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Nursing care could be substantially extended and a national nursing-care insurance created under proposals by the National Insurance Institute and the Health Ministry.

Last week, the Health Ministry proposed making nursing care part of the basket of nationally subsidized health services, in exchange for a 0.5% increase in health taxes.

In response, the National Insurance Institute countered with a plan that would keep nursing care as part of national insurance, but would expand it greatly. The main advantage of the latter plan is that it does not necessitate raising taxes in the short term. This plan has the support of Social Affairs Minister Moshe Kahlon.

"We need to consider the aging population - it's a time bomb," said NII head Esther Dominicini. "Around the world, countries are saying that the stability of national insurance programs is the next macroeconomic problem, primarily because life expectancy is increasing. Currently it takes three people working to finance one elderly person, and that's nearly impossible."

There are currently two phases of nursing care. In the first phase, which applies to most elderly patients, nursing is administered in the patient's home. The NII funds a set number of weekly hours of care depending on the individual's needs. The nursing is generally carried out by foreign workers employed through manpower companies, which are paid by the NII.

Currently, 145,000 people receive home nursing care at a cost of NIS 4.1 billion a year.

The second phase of care is institutionalization for patients who can no longer be cared for at home. This is much more expensive, since patients may spend years living in private or public nursing institutions. This is funded by the Health Ministry, and costs NIS 1.5 billion a year.

Health Ministry sources say the current structure of nursing care in Israel is inefficient, for two main reasons: The first is a lack of coordination between health maintenance organizations, which are responsible for keeping patients from needing nursing care in the first place, the NII and nursing institutions. As a result, the parties push responsibility for patients onto each other. HMOs do not bear the cost of neglecting nursing patients' care, for instance.

The ministry sources also argue that the government does not provide enough nursing care. The NII offers a minimal number of home nursing-care hours, and the top two deciles receive almost no assistance, even though they have paid national insurance their entire lives - 15% earn too much to receive any assistance, and another receive only 6% of the assistance for which they are eligible.

Things are even worse when it comes to nursing institutions. A full 30% of patients receive no assistance at all because they earn too much, and are forced to fund the NIS 15,000 a month on their own.

Given that life expectancy is increasing, the number of people who need nursing care is expected to grow - within the next 25 years, 145,000 are expected to need home-nursing care, up from the current 10,000. Therefore, the state needs to expand nursing services, say Health Ministry sources.

The ministry proposes to do so by introducing a national nursing-care insurance, and by having all stages of care handled by the HMOs. It also wants to lower the requirements for receiving care.

This program would be funded by raising health taxes by 0.5% a year, worth NIS 1.2 billion, the ministry proposes.

Not surprisingly, the NII opposes a plan that would take away part of its authority. It argues that nursing services are essentially an allowance - one paid in services, not in money - and notes that it pays disability benefits to eligible individuals who receive care in parallel from the HMOs.

No need for new taxes

Dominicini said the NII was pleased the Health Ministry had broached the matter, although she rejected its program and instead proposed a plan that would use current funding sources, without necessitating new taxes.

The NII's program calls for reallocating care hours from relatively functional patients to those who need assistance more, and for doing away with extra hours for hiring Israeli home nurses as opposed to foreign nurses.

For instance, the minimum number of weekly care hours would be reduced to five, down from the current 9.75, while the maximum number of care hours would be raised to 30, up from 22.

This means 57% of people currently receiving care would get fewer hours, 5% would receive the same number of hours, and 38% would receive more home assistance.

However, the NII proposes introducing the new system only for new patients, meaning that over the short term, it would need more funding.

Dominicini also wants to relax the income eligibility requirements. Currently a person who receives a pension and other sources of income equal to the average wage - NIS 8,300 a month - receives only 50% of the NII allotment, even though hiring a foreign worker costs NIS 4,500, or half the individual's monthly income. Someone who earns more than 1.5 times the average wage - NIS 12,500 a month - receives no NII nursing assistance at all.

Instead, she proposes giving 75% of the hours to the first group, and 25% to the second group. Another 27,000 people would become eligible under these new requirements.