Reading Obamacare In Jerusalem
I lay no claim to expertise, wonkish or otherwise, when it comes to health care financing or policy yet, observing the furious debates around Obamacare from here in Israel has been a curious thing. That's because I live in a country where socialized medicine is taken for granted, offers many advantages and, while it has some real problems, is far removed from the ghoulish nightmare of 'death panels' and dystopian hells of health care rationing that seem, from here at least, to be standard fare in the American media.
The origins of Israel's health care system date to pre-state days, when various workers' parties had their own health plans, which carried over into the new state. Starting in 1973, employers were required to contribute to their employees' health plans; 1995 saw the enactment of the National Health Insurance Law. Under the law, every citizen chooses one of the four national health plans as his or her provider (with the possibility of changing plans once a year), the plans are not allowed to turn away any prospective customer (i.e. preexisting conditions don't matter) and each has to provide a basic 'basket' of services (formally and awkwardly translated as the Uniform Benefits Package). The system is funded through a tax administered by the national Insurance Foundation (the local version of the Social Security Administration), as well as by modest co-payments and supplemental insurance if you so choose. Hospitals are publicly funded, but also do their own fundraising. (Remember the Hadassah Ladies we grew up making fun of? They built this.) Recent years have seen an increase in private sector health care, to, inevitably, the relief of some and discomfiture of others.
We have here all the makings of the hell on earth described by Obamacare's critics. Taxes, unelected panels deciding which life-saving treatments go into the health basket and for which you'll have to go out of pocket, mandatory health insurance without regard to preexisting conditions. The net result is just harrowing: Israel has the fourth highest life expectancy in the world (The US, in case you don't already know, is listed at 38, trailing not only the usual suspects, but also Puerto Rico and the Virgin Islands.)
Of course, one can't compare Israel to the US in terms of sheer scale and complexity. What's more, the Israeli system has definite drawbacks, and they're the ones you'd expect: Not everything gets into the health basket; you may have to wait longer than you'd like for an appointment; while you have some freedom to determine who will treat you, your options are limited to the doctors on your plan; the doctors are regularly overworked and underpaid (nobody here goes to medical school to get rich), and bedside manner is less a mark of professionalism than a sign of grace. When my wife was expecting I dutifully accompanied her to her obstetric appointments; we went from one doctor to another trying to find one who was halfway pleasant to deal with—and though we did find one in the end, she, like all the others, never so much as acknowledged my presence. You know those hopelessly self-parodying "What to Expect" books that guide over-educated middle class folks through the life events that extended families used to help us with? In a mix of escapism and comic relief, I would read their messages from another, coddled planet ("Now you've got to decide which kind of medical practice you'd be most comfortable with…" "Of course…mention the pain – like all pain – to your practitioner at your next visit so you can be reassured…")
There are other, deeper problems—and they may well derive from Israel's starting to follow America's lead. As public health spending has been declining relative to the rest of the OECD, and more like the US, costs have been rising and the system becoming less efficient on the whole.
The upsides, though, are powerful. When one of our nieces contracted terrible cancer she received world-class medical treatment nearly for free. Israel's hospitals are like everything else here—the mediocre ones are just that, and the best are among the best in the world. (They are also oases, where Jews and Arabs of all kinds interact as equals.) And there's another upside—it may take me longer to get an appointment, but I know that everyone will get one.
That last point seems to be a crucial difference and the place to begin if you want not only to think about health care, but with it, as a signifier of deeper currents in both Israel and the US. Israel's ethos is, still today, more collectivist, asserting strong claims of social solidarity, rooted, for better or worse, in a sense of national community. There are, to be sure, Israelis who opt for strong individualism, but they rarely if ever justify it as being the truest realization of their republic's ideals, which is exactly the claim of the American argument against Big Government (at least those who argue honestly).
Israel does have much to learn from America's robust version of personal freedom; and America may have what to learn from Israel and others about how guaranteeing the fundamental, bare minimum well being of all its members, is not freedom's contra, but precondition. Maybe both need to learn more about what Talmudist Aryeh Cohen, in his terrific new book Justice in the City calls "the community of obligation" in which my responsibilities for others are not impossibly absolute but proportional and " my proportional obligation is mediated by the polis, the institutions of the city which are, or should be, the institutions of justice." With liberty—and justice—for all.