The privatization of health care.

"Privatization" refers to two distinct areas: (1) the increasing provision of services by private businesses and non-profit organizations rather than by the government, and (2) direct payments imposed on consumers for health services formerly financed by the government through taxation.

The privatization of health care provision involves both the creation of new for-profit medical services - nursing homes, hospitals, specialized clinics for menopause, pain, cosmetic surgery, child development, diagnostic services and a plethora of alternative health services like homeopathy, naturology, and reflexology, and the conversion of public health care facilities into private ones.

Health economists agree that health services are not like other commodities sold on the marketplace; rather they are a prime example of "market failure." As most of the information concerning the "product" is in the hands of the seller-physician, the buyer-patient has limited knowledge and thus bears little resemblance to the classical model of the rational consumer. As a result, there is a "moral hazard" of the physician selling the patient a service or product that he or she does not need or, much worse, one that may be dangerous to their health.

Who Provides Health Services

Regardless of whether health services are financed directly by the consumers' fees for services or by the state, they are paid for by citizens. However, the difference is significant. To illustrate, the table below compares the total payments by households for social services and taxes in two very different societies: the United States and Sweden.

The average household expenditure for social services is about the same in the US and Sweden, 39.6% and 41.2%, respectively. The difference is that in Sweden the expenditure is utilized to provide health care for all, as revenues go to the government in the form of taxes, while in the United States, the figure represents an average between higher income families that purchase health care on a private basis and low-income families that go without (unless they are eligible for Medicare or Medicaid). The health outcomes: in Sweden, income disparities are much smaller than in the US, and the health of Swedes, as measured by indicators like infant mortality (4 per 1,000 live births in 1996) and life expectancy at birth (82 for women and 76 for men) is better than that of US citizens (infant mortality: 8 infant deaths per 1,000 live births - twice as high as that in Sweden; life expectancy at birth: 80 for women and 74 for men). In Sweden, the national expenditure on health is 7.3 % of the GNP, whereas in the US i t is nearly twice as high - 14.2% (World Bank, 1998: 18, 22, 90).

In a similar vein, one can compare the expenditures and health outcomes of two health services in Israel, one provided by the state on a universal basis and the other dominated by the private market. Preventive care for pregnant women and newborns is provided by a network of public Mother and Child clinics. The service is financed by the Ministry of Health and by a low user's fee. The total cost: 2% of the national expenditure on health. More than 95% of Israeli parents visit one of the clinics at least once during the first year of life of a newborn (Palti, 1996: 86). Looking at health results nationwide, over 90% of babies receive the necessary inoculations on time. Maternal mortality is negligible, and infant mortality is low.

The picture for dental medicine is entirely different: 90% is private. Expenditures for dental care constitute 12% of the national expenditure on health. Care is far from universal: the most recent national commission on health care (1990) found that 75% of Israelis did not have regular dental checkups. As a result, in 1992, the proportion of children aged 5-6 with no cavities was 41% in Israel, compared with 60% in Denmark, 58% in Norway and 49% in Great Britain, countries in which dental medicine is included in public health programs (Horev, 1996: 108). The number of adults aged 35-44 with serious gum problems (periodontal pockets) was 17% in Israel, compared with 8% in Norway, 11 % in Denmark and 12% in Great Britain (ibid: 109). And the proportion of persons 65 and older with no teeth of their own was 60% in Israel, compared with 31% in Norway and 50% in Denmark (ibid: 109). The fact that in Israel dental medicine is left to the private market leads to inequity in the provision of services: low-income pe rsons who cannot afford dental care have bad teeth.

Privatization: Private Services Instead of Public Services 

The privatization of health services involves a number of processes: the retrenchment of government, the development of private services alongside public ones, and the conversion of government services into non-profit and for-profit companies. It also means the increase of co-payments for public services and the proliferation of private medical services.

Government Stops Paying

A year after the National Health Insurance Law was implemented, the Israel Ministry of Finance began to retrench. In 1995, it paid out MS 1.5 billion to cover the difference between revenues and expenditures under the National Health Insurance Law - more than it had anticipated. Finance officials accused the health funds of inefficiency and waste, while the latter pointed out that the law was underfinanced, as the budget failed to take into account (1) population growth and aging, (2) technological advances, and (3) the full increase in the cost of health services. The General Health Fund contended that it was not being properly compensated for its larger-than-average share of persons aged 75+ (79%) and chronically ill persons (75%). An objective observer - The Brookdale Institute - examined the balance sheets of the four health funds for 1995 and found instead of waste an average decrease in per capita expenditures.

At the end of 1996, the employers' health tax was abolished; in its stead, a sum of about NIS 7 billion formerly earmarked for the health care delivery system was put at the discretion of the Ministry of Finance. The same year, attempts were also made to impose co-payments on health services, but the Knesset refused to pass the budget bill as long as co-payment strings were attached.

The Cabinet's 1998 Budget Reconciliation Bill included far-reaching changes in the National Health Insurance Law. Following intensive lobbying efforts by a coalition of NGOs, compromise legislation was passed, under which responsibility for financing the services provided under the National Health Insurance Law devolved from the Finance Ministry to the health funds. The funds were instructed to prevent future deficits by imposing copayments and by selling more policies for supplemental insurance. They were also encouraged to add, but not subtract, services from the uniform benefits package, provided they could finance the additions (subject to approval by the Minister of Health and the Knesset Finance Committee). This change delivered a blow to equity in health care: henceforth, there would be a connection between the ability to pay and the services rendered, and health funds would be able to redesign their benefit packages so as to attract the healthy and affluent and thus "improve their patient mix."

Among the other changes instituted: a fiat that no more than one health fund serve localities of under 5,000 residents and no more than two localities of under 10,000. This will mean a decrease in the variety of public services offered to Arab communities - the main beneficiaries of the competition between health funds stimulated by the National Health Insurance Law.

Public Services Go Private

Sharap

A prominent example of the use of public institutions created by taxpayers' money for private profit is the Private Medical Services (Sharap) arrangement, under which senior physicians employed by the hospitals may see private patients in separate rooms and utilize other hospital facilities for their treatment. Hospitals regulate and collect Sharap fees, from which they deduct taxes and their own charges. This arrangement has been instituted in two public hospitals in Jerusalem, Hadassah and Shaa're Zedek. The physicians' unions would like to see it extended to all public hospitals in Israel.

Sharap can be viewed as an attempt to control "black market" medicine, in which patients paid hospital departments and physicians under the table in order to be operated on by the surgeon of their choice or to advance to the head of the waiting list (Lackman and Noy, 1991, 1998), by institutionalizing the practice. In 1995, 10% of surgical procedures and 18% of outpatient clinic services in the Hadassah and Shaa're Zedek hospitals were done under the Sharap; between 30% and 40% of the permanently employed physicians dispensed private care under the program (Shuval and Anson, 1999).

There is no empirical evidence that the Sharap arrangement contributes to the improvement of hospital services (Shirom and Amit, 1996: 64). What it does is to channel public resources to a thin stratum of senior physicians and affluent patients. While hospital overhead in the operation of the Sharap is supposed to be limited to 35%, an estimate of the overhead involved in scanning, pathology, and clinical lab services performed at the Sha'are Zedek hospital under the Sharap came to nearly 47%. This prompted Amit and Shirom to conclude that Sharap activities "in effect involve transferring resources from the general public to a group of doctors," (ibid: 64), for the charges the doctors pay the hospital come nowhere near reimbursing them for the real value of the use of the premises, equipment and services. Nobably, Lackman and Noy found that "black market" medicine was no less prevalent in Hadassah and Shar'are Zedek than in public hospitals without Sharap arrangements (1991).

The institutionalization of the Sharap in public hospitals leads to the creation of two levels of treatment within the same institution and to differences in access, depending on the pocketbook of the patient. Thus, it is expected that the expansion of the Sharap will contribute to class polarization and that it will have an adverse effect on whatever social solidarity exists in Israeli society (Amit and Shirom: 68).

The question is: what are the alternatives? A series of articles published in Hair, a local Tel Aviv weekly (Shadmi, 1998a,b,c) in the summer of 1998 revealed that in three large public hospitals, Ichilov, Assaf Harofe and Rambam, private services are being offered by senior physicians alongside the public ones under a different arrangement. Unlike the situation under the Sharap, in the above hospitals doctors set their own fees, and payment is made through a commercial insurance company, which charges 10% of the doctor's fee for its services. Whereas one of the justifications for permitting private services in public hospitals was to prevent doctors from engaging in private practice outside the public hospitals, in the one hospital investigated, most of the physicians did not reduce their private practice outside the confines of the public hospital after institution of private services under its roof (Shadmi, 1998a).

Yet a third model is to be found at the Haim Sheba government hospital, where patients with supplemental medical insurance from health funds or commercial firms receive private medical services in the public facility. Doctors' fees are set by the health funds or insurance companies, not by the physicians themselves. Here, too, domesticating "black market" medicine by institutionalizing it within the confines of a public hospital does not prevent doctors from practising private medicine outside as well inside the public facility employing them (Shadmi, 1998b). The result is that many of the best doctors in some of the public hospitals devote most of their time to treating persons with means; those without are treated by the less experienced (ibid).

The Sale of Supplemental Insurance

A second example of the development of private services alongside public ones is the health funds' sale of supplemental insurance for health benefits not included in their regular package. Supplemental insurance received further boosts in 1995, with the implementation of the National Health Insurance Law, when the funds with a more generous benefits package than that stipulated by the law transferred the extra services to their supplemental plans, and in 1998, with passageare in Israel 27 of a budget reconciliation bill that expressly encouraged health funds to develop private insurance to help them balance their budgets. It has been noted that the proximity of public and private insurance involves a danger of "slippage" from public to private and is threatening to equality, especially if the private services offered - like jumping ahead in the waiting line for surgery, are closely tied to those in the public benefits package (Ofer, 1997: 746: Chernichovsky, 1996).

Conversion of Government Hospitals to Public Trusts

In 1992, a process was initiated whereby 6 government hospitals were to be reorganized as self-sustaining public trusts. These new entities were to be not-for-profit, but they were to be run more like companies than previously, that is, management was to take into account not only the quality of services provided but also the costs. The major purposes of the reform: to free the Ministry of Health from the running of hospitals so that it could concentrate on planning and policy, and to increase the efficiency of the hospitals by creating competition among them. What was not considered by policymakers was "what ought a public firm to do?" - that is, what other objectives were the hospitals to pursue - as "public" bodies - beyond their own financial interests, like, for example, increasing equity and access (Saltman, 1995:175).

Actually, the process of privatization had begun as early as 1987, when government hospitals were first permitted to sell for profit - services not included in the benefit packages of the health funds. At the same time, they were allowed to hire staff on a temporary basis and to make some acquisitions on their own (Shirom et al, 1997: 140). The hospitals set up separate accounts for revenues from for-profit services; these services also provided additional employment opportunities for hospital staff. In other words, even before the reform had begun, "de facto trusts [had] been created within the big public hospitals in the form of a subsidiary budget, uncontrolled and unmonitored" (Adar, 1995:171).

Hospitals slated for independence were to lease real estate and other property from the government and to cover all payments - salaries, maintenance, acquisitions and research from their own income. Sources of income were to include payments from health funds for hospitalizations, revenues from sales of for-profit services and contributions. Hospital employees were to be transferred from the public service to the hospital trust: they would cease to be government employees protected by collective bargaining agreements. In 1992, the six hospitals were duly registered as public trusts and Boards of Directors were appointed.

The reorganization was arrested by the Nurses and the Auxilliary Workers Unions, whose members feared - with good reason - a worsening of their terms of employment.

In the meantime, directors of the hospitals slated for conversion have become more independent (Ofer, 1997), and some of the government hospitals have begun to operate like profit-making institutions (ibid and Shirom et al: 149). The development of for-profit ambulatory services has already been mentioned. The Ministry of Health's introduction of differential payments for certain medical procedures - following the international fashion - resulted in large increases in some expensive procedures, like by-pass operations, the rates of which have risen to a level double that in European countries (Shirom et al: 150). Another example: in 1995, some government hospitals announced they would limit lowcompensation procedures like hip replacements due to financial constraints (ibid).

The process of privatization of government hospitals in Israel has resulted in the coexistence of public non-profit and private for-profit services under one and the same roof. This may well prove detrimental to equity, for it creates an incentive to transfer some of the services meant to be provided under the public framework to the private one. Another problem is that institutions with a public service image are now marketing new, expensive technologies whose effectiveness may be unknown or questionable (ibid: 151).

If Israeli hospitals follow the example of American government hospitals that became public trusts, there is danger of their shifting revenues from patient care to "exorbitant salaries" for administrators (Saltman, 1995:175).

The privatization experience of the United Kingdom is also instructive. Once they were on their own financially, the English hospital trusts found they had to "make redundancies in order to remain viable and survive" (Hunter, 1995:162). Some job losses were justified because there was over-staffing, but others were the result of tight financial constraints (ibid). Whatever the case, the privatization process involves making labor relations "more flexible"; that is, making health care workers, especially those on the lower end of the occupation ladder, easier to fire.

It is now recognized that hospital employees are stakeholders, and that as such, they need to be involved in the process of privatization (Ofer, 1997: 734). However, the bottom line is still the same: lower-level health care workers will lost their bargaining position - and their jobs. Unless a search for the answer to the question, "greater efficiency for what social aim" becomes an integral part of the privatization process, Israelis are liable to find former government hospitals giving preference to income-producing services and clients at the expense of unprofitable services and poor clients.

Privatization: The Increase of Co-Payments for Public Services and the Growth of Private Services

Co-payments

As government financing of public health services decreases, consumers co-payments increase, and the result is a lessening of equality. The latest available figures - for 1995 - show that the share of total household outlays for medications, co-payments and private physicians and dentists in the national expenditure on health has remained stable at between 25% and 29%. However, there have been increases in payments for specific services. In 1995, co-payments for services provided by the health funds in the framework of the uniform benefits package constituted 6% of the total cost of those services (Ben-Nun, 1996: 26). This figure is expected to increase with the implementation of additional copayments in 1998.

Consumer co-payments constitute 10% of the cost of the services provided by the Israel Ministry of Health. These include payments for hospitalization in psychiatric and geriatric institutions, for treatment for drug or alcohol addiction, and for visits to outpatient clinics, as well as payments at Mother and Child clinics for childbirth preparation, for inoculations, and for IUDs (Ben-Nun, 1996:13-14). They have increased in recent years, in the face of budget cuts (ibid: 12). The greatest proportional increase has been in the total co-payments for nursing homes, which rose by 340% between 1975 and 1992 (ibid: 9), due to the needs created by population aging (More recent figures are not yet available).

Private Health Services

Private services include dental clinics, private health insurance plans that supplement the public services, alternative health services, private doctors and private hospitals.

Data on these health services is spotty. Regarding private health insurance plans, a study conducted by the Brookdale Institute reported an increase in private premiums between 1991 ,when these constituted 2% of the national expenditure on health, and 1993, when their share increased to 3.4%. Likewise, the percent of the population of Hebrew speakers aged 22 or above purchasing commercial insurance increased from 13% in 1990 to 16.7% in 1995 (Gross and Bramli, 1996: 38); 54% of policies included dental insurance, and 25% surgery and/or consultations with private physicians (ibid, abstract). This item is expected to increase following the Budget Reconciliation Bill of 1998, which stipulates that insurance for geriatric services be sold only by private companies, effectively ruling out the possibility of including long-term care under the National Health Insurance Law - the original intention of the lawmakers. It is also increasing due to the fact that foreign workers are not covered by the National Health Insu rance Law: their employers are required to purchase private health insurance policies for them.

In 1995, dental care, most of which is private, constituted 12% of the national expenditure on health and about half of the household expenditure for medical services and medications. This expenditure has remained stable over time and is expected to remain high, as there are no plans to integrate dental medicine into the National Health insurance Law, aside from special services for school children and senior citizens.

No quantitative data on private, alternative medicine is available; we do know that public hospitals have been developing private, ambulatory care, and that this care includes an expanding range of alternative services. As for private hospitals, the available evidence seems to contradict the "common knowledge" concerning the large increase in the share of private facilities. Between 1950 and 1996, the proportion of private institutions remained more or less stable, accounting for about 38% of total hospitals; during the entire same period, the percentage of private beds increased from 19% to 24% of the total beds. Breakdowns for psychiatric and long-term care beds actually showed a slight decline: in 1984 private beds constituted 41.5% of the total psychiatric beds in Israel, whereas in 1996 they accounted for 36%; the picture for long-term care beds is similar: in 1984 they constituted 41.7% of the total beds, and in 1996, 39.5% (CBS, Statistical Abstract of Israel, various years). In 1996, there were 104 pr ivate for-profit hospitals in Israel (CBS, 1997a: Table 24.5); most private beds were concentrated in nursing homes and psychiatric hospitals.

The question is how different types of privatization and cost increases for households affect equity in health care. In most democratic states, social services, including health care, are financed by a combination of the government (through taxes, of course) and the consumers, though Israeli consumers pay comparatively more than those in OECD countries (Ben-Nun, 1996: 6). Whereas government financing reflects a commitment to meeting the health needs of citizens which would not be met if health care was sold on the open market like any other commodity - a commitment affirmed in the passage of the National Health Insurance Law - decreasing government financing and increasing privatization reflect a retreat from that commitment. While public health services increase the income of those in the lower income brackets and therefore increase social equity, privatization has the opposite effect. The present trends of (1) decreasing government financing of the National Health insurance Law, (2) transfer of public goods and services to private non-profit or profit-making bodies, and (3) increasing co-payments for public services do not augur well for equity in health care. Moreover, they have no potential for closing the gaps in health care delivery between rich and poor; neither are they targeted at the specific needs of women or of Arab citizens of Israel.

Social Services and Taxes as Percentage of Household Expenditure

                                        Sweden  United States

Health, education and private pensions   2.7%       18.8%
Daycare                                  1.7%       10.4%
TOTAL                                    4.4%       29.2%
Taxes                                   36.8%       10.4%
TOTAL OUTLAY                            41.2%       39.6%

Source: Gosta Esping-Andersen, 1998, "The Inequality-Employment
Trade-Off in Postindustrial Economies: Towards a Pareto-Optimal Welfare
Regime," paper presented at "The Welfare State at Century's End: Current
Dilemmas and Possible Futures," Tel Aviv University, May.
Cost and Utilization Rates of a Public and a Private Health Care
Service: Dental Health and Well-Baby Care

                               Utilization  Cost as Proportion of
                                  Rates     National Expenditure
                                                  on Health

Preventive Care for Infants -      95%                2%
 Public Service
Preventive Dental Care -           25%               12%
 Private Service

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