Under Israeli law, all migrant workers in Israel - legal or otherwise - are entitled to medical insurance. But the law is not always enforced and many do not receive the medical care they need. Leaving aside the moral dilemma, the state does itself no favors by neglecting this matter
The atmosphere was optimistic on May 30, 2000, when the final draft of the Health Insurance for Labor Immigrants' Law was discussed in the Knesset committee on foreign workers. Although there were still some issues that remained unresolved, there was a general air of confidence that the law would improve the workers' situation. "I think that all of us - the Knesset, the government and the state - have done very important work in the past few months on this matter of health insurance," said the committee chair, MK Yuri Stern. "Now we have to see how this will work on the ground."
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Two years after the passage of the law, here is one example of what's happening on the ground: A 55-year-old woman, a migrant worker without a residence permit in the state of Israel, was admitted into hospital suffering from heart failure. She was discharged with a prescription for medication that she could not afford. Within two weeks, she was readmitted into the hospital, but this time she could not afford to pay for the medications she needed even while in hospital, and consequently became partially bedridden. She was flown back to the Ukraine.
And another: A Chinese man, 28, a foreign worker with a residence permit in Israel, fell ill with an advanced case of cancer of the spine. He became paralyzed from the waist down but was not operated on in Hadassah Ein Karem hospital after his insurance company refused to pay for the surgery to remove the tumor. The patient was ultimately operated on for free at Ichilov hospital in Tel Aviv.
These two examples lead to a single conclusion: The combination of the presence of foreign workers (whose existence the state of Israel prefers to ignore), an insurance law with numerous loopholes and no effort to enforce it leaves foreign workers in Israel dependent on the kindness of strangers. If they happen to visit a kind doctor, he may agree to treat them for free; if they happen to go to a different doctor, they could find themselves being flown back to their country of origin without receiving any medical care at all.
All the diseases of the past
There are currently about 270,000 foreign workers in Israel, of whom 95,000 have permits and 175,000 do not have permits, or are "illegal." According to the law, all these workers are entitled to medical insurance through their employers during the entire time of their stay in Israel. A person that employs a foreign worker, even one that is illegal, without medical insurance, is liable for a penalty unrelated to the fact of his employing an illegal worker.
The purpose of this health insurance, legislated in 2001, is to solve the problem of health treatment for labor immigrants in Israel. Originally, the law was supposed to correspond to the Health Insurance Law provided to all Israeli citizens through the health maintenance organizations, with the exception of fertility treatments, impotency and several other conditions.
In actual fact, however, the insurance covers only very basic conditions: To prevent a situation in which foreign workers come to Israel to receive medical treatment here, the Health Ministry determined that the insurance would not include previously existing medical conditions. "So that questions regarding whether a worker lied do not become the central focus of our attention," as attorney Natan Samoch of the Health Ministry put it, it was decided that it would not matter if the foreign worker was aware of his or her condition before coming to and not even whether he or she could have known.
The removal of existing medical conditions from the insurance coverage, unrelated to diagnosis or the length of stay in Israel, means that any disease that theoretically could have begun before the worker arrived in Israel can immediately be declared by the insurance company to be the result of an existing condition. Thus, for example, relates Rami Adut, the coordinator of immigrants and refugees programs in Physicians for Human Rights (PHR), a foreign worker employed in nursing care in Israel for three years before she discovered that she had kidney stones was told that stones take years to develop and therefore she was not entitled to coverage for the treatment of the condition. In another case, another foreign worker employed in nursing care was diagnosed with cervical cancer and given a similar assessment. In fact, almost all chronic diseases - cancer, heart disease, diabetes, hormonal problems, etc. - can be defined as resulting from an existing condition, which means that the insurance will not cover treatment.
This restriction has aroused such opposition that Alfred Rosenberg, the representative of the insurance companies themselves, proposed that only diseases that were previously diagnosed before the worker came to Israel would not be treated. Attorney Samoch of the Health Ministry rejected the proposal. Another decision left up to the insurance companies is the determination whether or not a worker can return to his job within three months. If it is determined that the worker cannot return to work within three months, the company can withhold treatment, with the exception of stabilizing the worker's condition so that s/he can be flown back to their country of origin. The company has no obligation to find out if appropriate treatment for the worker's condition is available in the country of origin or if s/he is eligible to receive such treatment.
Thus, for example, the Chinese worker suffering from a cancerous tumor of the spine that paralyzed him was admitted to Hadassah Ein Karem, but the FEMI Health Services insurance company maintained that he would not be able to return to work within three months and consequently refused to pay for surgery to remove the tumor, which was expected to become fatal if left untreated. Thanks to the intervention of PHR, which maintained that it was not clear whether the worker could survive the flight to China, Ichilov hospital decided to operate on him without being guaranteed that the insurance company would pay the costs of the surgery.
UN Convention No. 97 stipulates that a worker whose entry into the country has been permitted on a permanent basis must not be returned to his or her country of origin due to disease or injury that does not enable him or her to work. "The problem is that even if we intervene and demand treatment," explains Dr. Dori Spivak of the Human Rights Program at Tel Aviv University, "the insurance companies quickly offer to settle by offering sums of money, and the clients are dazzled by offers of $4,000 and agree, for example, to leave the country with an active cancerous tumor in order to bring the money to their families. It is simply a cruel settlement."
In another case, a 31-year-old woman from Ghana was suffering from renal insufficiency as a result of an advanced case of AIDS and was unable to pay for the medication she needed. The patient was discharged from hospital and flown back to Ghana, where she died three days later. In the discussion on the amendment to the law, MK Stern said, "The state cannot send someone to die abroad. The Health Ministry must set out a communication protocol with the health institutions in the country of origin."
Attorney Samoch responded that what went on in other countries was not included in the law. Without supervision or rules to determine when it is reasonable to assume that a disease was caused due to an existing condition and when it is not, the decision remains in the hands of the doctor examining the foreign worker. And the doctor gets his salary from the insurance company.
The proposed solution is to enable the foreign workers to be insured by the HMOs, like all the citizens of Israel, in return for payment. The human rights organizations are in favor, the Knesset Committee on foreign workers was in favor, and Dr. Alex Leventhal, the director of the Health Ministry's public health department, agrees that "it would be better if they were insured via the HMOs." Even attorney Samoch of the Health Ministry told the Knesset committee, "We think that this could improve the level of service provided to the workers to a certain extent."
Despite this, the Health Ministry vehemently opposed this option. Why? Back in 1998, the State Comptroller's office offered an explanation: the ministry fears that it will have to pay more money to the HMOs. The State Comptroller's office asked that the insurance be transferred to the HMOs despite this. The Health Ministry refused to discuss the subject further.
An emergency? That depends
Despite all this, foreign workers with permits are much luckier than those without. While the employer of an illegally employed foreign worker is required to pay health insurance for the worker, the law is not enforced. "Do you believe that an employee of the state will go to the homes of the wealthy in Ramat Aviv and Herzliya to look for the people cleaning their homes there and file suit against the employers for not doing their duty by providing the workers with health insurance? Do you think that will ever happen? It won't," said Adut at a session of the Knesset committee.
"The matter is not under the authority of the Health Ministry," responded Dr. Yitzhak Berlovitz, the ministry's director-general. Additionally, the chances that the workers will actually see the benefits of the insurance are small. "There are cases when insurance companies that are approached by illegal workers threatened to turn them over to the immigration police," says Dr. Mordechai Fried, the director of the open PHR clinic. "There have even been cases of hospitals informing the police, even though it is illegal to do so," says attorney Spivak.
As a result, most of those residing in Israel without permits do not have health insurance. Even under these circumstances, all residents of the state of Israel, regardless of their legal status, are entitled to emergency care in a case of life-or-death urgency, or if irreversible damage could result. The Israel Medical Association issued a paper this year about foreign workers, in which it emphasizes that even beyond emergency treatment, doctors may provide additional treatments at their own discretion, and that it is the responsibility of every doctor to care for all people, regardless of gender, race or nationality.
The foreign workers are required to pay for all treatments that are not considered emergency treatments - and through the nose too. "Treatment for a foreign worker or tourist costs 1.5-2 times as much as it costs the HMO for citizens of Israel," says Adut. A day in hospital for a "tourist" in August of 2003 cost NIS 2,937 and consultation with a specialist cost NIS 278.
A patient that wants to receive the drug "cocktail" for AIDS must pay about NIS 3,300 a month. And the sum is not fixed; it can be bargained down. "Payment in cash, especially in advance, can lower the price significantly," says Adut. "It is obvious that foreign workers can't afford to pay NIS 3,300 a month; that's what they earn," says Professor Israel Yust, the director of the Crusaid Kobler AIDS Center at Ichilov Hospital in Tel Aviv. "And because it is in everyone's interest that they be treated for AIDS, a reasonable arrangement must be found. And it is all the more infuriating that the insurance companies are evading payment and at present only provide the workers with emergency treatment although it is obvious that they will soon need emergency care again because they are not getting medication. We appealed to the Knesset committee on AIDS Day, but the treatment of the issue is very problematic."
"I feel very uncomfortable that that AIDS tests are free but our ability to offer treatment is limited," agrees Dr. Zohar Mor of the Health Ministry's AIDS and tuberculosis department. Without preliminary health care, such as visits to the doctor, examinations and medication, it is clear that the state of the patients' health is likely to deteriorate. Thus, for example, the woman from the Ukraine became bedridden because she could not afford the medicine she needed. A foreign worker suffering from hypertension was not treated and as a result had subcranial bleeding. "I'm not an expert in economics," says Dr. Fried, "but it is clear that ultimately more money is spent on the hospitalization of these patients than would be needed for preventive care to prevent emergency hospitalizations - to say nothing of the moral issue."
Dr. Leventhal explains the Health Ministry's policy in the face of these claims. "It must be a policy decision, and at present, the policy is that all these people are to be deported. The Health Ministry works on the basis of this decision."
Everyone agrees that the solution must be on the general policy level and that no such solution currently exists. "The approach today - of ignoring the entire matter and not even trying to deal with it - simply leaves the doctors at the front all alone and helpless. We have sworn to treat people, but we are helpless because tests, for example, cost money and the indifference of the establishment is immoral," says Dr. Ori Elkayam, deputy director of Ichilov's Rheumatology Institute.
All that remains for the foreign workers is the kindness of some doctors. About 150 staff members work voluntarily at the open clinic in south Tel Aviv, which sees about 6,000 patients a year. The Committee for the War on AIDS has obtained free drugs with borderline expiration dates for foreign workers with AIDS. A volunteer doctor treated patients in his own kitchen with chemotherapy drugs donated by pharmaceutical companies. In 2001, the Sourasky Medical Center (Ichilov) in Tel Aviv gave three foreign workers free dialysis treatment and 60 free tests a month. The woman from the Ukraine suffering from heart failure had her plane ticket home paid for by the hospital. Before that, donations from the staff provided the money needed to examine her. "Volunteer doctors, an open clinic and hospitals," wrote Dr. Fried in last June's issue of the journal of the Israeli Medical Association, Refuah, "have for years served as the fig leaf for the shame of the state of Israel and Israeli society."
Without preliminary tests
The lack of medical treatment for foreign workers also has a direct effect on Israeli citizens. Since the beginning of the mass employment of foreign workers, the rate of tuberculosis among Israelis has more than doubled. The state of Israel should have prevented this state of affairs by testing for infectious diseases among foreign workers before their arrival in Israel. In fact, almost half the AIDS patients and two-thirds of all tuberculosis patients in Israel are foreign workers that have arrived in Israel from African countries south of the Sahara, where AIDS and tuberculosis are very prevalent. This would seem to indicate that the workers were already infected when they arrived in Israel.
"The Labor Ministry apparently does not make sure to test these people before giving them entrance permits," says Dr. Zohar Mor. Moreover, these workers cannot be tested in any case. The Health Ministry has not prepared testing centers for foreign workers in Africa as it did in Asia and Eastern Europe.
A paper issued by the Knesset Research and Information Center states: "It has not been determined which preliminary tests should be carried out, and there is no supervision of the fulfillment of this requirement." n
The Health Ministry's response
Health Ministry spokesman Robi Steinberg responded: "The Foreign Workers' Law (prohibition of illegal employment and assurance of fair working conditions) determines a list of medical tests that all workers must be given before arrival in Israel. The Health Ministry was required to recognize health institutions abroad where the tests are carried out and this is what is done. The Interior Ministry and the Labor and Social Affairs Ministry are the ones responsible for issuing entry, residence and labor permits in Israel, partly based on the medical certificates declaring that the worker is not ill with or a carrier of any of the diseases listed in the law. The responsibility for carrying out the medical tests on the foreign workers lies with the manpower companies that bring the workers to Israel.
"Workers that are not legally employed should be sent back to their countries of origin. The ministry has no plans to change the existing situation. Like in every Western country, Israel's HMOs are designed to provide health services for Israeli citizens. Foreign workers are not Israeli citizens and they should receive health services through the insurance companies. Any change in this arrangement will mean that foreign workers would be entitled to health services that are not essential.
"The State of Israel does not have the resources to offer a full basket of health services to foreign workers as an alternative to employers that default on their obligations. Nonetheless, in situations in which preventive medical care is justified, the Health Ministry has covered the cost of this treatment at its own expense (vaccinations, preventive treatment for tuberculosis). The Health Ministry does act in certain aspects of foreign workers' lives to provide certain services, such as clinics for sexual transmitted diseases, well baby clinics, which are provided `universally' (to foreign residents, including illegals) and the provision of health services to minors that are not residents (through an agreement with the Meuhedet HMO) as well as treatment for those suffering from tuberculosis.
"The ministry is aware that some of the hospitals' deficits are due to bad debts, including lack of payment by uninsured patients who were given medical treatment. According to Israeli law, the hospitals are required to provide emergency treatment unconditionally.
"The rates for health treatment for Israeli citizens, including those insured by the HMOs, are lower because the rate does not include the calculation of the cost of infrastructures and development, the funding of which is shared by the citizens by means of their taxes. There is no intention, except in cases that are justified socioeconomically, to lower the rates for health services provided to foreign nationals.
"There is an ethical problem in any situation in which a patient does not receive needed medical treatment because he can't afford it. In our view, the funding of medical treatment for foreign workers with AIDS by the state of Israel could serve as an incentive for AIDS sufferers from all over the world to come to Israel to receive treatment. To the best of my knowledge, this policy is the common practice in Western countries (even the rich ones).
"Over the years, the ministry has acted in various ways to improve the situation of the population of foreign workers, for example, by the updating of regulations regarding the health basket for foreign workers, the opening of government and municipal well-baby clinics for all those that need them and the determination of a broad basket of services, paid for by the government, for the children of foreign nationals in Israel, including the children of illegal workers. This basket gives the children of foreign residents the same treatment as the children of Israelis, and is one of the most advanced of its kind in the world.
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