Everybody has an opinion on healthcare reform. And as the debate accelerates, international allies have stepped up to offer advice. Specifically, representatives of Israel recently spoke out about how that country's successful universal healthcare system is worth examining for reference, if not as a model.
"If you ask me if Israeli healthcare hook, line and sinker can serve as a model for U.S. healthcare, I'm sorry that my short answer to your question would have to be no," said Bruce Rosen, MD, director of the Smokler Center for Health Policy Research, Myers-JDC-Brookdale Institute (Jerusalem). "There are too many structural and cultural differences. In fact, I don't think any one country's healthcare system as a whole can serve as a model for any other country. On the other hand, looking into the healthcare of other countries can be very helpful particularly at terms of ferment and possible change such as what you're going through right now in the U.S."
Rosen was one of three speakers in a teleconference last week – Healthcare in Israel: A Model for the U.S.? – sponsored by The Israel Project (TIP; Jerusalem), an international non-profit organization devoted to educating the world about Israel.
TIP reports that 100% of Israelis have full healthcare coverage. All citizens are required to join one of four healthcare funds but may also elect to purchase other forms of supplementary healthcare. The country's system is based on regulated competition among those four government-funded health plans compared with hundreds in the U.S. In Israel, the government pays for or subsidizes unaffiliated and even competing healthcare funds and medical research initiatives. It's illegal in Israel to turn down any healthcare applicant for any reason. On average, Israel spends about $2,000 per citizen on healthcare financed through taxes, compared to $6,000 in the U.S.
Another huge difference: "Most of our doctors are salaried so we don't have those perverse fee-for-services incentives," Rosen said.
But one of the biggest efficiencies behind Israel's healthcare system, Rosen said, is that every doctor uses electronic healthcare records (EHR).
"The basic philosophy in Israel is that the government ought to take care of financing to ensure access and equity so the nine governmental sectors, most non-profit, ought to take care of most of the healthcare delivery, that ensures responsiveness and choice," Rosen said. "Our government also plays an important regulatory role to make sure that the insurers and hospitals are really offering what's in the best interest of the population. They should do so while containing costs. This leaves a lot of room for innovation on the part of the providers."
Another speaker during the teleconference was Alex Leventhal, MD, director of the Department of International Relations, Israel Ministry of Health. Leventhal previously served for more than 15 years as the head of the Public Health Services in the Ministry of Health. He pointed out that one of the key tenants of the Israeli health system is that it's mandatory.
"We believe that voluntary insurance is not enough," Leventhal said. "There is a need for a law. We had 5% of people who were not insured 15 years ago, and we created a law in Israel in order to solve this problem about accessibility and a provision of medical care to all the citizens of Israel. Although, the situation in the U.S. is different, you have people who are uninsured."
Stephen Zuckerman, senior Fellow, Health Policy Center, The Urban Institute (Washington, DC) provided an American perspective on the Israeli system and how some of its attributes could be copied in the U.S.
"One thing that Bruce points out is that the basic philosophy is that the government ought to take care of financing and leave the non-governmental sector to take care of healthcare delivery," Zuckerman said. "In fact, I think that is exactly what the U.S. is going to do. Whether or not the financing is going to be sufficient to lead to universal coverage as the Israelis guaranteed remains to be seen, but I think the basic idea that the government is going to have to provide subsidies to low-income populations either through an expansion of our own Medicaid programs or through vouchers or tax credits or other types of subsidies that would be available to purchase private health insurance seems to be a given if we're going to really move forward and expand coverage in the U.S."
Just how successful is the Israeli system? The United Nation's 2006 Human Development report ranked this tiny country among the top 10 in the world with the highest life expectancy at birth. TIP reports that the average life expectancy of all Israelis is 79.7 compared with 78 in the U.S. and 78.7 in the U.K. Other populations in the Mideast region have much lower life expectancies: Syrian and Iranian citizens live on average 70.6 years.
Zuckerman pointed out that "a great deal of regulation" is required for universal healthcare to prevent health insurers from "behaving badly as health insurers can sometimes do.
"I think one thing that is quite different in the U.S. right now in the debate is that Israel's four health insurance plans are largely privately run plans and in the U.S., because of the hundreds of private insurers, I think there are some people that believe that in this mix of insurance plans you also need to have a public option," Zuckerman said. "To some extent, the largest Israeli plan may be viewed by some people as this public option, but I think in the U.S. we are going to have this additional twist or at least a debate over this additional twist but that remains to happen."
And how does this tiny country manage to provide coverage for all citizens at $2,000 each compared with $6,000 in the U.S. where a large percentage of the population still isn't covered? For starters, the cost of living is lower in Israel. But Leventhal also pointed out that the country's Minister of Finance is heavily involved in cost containment.
And although Israel's universal healthcare system doesn't have the long waiting times associated with universal systems in the UK or Canada, there are some problems when it comes to copayments and drug costs for low-income citizens.
"My hope and my belief is that Israel will address those in the next few years," Rosen said.