Health Care Lessons From Israel
In the debate over health care reform, what can the United States learn from Israel? Dr. Dani Filc, author of "Circles of Exclusion: The Politics of Health Care in Israel," has some ideas. Filc is a senior lecturer in the Department of Politics and Government at Ben Gurion University and chairman of Physicians for Human Rights - Israel. "Circles of Exclusion" was published in June by Cornell University Press.
GUEST BLOGGER: Dani Filc
The current discussion about health care reform in the United States sounds strange for anyone living in a country with a public, universal, health care service. Indeed, it is difficult to consider a country that does not guarantee its citizens universal access to health care as a true democracy.
For those who have no access to health care, basic principles like equality of opportunity are empty slogans. You cannot be an active member of the political community if you are not healthy enough, and although access to health care services is not the main contributor to health, still its importance is undeniable.
Thus, health care cannot be considered as any other commodity, to be bought and sold in the free market. Rather, access to health care must be universal and guaranteed by the state.
This is the reason, as President Obama claimed, most democratic societies guarantee the right to health care services. This is why for me the public option is actually a no brainer. Without it, one of the most basic human rights, as recognized by the Universal Declaration of Human Rights, is denied.
This is not to say that once a public option is adopted, other problems do not emerge. In Israel, unfortunately, a gap exists between the theoretical commitment to universal health care services and its implementation. Theoretically, Israel guarantees access to health care to every inhabitant.
The National Health Insurance law of 1994 declares that equal access to health care is a right. The law guarantees every Israeli a relatively broad health care basket of services. The Israeli system combines the advantages of single payer systems, with choice between different providers. In order to cover health expenditure, every citizen pays some 5 percent of his or her income as an ear-marked health-tax and the state adds monies from the general budget. Services are provided by four public, non-profit, health management organizations, with the state remaining responsible as a last resort.
Unfortunately, in practice there are several obstacles for the real enjoyment of the right of access to health care services. First, the Palestinians in the Occupied Territories do not enjoy access to health care services since they are not covered by the National Health Insurance law. Moreover, Israel did not allow for the development of good quality services in the Occupied Territories and has dramatically restricted the freedom of movement which severely limits access to health care.
Second, the Israeli structure of citizenship excludes migrant workers from access to the public health care system. Documented migrant workers are insured with private insurers that provide much more limited coverage than the public system. Undocumented migrants lack regular access to health care and have access only to very limited services: life saving emergency medicine, pregnancy and well-baby follow up, and treatment for specific diseases such as tuberculosis and sexually transmitted diseases.
Third, while the Israeli Arab minority is covered by the National Health Insurance system, its health indicators are worse than those of the Jewish population. This stems from differences in the social determinants of health such as poverty or geographical segregation and other inequalities caused by segregation and lack of development of culture-sensitive health care services.
Finally, the neo-liberalization of Israeli society has eroded the Israeli health care system. During the last decade there is a tendency to shift costs from the state to the individual citizen in the form of increasing copayments, and restrictions on the development of the public sector are driving those who are able to pay to buy complementary private insurance.
As a result, inequalities in access to health care services have increased, and in the past decade about forty percent of Israel's poorest population claimed that they have refrained from buying prescription drugs or visiting a physician because of high copayments.
What can the Israeli case teach Americans during a period of heated debate over health care reform?
While the prolonged occupation, the discrimination and segregation of migrant workers and discriminatory treatment of the Israeli Arab minority have built circles of exclusion from access to health care, all those who are included within the public insurance system enjoy an efficient, broad and still relatively generous health care system. Indeed, the overall health indicators in Israel are better than those of the United States.
The combination of a single-payer system with the possibility to choose between four public providers makes the system relatively equal, efficient and broad. Eighty percent of Israeli citizens are satisfied with their provider and Israel's national health expenditure is slightly lower than 9 percent of GDP, which is slightly more than half the American national expenditure on health.
Even though physicians earn considerably less in Israel than in the United States, as a practicing physician I can say than we enjoy more clinical freedom and significantly less paperwork than American physicians dealing with for-profit HMO's and insurance companies. Moreover, when thinking about health policy we need to think much more about the benefit of patients and not of physicians.
Americans, in sum, can learn a great deal from Israel. The advantages of a public single payer health care system which leaves room for individual choice is something that they should adopt without hesitation.
By Steven E. Levingston |
September 24, 2009; 5:30 AM ET
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