Groups with special needs.
In 1996, there were 543,300 persons over the age of 65 in Israel, constituting 9.6% of the total population, and 219,300 persons over the age of 75 (3.85% of the total population) (CBS, 1997a: Table 2.10). In OECD countries, the average proportion of the 65+ cohort is 13%; in Sweden it is 17.6%, in the United Kingdom, 15.7% and in Switzerland, 14.2% (Ben-Nun and Ben-On, 1996: 3). It is well known that health problems increase with age, and that the average per capita outlay for persons over the age of 65 is about 4 times the average expenditure.
What is less well known is the fact that 58% of persons aged 75+ and 70% of elderly inpatients are women. Although Israel's population is young compared to that of most OECD countries, the 75+ cohort is growing, and, with it, the need for community services for the elderly and long-term geriatric beds.
Among immigrants from the former Soviet Union, the proportion of the elderly is higher than in the general population (14%, compared with 9.6%). Elderly immigrants report suffering more than veteran Israelis from hypertension, chest pains, shortness of breath and arthritis (Neon et al, 1993). However, a 1998 analysis of data from four national surveys found no difference between veteran and new Israelis in either the incidence or types of chronic diseases for which they reported actually receiving treatment (Niral et al, 1998: 104). Thus, either the difference is a subjective one, or elderly immigrants are not receiving (or not reporting on receiving) the treatment they need.
A 1990-91 study of 70-year olds in Jerusalem identified another group with special health care needs: women of African-Asian origin, whose rate of hypertension was found to be 63%, compared with 43% for women of European origin. Bursztyn et al suggest that this may be due to the higher body mass index in women of African-Asian origin (Bursztn et al, 1996: 632). While high levels of awareness and treatment were found, according to the authors, this awareness was not translated into adequate control of hypertension levels (ibid: 633).
In Israel - as elsewhere - services for the elderly suffer from fragmentation: The National Insurance Institute (Social Security) is responsible for home care, the Ministry of Labor and Social Affairs for placing physically frail elderly persons in homes for the aged or sheltered housing, and the Ministry of Health for care of mentally frail seniors or those in need of nursing homes.
Most geriatric care is provided by female family members. The proportion of elderly who obtain assistance solely from family members is higher among Asian- and African-born Israelis than among the American and European born Israelis (Walter-Ginzberg et al, 1997:11), among immigrants from the Soviet Union than among nonimmigrants, and among Arabs than among Jews (Be'er, 1996). An estimated 70-75% of the aged who need assistance in carrying out daily functions from agents outside the family obtain it within the community (Swirski, 1997: 16).
The Long Term Insurance Benefits Law, which came into effect in 1988, greatly improved home care for elderly citizens. It provides a maximum of 10-16 hours of home care a week on a nearly universal basis for persons over the age of 65 who have difficulty carrying out daily functions. In June 1998, 80,500 persons were receiving benefits under this law, 73% of them women (National Insurance Institute, 1998b: 63).
The proportion of senior citizens receiving home care in Israel is high relative to that in other countries - 10.7%. In contrast, the proportion of senior citizens receiving long term institutional care is relatively low. Assuming that in 1994 all existing beds were occupied (which they were not), 4.5% of Israeli elders were receiving institutional care - compared to the average rate of 5.5% in twenty OECD countries (Swirski, 1997: 18).
This finding may be connected to the fact that the benefits package under the National Health Insurance Law does not include long-term nursing care for the elderly. The Ministry of Health has a special budget to assist those who require but cannot afford this care. Pursuant to functional and financial screening, the Ministry provides a monthly payment (based on the patients' income and that of their spouses and children) to cover the difference between the actual cost of care and a co-payment determined on the basis of patients' financial resources.
In 1990, 68% of long term care and mentally frail patients in geriatric institutions were receiving government assistance. Although the Health Ministry assistance budget is sizable, it falls short of need. In June 1997, 2,300 patients - about 25% of those identified as requiring institutionalization in nursing homes - were waiting for government assistance. Thus senior citizens who require inpatient care because of an acute but transitory problem such as a fracture, pneumonia or a cerebral event, obtain it from their health fund. In contrast, senior citizens who need long term care because they have become bedridden or have lost their memory or sense of orientation may find themselves footing the hospital bill themselves, because this service is excluded from the benefits package.
New Immigrants from Ethiopia and the former Soviet Union
Between 1989 and 1996, some 600,000 immigrants came to Israel from the former Soviet Union and about 35,700 from Ethiopia (CBS, 1997: Table 2.22). As Soviet immigrants comprise about 10% of the population, any special health needs they may have are likely to impact on the health care delivery system. And while Ethiopian immigrants constitute a much smaller minority, they come from an area of the world in which diseases relatively rare in Israel, like malaria, AIDS and tuberculosis, are endemic (tuberculosis is also found in higher proportions among Soviet immigrants), and thus their health needs require special attention. Additionnally, the distress of immigration has had negative health effects on both groups, necessitating awareness and outreach on the part of mental health professionals, as well as culturally appropriate care.
With regard to Soviet immigrants, a study of national survey data found that immigrants up to the age of 64 appeared to suffer significantly more than veteran Israelis from heart disease. A higher proportion of immigrants also reported mental distress, though a lower proportion reported utilizing mental health facilities. Immigrants over the age of 50 also reported suffering from more handicaps than veterans. Some of the differences between immigrants and veteran Israelis may be connected with the stresses of immigration (Nirel, 1998), but others clearly require attention.
To date, no systematic study has been made of the health needs of new immigrants from Ethiopia. Their relatively high rate of infectious diseases has been pointed out by a number of researchers (for example, Epstein, 1996: 70). A higher rate of suicide has been noted among Ethiopian immigrants than among the general population (Arieli et al, 1994; Arieli and Ayche, 1993), as well as a high level of mental distress (in a local study of immigrants in Netanya), attributed to the trauma of immigration and the conflicts and stress caused by the immigrants' experiences as newcomers in an entirely different culture (Arieli and Ayche, 1993). No data are available on the comparative utilization of services by Ethiopian immigrants and other immigrants or veteran Israelis.
Palestinian Residents of East Jerusalem
In 1996, the Israel Ministry of the Interior changed its policy with regard to Palestinians living in East Jerusalem (annexed by Israel following the 1967 war), the purpose of which was to rescind the residence rights of as many Palestinians as possible. The new policy has had an adverse effect on rights to health care. In cases in which a Palestinian resident of East Jerusalem married to a non-resident gives birth, the infant is not automatically covered; the mother must file a special request - despite her membership in one of the health funds. The ensuing "investigation" may take a year or more, and in the interim, the infant is uninsured.
Likewise, residents of East Jerusalem who register for birthing hospitals are not accepted automatically like other residents of Israel; rather, they must first obtain confirmation from the National Insurance Institute of its willingness to cover the expense.
The spouse of a Palestinian resident of East Jerusalem whose former dwelling was outside of East Jerusalem does not automatically receive health insurance either. Again, an investigation needs to be conducted by the National Insurance Institute, leaving persons in need of care without it until the procedure is completed (Physicians for Human Rights, 1997).
In the summer of 1997, a quarter of a million foreign workers were employed in Israel, about 100,000 with permits and the remainder without permits (Kondor, 1997: 52). Foreign workers are not covered by the National Health Insurance Law. Their visas are contingent upon the workers being covered by private health insurance. The cost is $1- 1.5 a day, more than the amount paid by Israelis earning the minimum wage (foreign workers earn less) for coverage that is less extensive.
Human rights organizations in Israel have identified several problems with the health insurance arrangements for foreign workers: at the end of the insurance period, usually a year, the insurance companies do not renew the policies but rather obligate the employer to take out new ones. Since none of the policies cover treatment for illnesses incurred prior to the beginning date of the policy, any worker coming down with an illness is not insured for that same illness in the next insurance period. Other exclusions include chronic illnesses, self-inflicted injuries, AIDS, physiotherapy, and routine checkups.
Before a hospital will accept a foreign worker as an inpatient, it requires confirmation from the insurance company that it will finance the hospitalization. Whereas hospitals cannot refuse a foreign worker emergency treatment for an acute problem, due to, among other things, the Patient's Rights Law, they can refrain from hospitalization if there is doubt about who will cover the costs.
An estimated 150,000 illegal foreign workers and their families, who live in Israel on a temporary or permanent basis, have no health insurance. The Association of Physicians for Human Rights estimates the number of children of illegal foreign workers in Israel at between 2,000 and 3,000 (Physicians for Human Rights, 1998). These children receive well-baby care in Mother and Child clinics and in schools and cannot be refused treatment in hospital emergency rooms. However, they and their parents have no access to specialist care or hospitalization. Theoretically, parents can purchase private policies for themselves and their children, but this is unlikely because of the cost. Moreover, companies refuse to insure children under the age of three, and none will insure children born with medical problems. In Holland, in contrast, all children of foreign workers receive medical care under the national insurance program after three months sojourn in the country, regardless of their legal status.
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|Publication:||Israel Equality Monitor|
|Date:||Nov 15, 1998|
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