Public Funding for Public Health Care

Medical care must be separate from the individual’s ability to pay for it.

Aeyal Gross
Aeyal Gross
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The package of state-approved medications must remain available to all.
The package of state-approved medications must remain available to all.Credit: Nurit Spivak Kovarsky
Aeyal Gross
Aeyal Gross

What will Israeli health care look like once the government’s Advisory Committee to Strengthen the Public Health System completes its work? The panel might live up to its name and actually strengthen public health care, in the spirit of the principles of justice, equality and mutual assistance described in the National Health Insurance Law and in the committee’s official charter – or it could perpetuate the erosion of public health care through continued privatization.

The health insurance law created universal health insurance for all Israeli residents. At its core is a progressive, income-based health tax that is paid to the state in exchange for medical care from one of the recognized health maintenance organizations.

This care is provided on the basis of medical need and the package of government-approved medications and medical services available to all. In other words, medical care is disconnected from financial wherewithal.

But public health care has been weakened over the years. The ratio between public and private expenditure on health is changing for the worse; it has gone from 75-to-25 in favor of public expenditure in the 1980s to just 58-to-42 today. (In OECD countries the ratio is 72-to-28, placing Israel among the developed nations with some of the worst public-to-private ratios on medical spending.) This process increases the inequality in access to health.

One example of what the increase in private expenditure has wrought is the patient copayment required for the approved services and medications, collectively known as the “health basket.” These are regressive payments, on top of the health tax; they are paid directly to the HMOs, effectively meaning that medical treatment is contingent upon those payments.

Studies show that a significant portion of the population refrains from obtaining medical treatment because of an inability or reluctance to pay for it.

These co-pays – combined with the increase in private expenditure and concomitant decrease of public expenditure – constitute the privatization of funding for the health basket.

The issue of privatization is even more blatant when it comes to a kind of private health care known in Hebrew by the acronym sharap, in which patients are allowed to pay for services in hospitals, including publicly funded ones, that other patients don’t normally get.

The High Court of Justice has ruled that if the right to choose your surgeon, which is at the basis of the sharap system, is a basic right, then it must be accorded to all patients, not just those who can afford to pay for it.

If the health care committee – widely known as the German committee, after its chairwoman, Health Minister Yael German – institutionalizes the private health care system, it will heighten the disparity between rich and poor. This will create two categories of patients within the public health system, in violation of the principle of separating medical care from the wherewithal to fund it.

A similar danger is posed by the proposal to allow the HMOs to offer lifesaving medication to Israelis with supplementary insurance, although this is currently legally prohibited. This, too, is a threat to public health.

These drugs must be part of the national health basket and available to all on an equal basis. Making them part of the supplementary insurance provided by the HMOs will amount to neglect of the poorest 20 percent of the population that does not have this sort of insurance. The result will be reduced pressure to include these drugs in the general health package, which will then become exclusively for the poor. Such a situation will also hurt those who do have supplementary insurance, since the cost of the extra coverage and the co-pays will rise as a consequence.

Co-pays, private health care and supplementary insurance are being portrayed as a way to inject money into the health care system. But the solution lies in public funding for public health care, not in creating pockets of private medicine. For instance, the government could raise the progressive health tax by 0.5 percent or 1 percent, an increase that a survey conducted last week found to have broad public support. Sufficient public funding for quality public health services must be guaranteed.

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