Protecting Public Health in Israel
Israel's nationalized health-care system protects every permanent resident.Yet economic strain has created cracks in that system. And now, the women of Israel — particularly the poor, the elderly, and immigrants — are paying the price in out-of-pocket costs, as well as their health.
by Barbara Swirski
How does health policy in Israel affect women's well-being? As in America, women in Israel are disproportionately impacted by health issues. They suffer more illnesses than men, and require significantly more physician and hospital services. Unlike their American counterparts, however, almost all women in Israel have health insurance and are served by a public health-care system. Unfortunately, a combination of under-funding and policy decisions is hurting that system and the women it supports.
Overall, Israeli public health insurance includes a generous package of services, including visits to general practitioners and specialists, a long list of medications and treatments, and some preventive services, including mammograms every two years for 50- to 74-year-old women and each year for at-risk women from 40 to 49.
Hospitalization is free in Israel, although there are co-payments for diagnostic tests, visits to doctors, and medications (with exemptions for those who are hospitalized or have severe diseases like cancer). And Israel’s public insurance covers fertility treatments, including an unlimited number of in-vitro fertilizations for women 45 and under, until the birth of two children.
Yet the Israeli system does not cover any form of contraception. This reinforces Israel’s pro-natal policy and the medical establishment’s technological bias. And put simply, due to the role contraceptives play in women’s reproductive health, it is bad for women. Recently, four feminist and civil rights organizations — including the policy-analyst organization Adva — petitioned the Supreme Court, contending that the exclusion of contraceptives in the benefits package constitutes discrimination.
That said, Israel’s 1994 National Health Insurance Law states that every resident of the state must be covered. However, not everyone living there has coverage. Women who work in the country temporarily — migrant workers and women whose residency status is unclear, for example — are left to fend for themselves. The former tend to pay for private insurance policies, which are far inferior to public health insurance; the latter usually go without. The Patients’ Rights Law provides these uninsured women with free emergency hospital care. But Israel still needs to make provisions for the whole array of health-care services for them — for humanitarian as well as egocentric reasons: As bird flu has shown us, disease has no respect for residency rules.
The biggest problem with the National Health Insurance Law is that it is under-funded, meaning that it cannot deliver its full promise. The services covered by this law are provided by health maintenance organizations (HMOs) and the Ministry of Health. For HMO services, no fixed mechanism exists to update funding in accordance with demographic changes, increases in costs, or new medications and medical procedures. This has meant, for example, that the newest breast-cancer treatments are not available to most Israeli women, who cannot afford to pay for such treatments themselves.
Inadequate HMO funding led to the introduction of copayments in 1998, which, in turn, has resulted in low-income persons — many of whom are single mothers or elderly women — foregoing medications and treatment because they cannot afford these payments. Indeed, in 2004, 30 percent of low-income persons and 20 percent of persons with chronic illnesses went without a prescribed medication or treatment. And the HMOs have become less generous, no longer giving patients the benefit of the doubt when entitlement is ambiguous.
The services provided by the Ministry of Health are in even worse shape: Its annual budget depends on national priorities and politicking, not need. Recent years have seen cuts to most services that fall under the ministry’s rubric of “public health services”: geriatric nursing care, mental health services, wellbaby clinics, and school nurses. This is about women’s jobs and services that mothers need for their kids. Hundreds of nurses have lost their jobs; school nurses are no longer to be found in many schools; and pregnant women and young mothers in peripheral areas, especially small Arab villages, are seeing the closures of well-baby clinics. In the past, those clinics gave Israel one of the highest inoculation rates in the world: over 90 percent of infants.
Another basic problem, by no means unique to Israel, is the unequal provision of health services between the center of the country and the periphery. When the National Insurance Law was in the pipeline, HMOs in peripheral areas improved their services to help attract new members. Then, when funding problems became more acute, they cut back on services. The result: Israelis’ ability to access services depends on where they live. Bedouin Arabs in the Negev, for example, have the worst access.
The poor, particularly ultra-Orthodox Jews and Israeli Arabs, also suffer disproportionately from inadequate access. A 2003 study comparing the life expectancy of residents in different localities found that the lower the socio-economic status of the region, the lower the average life expectancy of its residents. As income disparities grow at an alarming pace, this may augur poorly for the health of Israelis at the wrong end of the income spectrum. Most of the nine percent of Israeli families with children headed by single mothers are there. And more elderly women than men are there, too.
Overall, while the challenges are significant, the public health system in Israel is well-structured. What it needs is adequate funding and affirmative action. De-linking geography, ethnicity, and income from access to health care — and, ultimately, health — will benefit all women and Israel at-large.