine not that one, but it was a hassle for us; the patient got the treatment she needed and there was never any doubt she would. A colleague a few years ago needed a brand new medicine that had just appeared on the market so her family bought it; a year later it was already in sal briut.

People I know who enjoyed top-notch American health care tell me what they had was better than what we have; mostly they seem to be talking about the bureaucracy of being ill. There's no Mayo Clinic in Israel, and indeed some procedures at the very top of the profession can't be had here. (They can't be had in Kansas, either). But not that many. As a general rule, it's probably better to be ill here than even in most of the developed world, and certainly no worse.

Israel-Palestine conflict: can't have a post without that, can we. You did notice that I said all Israeli citizens enjoy sal briut coverage, and I'm not going to add the obvious. It's needless to say. Foreign workers, not being citizens, aren't covered; it's my understanding that if they're here legally their employers are supposed to insure them; if they're here illegally, not. There's an organization named Physicians for Human Rights. On the Israel-Palestine topic they're about as anti-Israel as you can get, but they also deal with health issues of foreign laborers, and you've got to admire them for that.

East Jerusalem's Palestinians. If they claimed Israeli citizenship before the late 1970s, they're Israelis. A large majority of them didn't, so Israel unilaterally foisted permanent residency on them, and gave them bituach leumi and health care. One of the best kept secrets of the Israel-Palestine conflict issue is that each time anyone seriously talks about partitioning Jerusalem, the Arabs of East Jerusalem get a strong case of jitters. A Palestinian state would be a great thing to have, and they agree East Jerusalem must be in it, but relinquishing Israeli social security and health coverage is something no sane person would want to do. Which is one reason some theorists of human-rights-as-a-way-of-sticking-it-to-the-Jews now claim that even once Israel leaves East Jerusalem, it must continue to pay for the locals' health care until the end of their natural life span. I spoof you not.


Anonymous said...


I am currently living in Houston!!

And it's football season!

Menachem Mendel said...

One of the things that my wife and I miss most about Israel is the health system. When our son was two weeks old he was hospitalized in the Hadassah Pediatric ICU for a week. He got very good care and we had no worries about health insurance, bills, etc. We have pretty good insurance here in NY and I want to tell you that there is tons of bureaucracy in the American health care system, maybe even more than in Israel. There are often forms to fill out, you get a description of benefits in the mail, then you may get a bill for what isn't covered by insurance. Each doctor visit generates lots of paperwork. Regarding how long you have to wait for a doctor, something which people sometimes criticize about the Israeli health system, we have experienced worse waits here in America. It is different everywhere, but I am describing our experience here in NYC. While I recently needed to see a specialist and it took only a few days, our son has to see two specialists and the wait to get an appointment for both of them was a number of months. I know that we could have gone to another doctor and gotten an appointment sooner, you could do that almost anywhere, but one was already working with his pediatrician and the other came highly recommended by a friend who worked with him at one point. For one of them the doctor himself bumped us up b/c he wanted to see our son ASAP, but if it was a routine appointment it would have been a few months. I can't wait to have my Maccabi card swiped again instead of all the hoops that one has to jump through in America. I haven't even mentioned all of the times that our insurance has changed b/c employers are always trying to get a better deal and the finding of new doctors on the new plan that it entails or the many specialists who don't even bother with insurance and you must may out of pocket or just not get to see them. Don't get me wrong, if you have good insurance and can afford it, health care is very good in America and we are lucky to benefit from it.

Anonymous said...

When Americans think about National Heath Care, we think about:
1) a capable National Health Care system that saves tons of money, allows more doctors past the AMA blockade, etc.
2) the spoils system that ate out industrial base -US Steel, Bell Labs, Detroit's Big 3 etc RIP-
the spoils system kills grandma. And holds our kids hostage.

Joe in Australia said...

In Australia we have something that's more like Britain's NHS, but seems to work rather better. If you're earning more than a certain amount then you pay a surcharge on your income tax for it, plus another surcharge if you don't private health insurance. It seems to work pretty well.

With respect to the last poster (3:26 AM) I get that feeling from a lot of people in the USA: yes, they'd like a national health system; no, they don't think it would work in the USA.

Avi said...

I have been living in Jerusalem for the past 30 years after moving from the UK and am very pleased with the level of health care we get here, especially compared to the NHS. Frankly the NHS managed to kill both of my parents with waiting lists for treatment which did their job by them dying before their turn came up for treatment.