Chapter 3 - 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 21st 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
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
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
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,
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
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 32nd week of pregnancy, bi-weekly examinations between the 32nd and 36th 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 32nd week, the norm is a minimum of three
examinations by a physician, and from the 33rd 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,
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
U.S. Infant Mortality Rates by Race and Origin, 1996
|All races combined
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.