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Thirteen years after the National Health Insurance Law was supposed to supply health services for all, equity in the medical system has seriously declined and gaps in services between the rich and the poor have widened. The increasing inequity in health care has been highlighted by a 43-page report written by Prof. Leon Epstein and Dr. Tuvia Horev of the Jerusalem-based Taub Center for Social Policy Research in Israel and released for publication on Wednesday.
The authors propose a "national program" for correcting this situation, with a focus on incentives to the health funds and others to reduce the gaps. They suggest allocating a certain percentage of the national health budget each year to be divided among the four health funds to increase equity and meet goals set in advance. They also propose changes in copayments for health care and medications that would benefit the socioeconomically disadvantaged.
Who you are, where you live, how many children you have, how much you were educated and how much you earn have great weight in determining the level of your health and how long you live, say Epstein (former dean of the Hebrew University-Hadassah School of Public Health) and Horev (who lectures at Ben-Gurion University and has been an adviser to Kupat Holim Meuhedet). The lowest life expectancy is in the Beersheba region that includes Ashdod, Ashkelon, Beersheba and Beduin towns, with an average of eight years' difference between the highest longevity and the lowest.
The researchers noted that the worldwide trend is for more social equity, and that even though Israel has centralized health policy decision-making and national health insurance, it is bucking this positive trend by increasing inequity. They note that the health funds are not required by law to take initiatives to reduce the gaps in health services to their weaker members, and many health promotion and disease-prevention services are available only to those who can afford copayments.
The share of out-of-pocket expenses not covered by National Health Insurance continues to grow, and many of the disadvantaged forgo services to which they are entitled because they cannot afford these copayments. In addition, many doctors, nurses and other staffers are not trained to provide culturally and socially suitable services to members who are different from them and speak another language, they write.
The gap of life expectancy at birth of Jewish and Arab males in 1996 was 1.5 years (76.6 for Jews compared to 75.1 for Arabs), but a decade later, it has grown to almost four years. The life expectancy gap between Jewish and Arab females at birth was 3.1 years in 1996 (80.3 for Jews compared to 77.2 for Arabs) and has risen since then to four years.
While the death rate from heart disease is declining among Israeli Jews (246.8 deaths per 100,000), it is rising among Arabs (208) even though Arabs have long been at lower risk of heart disease than Jews.
Infant mortality rates are highest in the North, with higher rates in places like Beersheba, Hadera, Acre and Safed than in Tel Aviv and Jerusalem, which have rates lower than the national average. Within the Arab population, there are also gaps in infant mortality, with the rate of 15.5 infant deaths per 1,000 in the south compared to 5.4 in Jerusalem and 6.6 in the other regions.
The lower one's educational level, the higher the risk of diabetes, dental disease and even mental illnesses. The availability of hospital beds is smaller in the periphery, not only general hospitals but also geriatric nursing and psychiatric beds. There are also fewer beds in neonatal intensive care units for newborns in the north and south compared to the center of the country and fewer facilities for emergency medicine and surgery, the authors found. Fewer physicians - general practitioners and specialists - are available to treat patients in the outlying regions.
Taub Center director Dr Ya'acov Kop, along with the two authors, note that lack of equity in health services is "worrisome and dangerous not only because of the existing gaps but because of the trend of expanding gaps." If Israeli society sets a national target to reduce and eventually eliminate them, they add, the society would be more healthy and productive in general, and state solidarity and the feeling of togetherness would grow. They called on the government to implement a national program to reduce the gaps, especially by make good health services accessible to the poor.
Asked to comment on the Taub Center report, the Health Ministry spokeswoman said that "the ability of the health system to reduce these gaps is limited. Nevertheless, the health minister is trying to reduce the level of copayments for the elderly, as many of them have to forgo important medications because they can't afford them.
"Minister Yitzhak Ben-Yizri is also trying to include geriatric hospitalization in the basket of health services, which will significantly reduce the amount of self-participation in costs. In 2008, the minister intends to take a number of additional actions to bolster the public character of the health system and reduce health gaps in the population as much as possible," she said.
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