Ahead of the decisive stage of the German Committee, chaired by Minister of Health Yael German, "Globes" revealed in a special investigation the projected positions of the committee members. As of now, the committee is almost equally divided, with a difference of just one vote in favor of private medicine, and two wavering votes.
The identities of most of the supporters of private medicine are not very surprising. The supporters include people with definitive neoliberal positions, such as Eugene Kandel. As far as is concerned, the wealthy deserve more rights. Israel Medical Association secretary general Adv. Leah Wapner supports private healthcare, in line with the association's position, which favors the interests of a thin layer of doctors over the interests of the general public in Israel.
Belying earlier assessments, the projected position of Yael German, as reported by "Globes", is surprising. Why is it surprising? First, because it goes completely against her party's position. Yesh Atid's platform states that the party supports "strengthening public medicine, so that the choice of private medicine is a right, not a necessity; to guarantee the complete separation between public medicine and private medical services." Second, in her decision to establish the committee, which is officially named the Advisory Committee to Strengthen the Public Health System, she created an opportunity to deal with two major problems that are jeopardizing public healthcare: the public health system's budget shortage, and the erasing of the line between the public and private health systems. If the results of this committee is the validation of private healthcare, it will be one of the last nails in the coffin of public healthcare.
It is necessary to understand that the budget shortage and the erasing of the line between public and private healthcare are two separate processes which reinforce each other. The budget shortage passes with no real opposition because supplementary health insurance and other forms of private/public combinations offer a relative solution for people who can afford it. This breaks apart the alliance between the middle class and the poor, an alliance on which the welfare state is built. The result of the budget shortage is a massive reduction in the basket of healthcare services, no infrastructure development, and a personnel crisis. (For example, Israel has the lowest proportion of nurses in the OECD).
The budget shortage is justified by the Ministry of Finance for the sake of streamlining, but this argument does not hold water. According to the OECD, Israel's public healthcare system is one of the most efficient in the world. Public spending per capita is around $1,400 a year, compared with the OECD average of $2,400. Nonetheless, healthcare output in Israel is among the highest in the world. As public healthcare adopts more patterns of private healthcare, efficiency will fall (the US healthcare system is the least efficient in the world).
The erasing of the border between public and private healthcare was the health funds and hospitals' response to the budget shortage, and it takes varied forms. Public hospitals have private healthcare services, medical tourism, special arrangements with private insurance companies for priority appointments, closer medical attention, and the sale of services that are not part the basket of healthcare services or the opening of private practices at public hospitals.
At the health funds, this blurring takes the form of supplementary insurance, which is private insurance for all intents and purposes, and by the strengthening of private hospitals (Maccabi Healthcare Services owns Assuta Medical Center Ltd. and Clalit Health Services owns Herzliya Medical Center). The result is that some doctors work at a public hospital in the morning and at a private hospital owned by a health fund and financed by supplementary insurance in the afternoon, and as independent doctors or at private practices in the evening.
This system causes inequality, the subsidizing of the private healthcare system by the public system (for example, through the training of medical staff and because patients with complications from private hospitals receive follow-on treatment at public hospitals), wastefulness of resources, and the carrying out of unnecessary medical procedures. There is also a conflict of interests because health funds send patients to their private hospitals, financed by the patients' supplementary insurance sold by the same funds, instead of to public hospitals, while hospitals give priority to patients who bring private financing and doctors direct patients in public hospitals to their private practices.
The result is a serious blow to public confidence in the health system. The heads of the health system are fully aware that the erasing of the line between private and public healthcare is a real threat to the future of public healthcare. The managers of large hospitals have meticulously described how supplementary healthcare has emptied the hospitals of their best doctors. Healthcare fund CEOs have meticulously described how the threat of private healthcare threatens the public system. The German Committee's job is to combine the right perspectives of both side and to come up with a possible unified solution: separation between the private and public health systems.
The "Globes" investigation found that German is considering a "softened" form of private healthcare as a kind of default option, because as she understands it, she will find it difficult to pass such an important decision for the health system by just one vote. However, experience shows that there is no such thing. Even before the decision to expand private healthcare to public hospitals is taken, we are seeing things which demonstrate that it is impossible to rein in private healthcare when it exists within the public system. Examples are the difference in waits at Hadassah Medical Center between private healthcare patients and ordinary patients, the scandal of payments to the director of the prenatal ward at Shaare Zedek Medical Center, and the medical tourism affair at Tel Aviv Sourasky Medical Center - Ichilov Hospital.
The Ministry of Health cannot function as a regulator of these incidents, not because of its limits, but because we're talking about two systems with fundamentally different logics. The public health system's purpose is to treat patients and money is a means to an end; whereas the objective of a private health system is to make profits for which medical care is the means. This means that there is no such thing as softened private healthcare. Public healthcare and private healthcare are like oil and water: just a few drops of oil in water renders it unfit for drinking.
What, therefore, is the alternative? A single act can solve the two major problems: increase the public resources so that the ratio between public and private financing will be around the OECD of 75/25, compared with the Israeli ratio of 60/40. To do this, the health tax should be raised. Israel's health tax is low in comparison with countries like France of Germany, which have a designated health tax. A 1% hike in the health tax would allow the expansion of the basket of healthcare services and make possible a degree of choice within the public health system. In practice, Israelis would not pay more for healthcare because such a tax hike would render the need to buy supplementary insurance unnecessary.
To save the public health system, German only has to listen to what the hospital managers say about supplementary insurance and what health fund CEOs say about private healthcare, and to be true to her party's platform and the good of the public, and to act accordingly.
Prof. Dani Filc is a senior lecturer in the Department of Politics and Government at Ben Gurion University of the Negev
Published by Globes [online], Israel business news - www.globes-online.com - on January 7, 2014
© Copyright of Globes Publisher Itonut (1983) Ltd. 2014