Israel's general population is still significantly younger than that of other western countries, as a result of a relatively high birth rate. The proportion of elderly in Israel is roughly 10% of the total population of 5,200,000. Compared with the United States and Europe, Israel has a unique position on the aging map. Israel has a disproportionate number of the old-old: more than 42% of Israel's elderly are aged 75 and over. The number of those 75 and over increased by 90% between 1970 and 1990. The recent wave of immigration from the former Soviet Union has increased the number of elderly by 15% from the beginning of 1990 to mid-1994.
During the 1970s there was major growth in social services in general in Israel and the services for the elderly increased in tandem. In the 1980s, while this general growth had come to a halt, the broad range of services for the elderly continued to increase, reflecting recognition of the considerable degree of unmet need. This awareness led to the expansion of a broad range of services, including increased entitlements to home care and day care under a new Community Long-term Care Insurance Law, enacted in 1988.
Rates of institutionalization are low in Israel: 3.0% reside in skilled nursing facilities and 1.4% reside in non-medical facilities. The expansion of community services, together with the commitment of families to maintain the elderly in the community as long as possible, are viewed as major factors in preventing or delaying institutionalization among the elderly.
Responsibility for services for the aged is shared by numerous governmental, public and voluntary agencies. These agencies operate within a clearly defined but complex system in which responsibility for financing is determined by type of service and level of disability as classified along a continuum of dependency - semi-independent (dependent primarily in homemaking ability), frail (moderately dependent in personal care (ADL)), and severely dependent or cognitively impaired (the severely disabled in personal care, the homebound and incontinent, and the mentally frail). The main government agencies involved in the care for the elderly are the Ministry of Health, the Ministry of Labor and Social Affairs and the National Insurance Institute (Israel's Social Security Administration). The principal public and voluntary organizations responsible for the development of services for the aged are the four major health insurers (HMOs), including the Kupat Holim Sick Fund of the General Federation of Labor (the Histadrut); the Association for the Planning and Development of Services for the Aged in Israel (JDC-ESHEL); and the division of the Histadrut for services for the elderly (MISHAN). In addition, there are many other smaller voluntary organizations involved in the provision of services throughout the country, including local associations for coordinating services for the elderly at the community level.
The Ministry of Labor and Social Affairs has primary responsibility for services for the well elderly, which include a network of social clubs. These services are supplemented by a number of voluntary organizations, including MISHAN, and a range of immigrant associations. The Ministry of Labor and Social Affairs is also responsible for institutional care and the provision of personal care services for the semi-independent and frail elderly, the provision of homemaking services to all the disabled, and the operation of day care. The Ministry operates through a network of social welfare offices that are administered by local authorities and which provide care on a discretionary basis within defined budget constraints.
The Ministry of Health is responsible for institutions for the severely disabled and mentally frail elderly, the operation of psychogeriatric clinics, and the development of preventive services in family health clinics. The care is provided through a network of regional public health offices.
The National Insurance Institute (NII) has responsibility for implementing social security programs for the elderly which include a flat rate basic pension and supplementary benefits for those without additional sources of income. The national pension system is supplemented by work-related pensions. The NII has also become heavily involved in the provision of long-term care services as the administrator of the Community Long-term Care Insurance Law, which provides financing for community services for the more severely disabled as well as funds for construction and development of the infrastructure of institutional and community care.
Medical care is the formal responsibility of the Ministry of Health, but most medical care is provided by voluntary sick funds. Israel's citizens may enroll in one of four sick funds (HMOs). Less than 5% of the population is presently uninsured, however the recent passage (June, 1994) of a National Health Insurance Law mandates universal coverage. The sick funds provide primary, hospital and rehabilitative care to the population and some degree of long-term care. For example, the sick funds provide some supplementary personal care services, particularly during the first several months of disability, and for the more severely disabled on a discretionary basis. Moreover, they are the exclusive providers of professional home care, including home care visits by nurses, doctors and other paraprofessionals.
Reforms in the Israeli health care system following the implementation of the National Health Insurance Law slated to be implemented in January 1995 will affect the overall system of services for the elderly. The new law will prevent discriminatory enrollment practices, by requiring that all health insurers accept members regardless of age and preexisting conditions. While the basic level of benefits currently provided will not decrease, the extent of the impact of the reform on the system of services for the elderly will only become clear over time.