|All races combined||7.2|
Source: Federal Interagency Forum of Child and Family Statistics, 1998, America's Children: Key National Indicators of Well-Being.
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 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.
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.