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The Health Ministry's Dr. Michael Dor spends an hour of every work day going over receipts, checking drug registries and consulting medical specialists and legal experts - all for the benefit of 578 privileged Israelis - Very Important Persons. The acting head of the ministry's medical division (until December 1) and permanent director of the general medicine department is then free to worry about the country's other seven million citizens.
Dealing with this privileged group is frustrating, and Dor didn't choose to do it. If he can "blame" anyone for it, it would be David Ben-Gurion, who in the early 1950s innocently solved the problem of a Supreme Court justice who wanted health insurance but didn't feel comfortable being a member of one of the public health funds (which in those days were owned by political parties).
"The legend is that it was the late great judge Haim Cohn who made this request, but no one here in the ministry has been here long enough to remember," says Dor in an interview with The Jerusalem Post. "The justice said he didn't feel comfortable, as a judge who had to be impartial, being beholden to a political organization to insure himself and his family. So Ben-Gurion gave an order that Supreme Court justices and their immediate dependents be reimbursed for their medical expenses."
When others in power heard about this generous benefit, laws were changed to encompass more people - all civil court judges, dayanim from the Jewish religious courts and kadis from the Muslim courts.
"Then MKs were added to the list in the 1960s, followed by government ministers, directors-general of the ministries, MKs, the civil service commissioner, the state comptroller, and of course the president and the prime minister - and any dependents who live with them.
After president Moshe Katsav left Beit Hanassi in disgrace after admitting he had abused female employees, the Knesset did not cancel his VIP health benefits.
Over the years, two levels of entitlement developed, with more privileges for the president, prime minister, other ministers, top judges and ministry directors-general and fewer for "ordinary" judges and MKs. But then in 1986, two MKs named Ehud Olmert and Yossi Sarid insisted that the list of beneficiaries and expenses were exaggerated and persuaded the Knesset to get it cancelled. But as there is no retroactive cancellation of benefits, says Dor, those already on the list... and their dependents... continue to get reimbursements. "MKs who left the Knesset before 1986 continue to be members of this club, while those who left afterwards are not."
However, current and former presidents and current and former prime ministers remain eligible for all benefits. Presidents also get fully reimbursed for dental expenses.
Fortunately, no new groups have dared ask to be included in the deal.
WHEN THE National Health Insurance Law was instituted in January 1995, every Israeli was entitled to join the health fund of his choice, and the financial and ownership connections between the funds and political parties were severed. However, the elimination of the original reason for the VIP arrangements established by Ben-Gurion didn't lead to the cancellation of all benefits, because retrospective abrogation of privileges is not permitted. Instead, the beneficiaries are still entitled to present receipts for all medical (but not dental, except for the president) expenses, including drugs - prescription and over-the-counter medications listed in the official Medic registry, which is updated every three months. But any service or treatment provided at no cost by the health fund is not included.
"The VIPs are bound to take advantage of what the health fund supplies - but they can be reimbursed within set limits for what is not supplied by the health fund," says Dor. Thus expensive cancer drugs not included in the basket of services supplied to the general population, and ambulance trips or subscriptions to private heart monitoring services like Shahal or Natali are fully covered for the VIPs. Costs of hearing aids beyond what the health funds pay are reimbursed. And Viagra and other treatments for erectile dysfunction (impotence) - which are not subsidized by health funds for mere 'mortal' men - are covered... and VIPs are not embarrassed to submit receipts for them.
There are no reimbursements for food supplements that are not registered drugs - even though some of the VIPs are insistent that they be reimbursed for things like cranberry tablets. In addition, no VIP will be reimbursed for medical treatment he or she underwent abroad, or for purely cosmetic surgery like facelifts, liposuction, Botox injections and so on. Orthodontic work on VIPs and their snaggle-toothed dependents are also not included, but some kinds of vitamins and nutrients (those registered as drugs) are - as are expenses for intensive geriatric nursing institutions, up to NIS 313 a day.
But, Dor shrugs, orthopedic insoles that cost thousands of shekels are covered as medical expenses if the VIPs get a recommendation from a specialist. Some VIPs ask for reimbursements for visits to complementary medicine practitioners. "There is a grey zone," says Dor. "I have to investigate. If the practitioner is recognized by the health authorities, such as an MD or licensed physiotherapist who offers complementary therapies, I have to accept the receipt. If he is not, I turn them down."
Medical insurance for foreign travel is also among the benefits, Dor notes, explaining that if a VIP is hurt abroad, "he returns home and is treated here, so it's best to provide travel insurance for them or it will only cost us more." But the beneficiaries of these generous benefits - which the average Israeli can't dream of - sometimes have no shame. "There are some who present bills for a NIS 12 copayment for visiting a doctor" rather than pay it themselves. "I myself would be ashamed to ask for a NIS 12 reimbursement."
There are VIPs who follow the Israeli dictum: "When you're offered something free - take!" Dor recalls a person who forgot to mail in receipts for years and suddenly sent him a bundle. "He got NIS 600,000. The law allows them to get reimbursed for medical expenses going back up to seven years."
The senior ministry official was shocked when, six months ago, a retired judge presented bills for the treatment of both his wife, from whom he was separated, and his mistress. "It was there that we drew the line. I told him he had decide which of the two women would be covered."
Another case of hutzpa was a VIP who asked for reimbursement for physiotherapy but said he didn't have a receipt. Dor told him that if he signs an official statement saying he lost the receipt, he could be paid. But the bold-faced VIP said his physiotherapist "doesn't give receipts" - meaning that she (or he) doesn't report income so as not to pay taxes. That VIP's request was turned down.
"I know of some cases in which doctors charge VIPs an inordinate amount of money," reports Dor. "They charge especially high rates, knowing their patients would be reimbursed. When VIPs, who are mostly elderly, ask for coverage of the medical expenses of a son or daughter living with them, we check. We had a case of coverage for a 40-year-old dependent. We found he indeed lives with the VIP and is dependent on him. We also received a receipt for contraceptive pills for a 17-year-old daughter."
So far, there have been no reimbursement requests for condoms.
Dor's time is further wasted when a VIP presents receipts from a pharmacy chain for a mixture of medications and food supplements; Dor must edit out the ineligible ones.
"The VIPs do not receive a booklet listing all their privileges, but we send them the relevant laws. I write detailed letters with explanations when I turn them down, and have a special luminous felt pen for explaining things," Dor says. "I am the person with the power to decide; there are pressures on me. There is an appeal process, but the special committee has never decided to overturn any of my decisions."
ALTHOUGH most of the beneficiaries are elderly and gradually leaving this world, the cost of VIP coverage is growing. "The greatest increase is for geriatric nursing, even as the number of beneficiaries is slowly shrinking," says Dor. Thus in 2006, the budget was NIS 13,283,000 for 578 VIPs, compared to NIS 11,734,257 in 2005. Today, 60% to 70% of all the reimbursements are for nursing care.
Last year, the VIPs included (in addition to current and former presidents and prime ministers): 95 former MKs, 23 ministers, 245 lower-court judges, 51 higher-court judges, 40 lower rabbinical court judges, 42 higher rabbinical court judges, 75 directors-general and seven kadis. The judges in civil and religious courts, being the most numerous, were responsible for the largest chunk of funds (NIS 9.8 million, compared to NIS 7.5 million in 2005). Fortunately for us ordinary citizens struggling with the slashing of services supplied by the Health Ministry, the budget for VIP medical expenses is supplied directly by the Treasury.
Dor, a bear of a man with a sensitive soul, doesn't enjoy this part of his work, and wishes that the VIP benefits could be cancelled. "I would be happy to be relieved of it." He is unaware of any similar benefits to VIPs abroad. "There have been efforts by the Treasury to put a tax on them, but so far they have not been successful."
Ten years in the ministry, Dor is a family medicine specialist who graduated from Tel Aviv University and Hebrew University Medical Faculties and is proud of having set up a community medicine network in Jordan Valley settlements. After earning a master's degree in public health at Harvard, he returned to Israel. He chose to run a Clalit clinic in Jerusalem's poor Kiryat Menahem quarter, and set up urgent-care clinics for the health fund. He bid on a tender to become a Clalit regional director, but lost to another doctor and joined the ministry instead. With the move of longtime deputy director-general Dr. Yitzhak Berlovich (who headed the medical branch and whose name remains on Dor's office door) to become director-general of Holon's Wolfson Medical Center last year, Dor was made acting branch head and given the broad responsibilities of supervising general, psychiatric and geriatric hospitals, ambulance services and others, including the VIP arrangement.
When Dr. Hezi Levi, a former IDF chief medical officer, takes Berlovich's job on December 1, Dor will revert to his general medicine department post, but will continue to be responsible for the VIPs.
"I was asked to become permanent head of the medical branch, but I turned it down, as I would not be allowed to continue my family practice in Jerusalem's Gilo quarter. I'm a community doctor who likes regular contact with patients in the field. I don't want to be a hospital director, because I think primary care, community medicine and disease prevention are more important than hospital care."
Dor is in a minority in the ministry's top management, as none of the other doctors there treats patients in a clinic. "Often during discussions among ministry officials, I'm asked about what's happening in the field. In Switzerland, senior health ministry officials are required to work in the community. I can tell my colleagues whether their directives are in fact reaching the public."
Dor sighs as we conclude our interview. "Every time somebody writes about the medical privileges of the VIPs, the amount we have to pay rises by half a million shekels. The VIPs learn something new about what they're entitled to - and then demand it."