‘You know, Doctor, I was never sick a day until I came to Israel.” “You were sick when you came here. Your lymphoma wasn’t diagnosed.”“I had two physicals before I made aliya. Both included blood tests. They would have picked it up.”“Maybe nobody looked at the tests.”“I was being treated for high cholesterol. Somebody read something.”The conversation ended there, with neither of us willing to state another possibility: that my American doctor ignored the results because the insurance company wouldn’t pay for treatment. Perhaps their “best practice” guidelines required a more advanced disease. Or maybe they were just hoping I’d go elsewhere or lose my insurance, and then I’d be somebody else’s problem.Or die. Death is, after all, the ultimate medical costsaver.And then it sunk in. If I’d stayed in America, I might very well be dead now.The State of Israel saved my life.And another realization. The medical system is an apt metaphor for Israel. Yes, bureaucracy and balagan are abound. They futz around and futz around. But when it’s time to get serious...Very Israeli.American medicine offers a different metaphor.Catastrophic collapse. Things grow so big, so complex, so many interests are threatened, so many opinions must be heard and so many politicians get involved, that necessary fundamental change becomes impossible.Then, one day, it fails. I once asked a doctor what it would take to collapse the system. He answered, bitterly, “Too many people showing up for a urinalysis on the same day.”How did America come to this? And of what relevance might it be to an Israeli? First, the American approach to collapse.By the early 20th century, as medicine became a research science as well as a serious profession, it grew obvious that the future would be large-scale and expensive.The more medicine can do, the more it will cost.The more it can do, the more people will survive to demand more. Eventually, this tandem of escalating costs and exploding demand, plus the political requirement of equity, must generate a state-administered and, to whatever extent, state-funded system. Call it “citizen medicine,” made available to all as a right of citizenship.The free market doesn’t work when money is made by withholding the product.Europe and Israel understood. America took the free market route. Or so we thought. In truth, by the 1920s, the American Medical Association, in alliance with insurers and politicians, had established medicine as a decentralized private monopoly. World War II created the employment-based insurance system. Wages were frozen; employers competed for scarce labor by offering fringe benefits. When the government ruled that providing health insurance was a tax-deductible business expense, the system locked itself in.By the 1980s, medicine was for-profit big business.Corporate techniques suitable for factories and chain stores – just-in-time inventories, closing unprofitable facilities, and the rest – became the norm. So did the mindset that shaped the Vietnam War. Alain Enthoven, a former Pentagon whiz kid under Robert McNamara, became one of the guiding lights of “managed care,” with its endless micromanagement, reduction of everything human to statistics and best practice jargon, hiding the fact that corporate medicine was now as much about trimming and denying care as providing it.While raising the rates.And now we have the latest exercise in futility, ObamaCare, as the corporate shills scream that under their system, you have “choice.” You can choose your doctor.But what can your doctor choose for you? And why should an Israeli care? Perhaps because the Israeli system is also showing early signs of possible catastrophic collapse.Perhaps because so much of America, Israel’s uneasy best friend, is also approaching catastrophic collapse.And perhaps, in some ways, so is Israel.Funny thing about catastrophic collapse. It happens suddenly. But you can see the danger signs a long way off.I left America because, among other reasons, I was no longer willing to be complicit in the approaching collapse.I did not become a citizen of Israel just to become complicit in the same.If indeed the State of Israel saved my life, I owe it my life. How to repay? Perhaps by becoming a serious citizen.Israel needs citizens. Zionists, post-Zionists, Jews of conflicting religious persuasions, ideologues and screamers, trendy, rapacious start-up boys and girls, minorities aggrieved and not: These we’ve got aplenty.But citizens? Serious participants in the governance of us all? I’ll never be a “real” Israeli. I’ll never have the formative experiences. There isn’t time. I remain, proudly, an American citizen, involved with America. But I am now also a citizen of the State of Israel. And that is precious – and worthy of care.The writer, an American immigrant, is author of Yom Kippur Party Goods (John Hunt/O Books, 2011). His first novel, Ha’Kodem, is in the works.
