With all the fuss about Obamacare and the Trump frustration at trying to end or limit it, a recent adventure at Hadassah Hospital has led me to think about things here and there.
Public policy is one of the things that have concerned me in an academic career that began when I stood before my first class in 1962, and continues at a lesser tempo. Twelve years into retirement, I continue to think, write, and teach a workshop on the subject of public policy for MA students one semester every two years.
US fascination with freedom of choice, opposition to a single payer and anything compulsory causes no end of wonder in comparison with what exists in every other Western democracy. Those thinking that America is unique may disdain comparison, but that is the only way to learn and judge.
What's available and what's compulsory differs in detail from one country to the next. However, what is typical is a universal program that goes beyond in coverage the services that most Americans get from Obamacare, at a lower cost to individuals, plus the option of adding on additional coverage via private plans.
My outsider's view about what I read and hear from the United States is bafflement at the complexity of its health options. Too many choices that also vary significantly from one state to another, and require a patient to work through a mountain of paper and regulations and conflicting claims about who pays what among insurance companies, hospitals, government, and themselves.
I sense from conversations with Americans that the emotional costs and nervous energy spent upon the administration and payment may outdo the physical worry and pain.
Israel's system resembles that in numerous other places.
We're all enrolled, pay a progressive fee defined by government and dependent on income. The poor and the retired pay nothing for the basic coverage. Seventy-three percent of the population pays a family average of $36/month for government defined supplemental insurance, which provides additional benefits, including even lower prices for medicines than the basic coverage. There are also additional private insurances that go beyond what the regulated programs provide in terms of nursing care, treatment for special cases outside of the country, and the costs of especially expensive medicines not included in the basket of what the basic plans cover.
So far we 70+ year olds are in pretty good shape. We visit our family physicians regularly. There is no charge for this service, and we're able to arrange an appointment within a day or two. My visits typically include political discussion and the provision of another three months of prescriptions to keep me in decent fit. We also eat well, drink moderately, don't smoke, walk several kilometers a day, visit a gym and work with weights several times a week.
When we visit a specialist, we pay the equivalent of $7, unless we've had more than a few visits with specialists in a calendar quarter, when our fee goes down to $0.
Blood tests are covered with no additional charge to us.
Almost all of our medications are generic, and come with deep discounts, as do the over the counter stuff we buy at the HMO's drug store.
Occasionally there is a procedure where we can choose "public" or "private." The difference is in cost, choice of physician, and waiting time.
Unless we are pressed by pain or worry, we usually go public, and get treatment within about three months.
My recent adventure fell under the heading of discomfort, and instead of what was likely to be three months I called each of the two major hospitals in Jerusalem and was able to reach a specialist for a consult within 24 hours, and he fit me into his surgery schedule two days later. Most of the cost was covered by the $36/month supplement in the HMO, and most of the rest by our additional supplemental insurance.
Israelis argue about the justice of private care. Those with resources can find quicker and perhaps more personal treatment. Morally it ain't perfect. In that, it joins just about everything else in mixed economies that shun the regimentation (along with the corruption and poor services) of the Soviet model.
The prime advantage of the private option that coexists with universal care and a single payer is that it allows for a degree of individual choice, without being so driven by personal resources as to distort opportunities in the American way. It also provides additional resources for hospitals, clinics, and medical professionals willing to work beyond the hours that they serve those in the public queue.
As noted above, we get almost all of our treatment in the public queue, even though we can afford to go exclusively private.
For those younger folks still working, Israel's basic coverage costs between three and five percent of monthly gross income, depending on level of income.
The physician who cared for me was pleasant and skilled. At the initial consultation, he explained the pluses and minuses of several alternative procedures, and accepted the choice that I made. The nursing staff not only helped me through a night of mild discomfort, but provided me with an early morning coffee when requested. And it all came with the appropriate blessings for the New Year and the impending Yom Kippur.
Paperwork? It;s usually nothing more than swiping my HMO card which puts my entire medical file onto a physician's computer, and causes an appropriate deduction from our bank account. The physician prints out what I need to obtain medications, blood tests and anything else. For my recent hospital procedure, the entire file of paperwork required for insurance coverage amounted to less than five pages.
Here and elsewhere, it's important where one lives. City people have easier access to specialists than those living in distant towns. On this matter, Israel's small size helps. Few of us are more than an hour from a medical center. Health also depends on education and income. Those with more tend to take better care of themselves and know how to find what they need. Israel's Arab population is less healthy than its Jewish population. However, Israel's Arab population has better health statistics than White Americans, and much better than American minorities. How much of those differences result from cultures and how much from better access to medical care is something to consider.
Our relations with the Arabs of Israel and Palestinians come with tensions, suspicions, and distrust on both sides. However, the hospitals, like the universities, are islands of accommodation. Staffs and patients are an ethnic mix, and they show levels of accommodation, cooperation, and friendships that stand apart from what some see as our international reputation.
Israeli and European taxes are higher than those of the US. But among the benefits are decent health statistics. Israel scores #8 in the world on life expectancy, while the US ranks #31,and below all countries of Western Europe. On the measure of infant mortality per 1,000 live births, Israel's rate is 3.5, that of the European Union is 4.0, and that of the US is 5.8.
Our taxes pay for other benefits beyond health care and the IDF.
There are lots of Americans paying $40-$60,000 per year for undergraduate tuition at colleges that teach how much to hate Israel. Here we provide as good an education without that political add-on for the equivalent of $3,000 per year.
Some of my earliest memories of politics are of Harry Truman losing to the power of self-employed physicians and their American Medical Association on his proposal for national health insurance. Now that most physicians are salaried members of an HMO, it's those HMO's, the insurance companies, major hospitals, and hospital chains that produced the monstrosity (2,200 pages) Affordable Care Act (Obamacare). It isn't easy, and apparently impossible for Donald Trump to change what has become accepted as an American entitlement, even though it's a small version and a paperwork nightmare compared to what is available outside of the US.
Comments welcome, including from those who insist that I don't understand the US.--
Ira Sharkansky (Emeritus)Department of Political ScienceHebrew University of Jerusalem