Good Medicine
III. Social Innovations in the
Israeli Health Care Delivery System

Of all the social services, health services in Israel are probably the most accessible and the most equitably distributed. They also exhibit the best outcomes. As we approach the 21^st century, the challenge is to preserve — and improve — what is basically a good system.

In this chapter, we review five social innovations of the Israeli health care system that might be applied, in some form or another, to the U.S. system: (1) the National Health Insurance Law, (2) the nationwide network of Mother and Child clinics, (3) the Long Term Home Care Benefits Law, (4) the Patient's Rights Law and (5) Beit Halochem, a service for war veterans that involves the whole family.

National Health Insurance Law — Health for All by the Year 2000

Prior to 1995, Israel had a voluntary health insurance system under which about 96% of the Jewish population, but only 88% of the Arab population, were covered for ambulatory treatment and hospitalization as members of health funds. The benefits package differed from fund to fund and was not publicized. Financing came from four sources: membership fees, co-payments, a tax on employers (the "parallel tax") and subsidies from the State treasury.

In 1995, the National Health Insurance Law made health insurance both compulsory and universal. All permanent residents of Israel were obliged to join a fund, and no fund was permitted to refuse membership on the basis of age, state of health or any other consideration. A uniform benefits package was stipulated and the list of services promulgated. In lieu of membership fees, which had differed from fund to fund, a health tax with two income gradations was imposed, to be collected by employers and transferred to the National Insurance Institute along with a health tax paid by employers (the latter was abolished in 1997). The law obligated the State Treasury to cover the difference between the cost of service provision and the income collected. It is notable that two of the major principles of the Israeli National Health Insurance Law — universal coverage and a guaranteed national benefits package — were integral to the President's Health Security Plan rejected by the U.S. Senate (White House Domestic Policy Council, 1993).

Another change instituted by the National Health Insurance Law was the application of an age-adjusted capitation formula to the distribution of all health tax monies collected by the National Insurance Institute among the four health funds. This change increased equity among the health funds, as the largest health fund — the General Fund — serves 75% of the elderly, for whom expenditures are four times higher, on the average, than those for younger members.

One of the unique features of the Israeli curative health system is the combination of a single payer and four providers of health care: The National Insurance Institute collects health taxes from employees, from the self-employed and from employers (before the employers' tax was abolished) and distributes the revenues among the four health funds. Another special feature of the system is the near universality of coverage. A third feature of the law is the uniform benefits package, designed to make the public health care system more equitable and more accountable.

Israel's health care delivery system under the National Health Insurance Law is far more equitable than the system in the U.S. In the U.S., 40 million persons under the age of 65, representing 15% of that population, are without medical insurance and where for those who do have medical insurance the extent of coverage varies considerably with the plan. As most coverage in the U.S. is employer-linked, losing or changing a job can mean losing one's health insurance. Moreover, becoming ill or developing a chronic medical condition can result in the loss of insurance coverage. The big losers are the foreign-born, who are twice as likely to be uninsured as the native-born (26.2% vs. 13.0% uninsured). Hispanic Americans born abroad have the lowest insurance coverage of all — 40.8% uninsured (Medical Technology and Practice Patterns Institute web site).

While Medicaid is supposed to provide health services for the poorest and covers 7-8% of the U.S. population, here, too, benefits vary by state. As is the case with all welfare plans targeted to limited populations, issues such as eligibility, awareness on the part of clients and social stigmatization limit implementation. The beauty of the Israeli system is that it provides a high level of comprehensive services for everyone.

A 1996 evaluation of the National Health Insurance Law from the standpoint of equity, microeconomic efficiency and macroeconomic cost control reported the following conclusions (Adva Center, November 1996):

1. The changes introduced by the law do not appear to have significantly increased or decreased the national expenditure on health. In 1993, the national expenditure was 8.2% of the GNP, in 1994, 8.9%, and in 1997, 8.4%. (In contrast, the figure for the U.S. was 13.7% in 1996.)

2. Efficiency is defined as the maximization of quality of care and consumer satisfaction at minimum cost. While there are no objective measures of quality of care before and after implementation of the National Health Insurance Law, a consumer satisfaction survey conducted by the Brookdale Institute nine months after the law came into effect found most respondents reporting no change in the quality of the services they received (Farfel et al, 1997: 2). However, differences were found among the members of different health funds: 23% of General Health Fund members reported that services had improved, compared with 11% of National Fund members, and 8% and 7% of Meuhedet and Maccabi members, respectively.

The highest level of satisfaction was found in the Arab population: 31% stated that services had improved, compared with 17% in the veteran Jewish population (ibid: 3). .

3. Both the World Health Organization and the OECD consider equity the most important criterion of success in health reform. Here the National Health Insurance Law has stood the test — with the following qualifications:

A. Like health care systems worldwide, the Israeli system is characterized by inequities between center and periphery, between the big cities and the development towns, and between Jewish localities and Arab ones. The National Health Insurance Law has no provisions for distributing resources among different geographical areas and among different social groups in a more equitable manner, and no program for closing existing gaps.

B. Prior to implementation of the National Health Insurance Law, inpatient nursing care for the elderly was not included in the health funds' benefit packages; the law and its various amendments have thus far failed to right this inequity.

Notably, the American Health Security Plan did not include long-term inpatient nursing care either. What it did propose was to improve the coverage for institutional care under Medicaid by allowing states to permit residents of nursing homes to retain $100 per month as a living allowance and to retain up to $12,000 in personal assets in the spend down for eligibility. Other aspects of the program included regulation of long-term care insurance, along with tax incentives and consumer education designed to increase private coverage of this exigency.

C. Dental health was not included in the health funds' benefit packages either prior to the law or after it.

On the positive side, the National Health Insurance Law made the health care delivery system more equitable in the following ways:

• By extending coverage to all residents of Israel (but not to foreign workers).

• By giving consumers the right to join the fund of their choice, and by stipulating that health funds could not refuse membership due to age or health status.

• By imposing a health tax with an element of progressivity, resulting in low-income persons paying out less than they had prior to the law and middle and high income persons paying more.

• By encouraging health funds (HMOs) to compete for new members, an incentive that resulted in funds building new clinics in peripheral areas and in their improving existing services.

• By distributing all health taxes on a capitation basis, adjusted for the age composition of the health funds. The General Health Fund, which insures about 60% of the population, including most of the elderly, the chronically ill and the poor, received a larger share of revenues under the National Health Insurance Law (Rosen and Nevo, 1996).

A year after the National Health Insurance Law was implemented, the Israel Ministry of Finance had some second thoughts about the law. In 1995, it paid out NIS 1.5 billion to cover the difference between revenues and expenditures under the National Health Insurance Law — more than it had anticipated. Finance officials accused the health funds of inefficiency and waste, while the latter pointed out that the law was under-financed, as its budget failed to take into account (1) population growth and aging, (2) technological advances and (3) the full increase in the cost of health services. The General Health Fund contended that it was not being properly compensated for its larger-than-average share of persons aged 75+ (79%) and of the chronically ill (75%). An objective observer — The Brookdale Institute — examined the balance sheets of the four health funds for 1995 and 1996 and found decreases in per capita expenditures for all but the General Fund.

At the end of 1996, the employers' health tax was abolished; in its stead, a sum of about NIS 7 billion formerly earmarked for the health care delivery system was put at the discretion of the Ministry of Finance. The same year, attempts were also made to impose co-payments on health services, but the Knesset refused to pass the budget bill as long as co-payment strings were attached.

The Cabinet's 1998 Budget Arrangements Bill included far-reaching changes in the National Health Insurance Law. Following intensive lobbying efforts by a coalition of advocacy organizations, compromise legislation was passed, under which the funds were instructed to act to prevent future deficits by imposing co-payments and by selling more policies for supplemental insurance. They were also encouraged to add, but not subtract, services from the uniform benefits package, provided they could finance the additions (subject to approval by the Minister of Health and the Knesset Finance Committee).

This change carries the potential for dealing a serious blow to equity in health care: it could encourage health funds to redesign their benefits packages so as to attract the healthy and affluent and thus "improve their patient mix." The Histadrut and "Finger on the Pulse," a coalition of 20 advocacy organizations, have vociferously opposed the new co-payments. A solution may be on the way in the form of an amendment that passed its first reading in the Knesset in December 1998. The amendment provides a formula that would guarantee adequate government funding for the law. The new Knesset that takes office in 1999 will find the amendment on its docket.

The Israeli National Health Insurance Law could certainly provide a model for the U.S. The Clinton Administration's Health Security Plan failed to pass, in large measure because of the U.S. preference for market solutions for provision of social welfare. As noted by Myles (1996), "The model of citizenship entitlements — benefits that accrue to individuals independently of need or labor force participation — is quite foreign to the American social policy tradition." A well-known exception, of course, is Medicare, which provides coverage for 99% of the population over 65 (Myles, 1996: 126).

The most important constraint on policy innovation in the U.S. appears to be limited state capacity to raise revenues to finance new initiatives (ibid: 134). A need for innovation exists, however, as the U.S. strategy of relying on economic expansion and employment growth to ensure economic well-being, which worked in the post-war period, is no longer sufficient (ibid).

A federal program similar to the National Health Insurance Law would overcome the problem of reluctance on the part of some states and assure medical care to low-wage earners and their families who are not poor enough to qualify for Medicaid programs but too poor to afford medical insurance. Such a program would create security for millions of Americans, while at the same time requiring everyone to share in the responsibility for coverage by contributing a percentage of their income.

Mother and Child Tipat Halav Clinics: An American Model Elaborated by Israel

Israel's nationwide network of roughly 1,200 Mother and Child clinics, modeled, as noted, on the well-baby clinics set up in U.S. cities to improve the health of immigrants from Eastern Europe at the turn of the century, is still the jewel in the crown of the health care delivery system. These clinics see about 50% of expectant mothers and some 90% of Israeli newborns. In small communities, the former figure is closer to 95%; in the big cities, where specialist services abound, it is much lower, as women have the option of paying regular visits to the obstetrician of their choice in the framework of the services they receive from their health funds. In a country of immigrants, Mother and Child clinics have been on the front line of "Israelization," imparting to immigrant women from a variety of ethnic and cultural backgrounds the latest advances (and fashions) in pre-natal and post-natal care for women and infant care. Among Israeli women, regardless of whether they are rich or poor, highly or poorly educated, a generally accepted part of pregnancy and new motherhood is going in for regular checkups for mother and child.

The Mother and Child clinics could well serve as a model for the United States, which lacks a system of care for pregnant women, infants or young children. What exists has been described as ". . . a collection of activities and funding mechanisms that create a complex, fragmented patchwork of services and programs (Grason and Guyer, 1995: 565). There is considerable variation in personal and family employee-based health coverage for expectant mothers, infants and children. Poor children are supposed to be covered by Medicaid's Early and Periodic Screening, Diagnosis and Treatment program, established in 1967. However, a recent study of the program's implementation in 4 states (Gavin et al, 1998) found that it reached only 40% of Medicaid children — half of the target rate (ibid: 234). The same study found a low rate of compliance with recommended immunizations among Medicaid children (ibid: 236). The states' transition to Medicaid managed care apparently did not lead to improved performance: the U.S. Department of Health and Human Services estimated, on the basis of a national sample, that only 28% of children in Medicaid managed care received all the examinations required by their states (Sardell and Johnson, 1998: 188-189). With regard to prenatal care, a recent review of Medline literature (Schuster et al, 1998) reported that a study of women belonging to six HMOs found them receiving an average of 82% of the recommended routine prenatal screening tests, while the variance was quite large.

The beauty of the Israeli Mother and Child clinics is their wide distribution and accessibility. In small localities in the Arab sector in which there is only one medical facility, that facility is a Mother and Child clinic. The public health nurses who constitute the backbone of the network usually speak the language of the community they serve. In the framework of efforts to narrow the gap between Arab and Jewish localities in the provision of social services, the Labor government that returned to office in 1992 initiated a program for the construction and staffing of 77 new Mother and Child clinics in Arab localities.

According to the Public Health Department of the Israel Ministry of Health, in October 1997 more than 326,500 toddlers, 73,000 infants, and 39,000 pregnant women visited Mother and Child clinics. The clinics are financed by the Ministry of Health and by users' fees — NIS 410 ($100) for prenatal care and services for newborns until they reach the age of five. These services, along with school health services — half of which are covered by fees and half by the State budget — amount to no more than two percent of Israel's national expenditure on health. This is a real bargain: as we have seen, maternal mortality is very low in Israel, as is infant mortality.

The prenatal care provided in Mother and Child clinics includes monthly examinations of expectant mothers by a public health nurse up to the 32^nd week of pregnancy, bi-weekly examinations between the 32^nd and 36^th weeks, and weekly visits until the birth. These examinations include weigh-ins, blood pressure readings and advice concerning diet and the importance of not smoking. Up to the 32^nd week, the norm is a minimum of three examinations by a physician, and from the 33^rd week, a weekly visit. The physician studies the results of the urine and blood tests, performs an average of three Ultra Sound examinations and refers the woman for further tests in cases of risk. All pregnant women are referred to Alfa Feto protein tests (triple) for Downs syndrome, for which there is a co-payment, and to screening for diabetes. In the second trimester, the physician may refer the woman for a special Ultra Sound examination (a biophysical profile). This is an Israeli innovation that comes in two forms. One is referred to as a "regular" profile, which involves examining the general development of the fetus, the amount of fluid in the amniotic sac, and some of the internal organs. The other is referred to as a "focused profile," which takes 20-40 minutes, requires a specialist, and includes an examination of all the organs that can be seen — for possible anomalies. The procedure costs $300-400, and payment is by the patient, unless the fetus has been diagnosed as at risk.

Notably, the Israel Ministry of Health recently informed obstetricians that there is no need to perform routine Ultra Sound examinations, following the U.S. finding that they fail to lower the infant mortality rate.

In cases in which fetal anomalies or diseases are detected, abortion is not always the only option (see Chapter 4, Medical Innovations in Israel).

The infant care provided by Mother and Child clinics includes the recommended series of inoculations, monthly weigh-ins, advice on feeding, developmental checkups, detection of hearing and vision problems, and health education in general. When problems do arise, mothers and infants are referred to curative services or to child development centers. The inoculations provided include Smallpox. Diphtheria, Tetanus, Whooping Cough, Polio, Tuberculosis, Measles, German Measles, and Hepatitis. According to the latest published figures, nationwide, 91% of Israeli infants receive all the recommended inoculations on-time, compared with 77% of U.S. infants (Federal Interagency Forum, 1998).

National Program for the Detection of Congenital Anomalies

In 1998, a budget of NIS 8 million was allocated to the National Program for the Detection of Congenital Anomalies, under which all newborns are tested for P.K.U. and for Hypothyroidism. The Ministry of Health reports that some 120,000 newborns are tested for these anomalies each year. In addition, women belonging to at-risk population groups are advised to test for other diseases, including Tay-Sacs, Gaucher's Disease, Thalassemia, Cystic Fibrosis, Canavan, and the Fragile-X Syndrome. All women are referred to Alfa Feto protein checks in the 16th week of pregnancy to test for Downs Syndrome, and those over the age of 35 are advised to undergo amniocentesis, a service included in the benefits package under the National Health Insurance Law.

National Intervention Program for Reducing Infant Mortality

The National Intervention Program for Reducing Infant Mortality was initiated in the 1970s, when it was discovered that infant mortality rates in a number of Jewish development towns were much higher than the average rate in Jewish localities. The program involves special efforts to determine the specific risk factors involved in the excess (higher than average) infant mortality rate in each locale, as well as steps to reduce these risks. Following intervention programs, the infant mortality rates in a number of Jewish localities decreased significantly. In 1997, intervention programs were being carried out in the Jewish development towns of Dimona, Ashdod, and Afula, and in several Arab cities and towns: Rahat, Abu-Gosh, Beit Nikofa, Gissar a-Zarka and Nazareth. In the case of Arab localities, where congenital anomalies are the greatest risk factor, the activities undertaken include providing genetic counseling in the community itself rather than referring patients to a hospital Genetics Counseling Clinic, training local medical personnel, distributing pamphlets on genetic diseases and giving lectures on the basic principles of genetics at local schools.

The U.S. embarked on a similar program in 1991 — "Healthy Start" — a national program to reduce infant mortality by 50% by the year 2000 — in 15 selected localities with the nation's highest infant mortality rates (Strobino et al, 1995).

Programs for New Immigrants

Since 1992, the Ministry of Health has been conducting outreach programs among Ethiopian immigrants. These are implemented by Ethiopian community workers who immigrated in the 1980s, and their objects are to assure on-time inoculations for newborns and to advise the new immigrants about the health services available in Israel.

Special outreach programs were also designed for new immigrants from the former Soviet Union: Russian-speaking personnel were hired and pamphlets prepared in Russian. Here the main purpose was to "educate Lena" to use contraceptives other than the one method of birth control to which they were accustomed: abortion.

Program for Bedouins Living in the Negev

Another special program, for the Negev Bedouins, is described in detail in the next

chapter. One aspect of the program deserves mention here: the special courses in nursing for women from the Bedouin community, conducted at the Barzilai Hospital in Ashkelon. The purpose of the program is to increase the opportunities of Bedouin citizens for culturally appropriate medical care by medical personnel who speak their language and understand their culture.

Should Preventive Care be Separate from Curative Care?

In 1978, at the World Health Organization conference at Alma Ata, a recommendation was passed to integrate Mother and Child and Family Planning services with primary curative services, as part of the implementation of the worldwide campaign, "Health for All by the Year 2000."

Indeed, several Israeli professional and national health commissions, including most recently the Netanyahu Commission Report of 1990, recommended that Israel, too, combine its primary preventive and curative services in the framework of the health funds. Integration was expected to increase system efficiency by reducing administrative costs and by decreasing the number of medical visits of pregnant women, many of whom were found to be attending more than one facility (Mother and Child clinics and health fund or private doctors). In addition, it was thought that integration would lead to a greater continuity of treatment and a more holistic picture of the patient's health; at the same time, it would prevent the possibility of conflicting prescriptions.

Despite these theoretical advantages, the Public Health Department of the Israel Ministry of Health, the health funds, the Israel Medical Association, the Israel Pediatricians' Association, and Israeli child advocacy organizations all seem to agree that in practice the time is not yet ripe to integrate preventive Mother and Child services and primary curative services under the health fund roof. They argue that integration will upset the present contiguity of services for mother and child, as gynecologists and pediatricians treat patients at entirely different locations. They also contend that the specialization that characterizes curative medicine will rule out the holistic approach desired by adherents of integration. While this drawback might be overcome by further developing the family medicine specialty, there are no answers to some of the other contentions brought forward by the opponents of integration. One of the most compelling is the fear that under conditions of financial constraint (which is the present situation), preventive medicine, which lacks the urgency of the curative, is liable to be swallowed up. When cutbacks need to be made, the preventive services will be the first to come under the knife, and the area that will suffer the most is likely to be health education. Another argument: Mother and Child Clinics are community oriented, while health funds are not.

The system of Mother and Child clinics (which originated in the U.S.) could be re-introduced to the American scene. Just as they serve as a channel of "Israelization," the clinics could serve as a medium of Americanization for immigrants to the U.S. The idea of providing nursing training for women from the immigrant community could be imported to the U.S., increasing job options for new Americans and opportunities for culturally appropriate care for expectant mothers from immigrant groups and their infants. Mother and Child Clinics would also benefit poor African-Americans and Hispanic Americans, whose infant mortality rates are higher than those of White Americans, especially if special intervention programs were developed as an integral part of the program.

U.S. Infant Mortality Rates by Race and Origin, 1996

Source: Federal Interagency Forum of Child and Family Statistics, 1998, America's Children: Key National Indicators of Well-Being.

Home Care for Senior Citizens

Community care in Israel received a real boost in 1988 when the Long Term Care Insurance Benefits Law came into effect. At the time, neither institutional frameworks nor community services for the elderly were very well developed in Israel, and the law served to encourage development of the latter — by private enterprises as well as by Eshel, the Association for the Planning and Development of Services for the Aged in Israel, and by the Community Centers Company.

The Long Term Care Insurance Benefits Law entitles disabled seniors to a personal home care benefit through the National Insurance Institute (Social Security Administration) if they pass a dependence assessment and an income test. The benefit may be used to hire a personal care giver, visit a geriatric day center, purchase absorbent materials and laundry services, or lease alarm transmitters. In June 1998, more than 80,000 senior citizens were receiving long term care benefits.

There is no equivalent of the Israeli Long Term Care Insurance Benefits Law in the U.S. Under the Medicare program, senior citizens in need of skilled medical services, such as those provided by a nurse or physical therapist, can also receive personal services during periods in which they are under the care of skilled medical personnel, but there is no provision for long-term personal care per se. Under Medicaid, poor disabled, chronically-ill elderly persons may receive a personal care benefit. The amount of care available differs from state to state. There are no equivalent provisions for elderly persons who do not qualify for Medicaid.

The Home Care Law (for short) was no doubt a landmark in the development of Israel's social security system. Ten years after it was first implemented (1998), more than 10% of senior citizens were receiving home benefits. The vast majority of beneficiaries opt for personal care services; a small minority use the benefit to attend day centers or to combine personal care at home with visits to day centers or other options.

While there is no evidence that home care services act as a substitute for institutionalization or that they occasion a decrease in the demand for nursing-care beds, there is plenty of evidence that home care services improve the quality of life of disabled elderly persons and ease the burden on family members. Perhaps the best indication of the effectiveness of the service is the steady increase in the number of beneficiaries. As Zipkin and Morginstin point out (1998), the rate of annual increase in beneficiaries has been far greater than the annual increase in the relevant age groups. While between 1990 and 1996, the total elderly population in Israel increased by an annual rate of 4% and the population aged 80 or more by 7%, the number of home care beneficiaries increased by an annual rate of nearly 16%.

The word is out: home care benefits improve the quality of life of both the disabled elderly and their families. While the personal care in question is not medical — it involves help with bathing, dressing, eating, and mobility - it also results in better medical care for disabled elderly persons. For one, caregivers often obtain and administer medications. For another, regular care and surveillance by care givers means that medical problems are often identified and aid sought earlier than would have happened without regular care. For yet another, the regular attendance of care givers often serves as an antidote against loneliness and depression.

As mentioned above, to receive home care benefits, an elderly person must pass an income test and a dependency assessment. The dependency assessment is based on two components: the ability to perform activities of daily living and the need for constant personal attendance. It is administered by public health nurses from the Ministry of Health, contracted by the National Insurance Institute. There are two benefit levels — full benefit, which provides 15 hours of care per week, and half benefit, which provides 10 hours of care. The income test is quite liberal, and the National Insurance Institute reports that each year only one percent of applicants are rejected on the basis of their income.

Who Utilizes Home Care Benefits

The National Insurance Institute does not provide a breakdown of recipients by ethnic origin. It does give gender figures, so we know that women constitute no less than 73% of benefit recipients. This is not surprising, as women are eligible for the benefit earlier than men (women at age 60, men at age 65), women live longer and are sicker than men, and women are more likely than men to be living alone in their old age. A recent survey (Zipkin and Morgenstin, 1998) also informs us that recent immigrants, most of them from the former Soviet Union, are coming to constitute an increasingly larger share of benefit recipients: in 1997, they made up 16%. Other studies have indicated that Ashkenazi families may be more disposed to apply for benefits than Mizrahi families (Walter-Ginzberg et al, 1997), and that Arab families may take advantage of the benefit more than Jewish ones (Weihl, 1995). It is worth noting that in Arab families, where it is not acceptable to hire extra-familial care givers for the home care of relatives, family members who do not live in the same household, usually granddaughters, are remunerated under the law for serving as personal care givers. The National Insurance Institute does not usually compensate Jewish relatives for care work, though there are exceptions. The average age of home care recipients is 80.

Major Issues in Home Care

Service or Cash Benefits?

Prior to its passage, the most hotly debated issue concerning the Home Care Law was whether to provide cash or service benefits. Those who argued for service benefits assumed that the family would continue to serve as the primary care giver, that service benefits would be supplementary to family care, and that the arrangement chosen should neither replace the care provided by family members nor compensate them for the care they were already providing. Some professionals were of the opinion that providing services rather than cash would protect elderly clients against families taking advantage of them. Finally, there were policy makers who thought that opting for services would encourage the development of community services.

Some professionals who argued in favor of cash benefits were of the opinion that families ought to be able to choose their own caretaking arrangements. Others argued that paying family members for care (as is done, for example, in Sweden, and in some states in the U.S. under Medicaid) would be a less expensive alternative than developing community or institutional services, both of which were under-developed prior to passage of the law.

In the end, Israeli legislators opted for service rather than cash benefits. This decision led to the development of a new economic sector: more than 500 personnel companies and non-profit organizations that recruit personal care givers and place them with clients. It also ushered in a new social phenomenon: the recruitment of thousands of foreign workers to serve as personal care givers, mostly from the Philippines. In 1998, some 12,000 foreign workers, most of them women, had work permits that allowed them employment as care givers for specific families. The foreign workers ordinarily live with their clients and provide around-the-clock care for a salary of $500-700 a month. Their employers sign them up with personnel companies that work with the National Insurance Institute, which pays part of the salary; the remainder is shouldered directly by the family.

Most senior citizens who receive personal care under the Home Care Law do not hire care givers directly; rather, they are sent care givers from non-profit or for-profit personnel companies, to which the National Insurance Institute transfers the benefit. Fifty percent of the benefit goes to the company for administrative expenses and profits, and the other 50% covers the salary of the care giver. Most care givers receive no more than the minimum wage. Thus, the law has resulted in the creation of new businesses and has created jobs for both Israeli and foreign workers; the downside is that these are low-paying jobs.

Quality of Care

Since personal care giving has not yet been recognized as a profession, care givers are not required to obtain training that would entitle them to professional certification. Wages are low, usually set at the minimum and paid by the hour. Typical Israeli care givers are women aged 40-64 with scanty formal education; most are of Mizrahi origin or recent immigrants from the former Soviet Union. Supervision and in-service training differ from one company to another, and there is considerable variance in the quality of care that disabled elderly persons receive from their paid care givers under the Home Care Law. Notably, the JDC-Brookdale Institute of Gerontology and Human Development has developed a training program for home care workers. In recent years, the Ministry of Labor has offered courses in care giving to unemployed women. Among the graduates of these courses are recent immigrants from Ethiopia and the former Soviet Union.

Footing The Bill

The care provided under the Home Care Law is financed by National Insurance Institute (Social Security) contributions, at the rate of 0.2 percent of employee wages, half of which was paid by the employer and half by the employee. In recent years, the government has reduced the contribution of employers and matched the reduction. In 1996, less than half of home care expenditures were covered by contributions; the rest came from National Insurance Institute reserves for other items and from general tax revenues. An unanswered question is whether new sources of financing will be found or benefits reduced, as the program cannot run indefinitely on an operating deficit (The program does have reserves).

What is certain is that the law has eased the lives of tens of thousands of disabled elderly persons and their families, improved the medical care that disabled seniors receive, created new jobs and stimulated the growth of private and public community services for the elderly.

It has been noted that new social circumstances require new social goals. In Israel, the aging of the population and the increasing participation of women in the labor force were two changes that provided the backdrop for the Home Care Law. The U.S., too, has been experiencing demographic changes, among them population aging and reduced family size. The increasing numbers of elderly persons will have fewer younger family members to care for them. And the sheer size of the U.S., combined with the well-known mobility of its citizens, means that relatives are often too far away to provide much caring work.

President Clinton's national health reform included a provision allowing states to offer consumer-directed discretionary payments to cover the long-term home care needs of the most seriously disabled population, without regard to income or age, through a federal-state partnership. The state was to shoulder the same burden as they did under Medicaid, while the federal government was to foot the rest of the bill. Unlike the Israeli plan, the U.S. one included co-payments on a sliding scale. (White House Domestic Policy Council, 1993). Had it passed, the reform would have constituted a major expansion of personal care services on a universal basis for needy persons of all age groups, including the elderly (Keigher and Stone, 1994: 341). Just as the principle of universal medical insurance was enacted for senior citizens via Medicare in 1965, it is conceivable that universal personal care services could be legislated for the same age group, borrowing aspects of the Israeli law deemed appropriate to the American scene.

The Patient's Rights Law

The Patient's Rights Law is another recent innovation in the Israeli health care system. Enacted in 1996, its object is to establish norms and codes of conduct concerning patients' rights that are binding on all medical practitioners. The law is based on the assumption that persons who require medical treatment are entitled to be treated with dignity at all times, and that they are capable of making intelligent decisions. The main problems that the law purported to redress were neglect of the principle of informed consent, the lack of confidentiality concerning medical records and the neglect of patients' rights to privacy.

The patients' rights addressed by the Israeli Patient's Rights Law are different from those of major concern to American lawmakers. The Patient's Bill of Rights law that failed to pass in the U.S. Senate in 1997 dealt mainly with economic issues, that is, with what health insurance plans, especially those provided by employers, were obligated to pay — although it also made emergency treatment mandatory and required conformity with the principles of confidentiality and informed consent (Alliance for Health Reform, 1998). At present, some 18 states in the U.S. have some legislation guaranteeing the right of appeal in cases in which health insurance plans refuse indemnification of health care expenses. The situation in the U.S. regarding patients' rights has been described as "a patchwork" rather than as a systematic or universal code (Pollitz, 1998).

As can be seen from the following principles enshrined in the Israeli Patient's Rights Law, the law covers all medical personnel and all patients. Its main concerns are with proper care and with human dignity.

The first principle is the right to medical care. The law states that medical treatment is to be provided to all and that neither the medical facility nor the clinician may discriminate between patients on grounds of religion, race, sex, nationality or any other criterion. In cases of emergency, patients are to receive treatment without any pre-condition. This means that any person who goes to a hospital emergency room, including foreign workers without work permits or health insurance, are to be treated without hesitation.

Other principles are the patient's right to be informed of the name and profession of every person providing treatment and the right to obtain, at the patient's own initiative, a second opinion. The clinician and medical facility are instructed by the Israeli law to assist the patient in realizing this right. The law also stipulates the right to continuity of proper care. In effect, this means that in cases where a patient transfers from one clinician or facility to another, she or he is entitled to cooperation between the clinicians and facilities involved.

The right to dignity and privacy are emphasized in the law. In practice this means that when a hospital ward is overflowing and beds line the corridors, as often happens in Israeli internal medicine wards during the winter months, patients are not to be undressed or treated without placing a curtain around them.

The right to informed consent is also guaranteed by the new law, as is the right to access to medical information. Patients are entitled to receive information from their clinicians or medical facility, including a copy of their medical records. Here the law includes a reservation: In cases in which the clinician believes that such information may cause serious harm to the patient's health or endanger his or her life, the clinician may decline to give the patient such information.

Finally, the Israeli law insures medical confidentiality and regulates the disclosure of information to a third party. A clinician or other staff member of a medical facility may not disclose any information concerning a patient, unless the patient has given his or her consent. However, the law also states that information may be disclosed to specific authorities if the clinician or the facility are so instructed by law (for example, the requirement that sexual abuse of minors be reported), or if the information is needed for continued treatment. In the case of both AIDS and Tuberculosis, spouses are informed.

Three committees were established to assure implementation of the law. An Investigative Committee was set up to look into patients' complaints and a Quality Control Committee was established to evaluate medical procedures when questions arise concerning them. The third is an Ethics Committee. In addition, The Patient's Rights Law requires each medical facility to appoint a staff member to be in charge of patients' rights, whose responsibilities include dealing with patients' grievances and educating members of the medical and administrative staffs in all matters relating to the law.

According to Ms Adina Marks, director of the Society for Patient's Rights in Israel, a nonprofit organization established in 1996, in the two years since its enactment the law has led to a number of tangible improvements. One is that members of medical staffs are no longer offended when patients ask for identification or for a second opinion. The right to a second opinion has become firmly established. The benefits package under the National Health Insurance Law does not pay for a second opinion, though the supplemental policies sold by the health funds and by commercial firms do foot second-opinion bills. In contrast to the situation prior to passage of The Patient's Rights Law, patients can now receive copies of their own medical records. According to Marks, some medical facilities have become more sensitive to patients' rights to dignity and privacy, and when complaints of abuse are filed, immediate steps are usually taken to remedy the situation (Marks, June 1998).

A comparison of Congressional patient protection proposals published by the Alliance for Health Reform (1998) reveals that the two protections considered most urgent, as indicated by their inclusion in the three plans examined, were provisions for emergency services and mechanisms for the external review of health consumers' grievances with regard to their health plans. Thus, it appears that a U.S. Patient's Rights Law would need to include these provisions before all others.

Beit Halochem — A War Vet Service that Gets the Whole Family Involved

It has already been noted that innovation often comes as a response to a pressing national need. Beit Halochem, a unique sports, rehabilitation and social center established for disabled veterans of the Israel Defense Forces (IDF), is a prime example of this principle.

In the aftermath of the War of Independence in 1948, it became apparent that Israel's future required the integration of disabled war veterans into society. In 1949, the Zahal Disabled Veterans Organization (ZDVO) was established to assist the 6,000 disabled veterans of the war.

The ZDVO recognized that the real challenges of social rehabilitation only begin when medical treatment ends. In 1959 Beit Kay was opened in Nahariya as a recreational holiday center for disabled veterans — the first of its kind in Israel. Despite its success as a vacation retreat, it soon became evident that something was missing. That something was a venue that could provide a supportive environment to help veterans overcome their disadvantages, a place where veterans could bring the family, take part in recreational activities without being hindered by their disabilities, and feel at home.

After investigating similar schemes around the world, the ZDVO found existing models inadequate. Veteran hospitals and rehabilitation units were not enough. A more active and integrative solution was required. Thus the unique model of Bet Halochem was created and the first Beit Halochem opened in Tel Aviv in 1974 after the Yom Kippur War. It was a community center-cum-country club where disabled veterans and their families alike could partake in many "normal" sporting, leisure and cultural activities. Participation in club activities served both a social and a rehabilitative purpose, as members learned new skills, maintained physical fitness and made new social contacts. The experience was enhanced by the beautiful surroundings of the center, designed to be accessible to persons with all types of disabilities.

Since the first Beit Halochem Center opened its doors, two additional centers have been established, one in Haifa (1986) and another in Jerusalem (1994). Membership as of 1998 included more than 11,000 veterans and a total of more than 30,000 persons, including family members of disabled veterans. The centers' services are in such great demand that the entry requirement had to be raised to include only the more acutely disabled veterans.

The World Health Organization defines health as a state of complete physical, mental and social well-being — and not merely as the absence of disease or infirmity. Aiming to fulfill this definition of health for its members is an essential element of the Beit Halochem philosophy. As Joseph Luttenberg, National Chairman of the ZDVO explains, Beit Halochem's first and foremost objective is to help disabled veterans resume normal life. This is done by providing a framework that offers not only medical treatment but also social support and integration.

One of the most important features of this framework is the program of inter-generational encounters. When old timers and newcomers meet socially, new members with disabilities who are just learning to adjust gain a new perspective from contact with older veterans. Older members provide living proof that the resumption of a full and productive life is an option, and new members begin to see that severe disabilities can be overcome and that it is possible to learn to cope with seemingly insurmountable obstacles.

Another benefit of the Beit Halochem structure is the opportunity to learn the rehabilitative value of discipline. The plethora of sporting activities offered at the facilities teach the meaning of sportsmanship, as well as the importance of self-discipline and group-discipline. Joining an organized group involves the responsibility of showing up regularly at training and competitions, where strong emphasis is placed on both outward appearance and sportsmanlike behavior. Participation in competitive sports is a source of great pride not only to Beit Halochem members but to the State of Israel as well. Beit Halochem Tel Aviv is the center for Sports for the Disabled in Israel. Since 1960, Israel's disabled athletes have made a name for themselves and for Israel in the Olympic Games for the Disabled, repeatedly winning medals and accolades.

Beit Halochem attempts to create opportunities for all its members according to their needs, education, background, age and disability. Needs also change, and Beit Halochem tries to adapt accordingly. Recently, a pensioners' club was set up for veterans who have reached retirement age. Its activities include lectures, discussion groups and trips abroad organized by the members themselves. Members' wives are also offered a variety of programs as diverse as aerobics, computers, bridge and alternative medicine. During summer vacations, extra activities are included for the members' children, and throughout the year childcare is provided in the afternoons in a well-equipped nursery. These and other facilities, such as hiking clubs and film screenings, reinforce the notion that rehabilitation involves the whole family.

Beit Halochem's members represent a cross section of Israeli society. Whether they are university professors, businessmen or taxi drivers, they all share a feeling of belonging and ownership. Beit Halochem is a non-governmental institution and for a reason. One of the main objectives is to restore the veterans' pride and position in society. If the members felt they were just charity cases or that the service was merely something they had coming to them from the State, then this feeling of affinity might be lost and the endeavor rendered counter-productive.

Members pay annual, affordable fees, which cover approximately half of the running expenses. The Ministry of Defense's Rehabilitation Division covers about a quarter of treatment costs, and the rest of the budget is funded by donations. Medical treatments and exercise programs are included in the fees, while cultural activities are offered at additional cost. Fund-raising, done by ZDVO, the parent organization, collects money for specific projects. For example, one of the latest projects aims to raise money for sonar boats for the delegation to the Sydney Olympics in 2000.

Although the primary purpose of Beit Halochem is social and not medical, the Centers boast rehabilitative therapy wings. In line with the integrative philosophy, these have been developed so that severely disabled members requiring ongoing treatment — e.g., blind persons, paraplegics and amputees — can receive therapy in a social, rather than a medical setting.

Facilities in the wing include a hydro-therapeutic health unit and a physical therapy institute, often utilized by members on personalized treatment programs. Therapists work closely with the hospitals and rehabilitation units that first treated the wounded servicemen; thus they are involved in rehabilitation from an early point. As the newly disabled veterans are discharged, they are referred to the Beit Halochem Center nearest their homes to ensure an uninterrupted course of treatment.

Treatment is also available to members whose health has deteriorated over the years. Members are often referred by rehabilitation specialists in hospitals or by clinics of the Defense Ministry's Rehabilitation Division. The rehabilitation program is overseen by local professionals from the Rehabilitation Unit at the Haim Sheba Medical Center. Together with this unit and other research institutes, the Tel Aviv Beit Halochem initiates and encourages research on topics such as sports for the disabled, spinal injury and brain damage, in order to develop new methods to benefit Beit Halochem members.

Swimming has been recognized as an important element in treating the seriously disabled, and Beit Halochem has heated pools whose temperatures can be gauged to those suffering severe paralysis and orthopedic problems. In addition, the hydro-therapeutic health unit contains rooms for therapeutic baths, massage and two well-equipped gyms for medical gymnastics.

Members are often medically prescribed a combination of physical therapy and fitness treatments as a way to improve their body functions and reinforce their potential for self-reliance. Beit Halochem boasts fitness rooms furnished with the most up-to-date equipment, specially adapted for a wide range of disabilities.

Beit Halochem is a model for integrative rehabilitation. Luttenberg acknowledges that part of its success is related to the country's size — the Beit Halochem model would be more appropriately adopted on a state level than a national level in the United States. A more significant factor is the Israeli attitude toward their war disabled. Veterans are respected and seen as an important part of Israel's family. This attitude is reflected by the enthusiastic sponsorship of many groups in Israel and the Diaspora.

Of course, Israel is not alone in providing special benefits for disabled war veterans. What is special about Beit Halochem is the family orientation — in keeping with the general emphasis on family in Israeli society (Safir, 1993). While as a whole the U.S. does not share this orientation, the approach might still be beneficial. The first social group into which disabled veterans need to be reintegrated is the family, and a place defined as "for families" rather than "for the disabled" might well facilitate the process of rehabilitation.