If there is anything of value that I have learned in more than 40 years of studying public policy, it is the value of simplicity. If it is not simple, it probably will not work as advertized.
There is no better demonstration of this than the mess of health insurance provided to Americans who think that they are insured. In other words, a serious problem is not only in the 15 percent or so who have no insurance. It is in the case of who knows how many Americans whose health insurance is too complicated for those who need to benefit from the coverage.
One manifestation of this appears in a recent New York Times article that follows the plight of a social worker whose job is to help clients sort through their bills and the demands of care providers, pharmacies, medical laboratories, and hospitals, plus the insurance companies and government programs that are supposed to pay some of the costs under definitions too complex for many mortals. Those who suffer most are the old, poorly educated, people unfamiliar with the language, and in need of care. (http://www.nytimes.com/2007/12/18/health/18tren.html)
Even more chilling is the story of an attorney, the father of a personal friend, who could not manage the paperwork shortly after retiring from a career close to the pinnacle of a major social service agency in Washington.
My curiosity led me to surf the internet, shopping for coverage as if I were a 50 year old with a spouse and two minor children.
The complexities were profound: numerous options associated with varying monthly charges, choice of care givers, co-pays, and deductibles. In cases where the monthly payments were in the range of a few hundred dollars, the annual deductibles were so high that it seemed likely that the plans would amount to no insurance at all.
An intelligent and healthy 50 year old, with the help of a spouse having similar traits and no problematic children would seem able to manage the paperwork. But what would happen 20 years on, when the couple needs more care, and may be overwhelmed with confusing requirements and their own increasing confusion?
Israel is not a perfect society, and its health system is not Paradise on Earth. But simple it is, and thereby scores reasonably high on effectiveness.
To begin with, every resident is a member of one of four HMOs, whose programs are similar. There is a medical tax that pays for basic coverage. It is collected by the government, graduated by income, and withheld from salary in the case of wage earners. Seniors get the benefits without the tax. The basic coverage includes medications, with a small co-pay, as well as all tests. Certain tests require a co-pay equivalent to $3.50. Most blood tests require no co-pay. A visit to a specialist costs the equivalent of $3.50; and if there is more than one visit to the same physician in a quarter, the subsequent ones are without charge. There is no charge for visit to a family physician.
There are options with respect to supplemental insurance, which give preference in terms of waiting times to see a specialist or have surgery, choice of surgeon, as well as nursing home coverage, and coverage of operations overseas that cannot be performed in Israel. Almost all the country's physicians, hospitals, and laboratories are wired into the system, and usually sort out for themselves who pays how much. To our sorrow, Varda and I have had the usual experiences of the aging, and have learned more and more about the costs and complexities. Nothing in our experience approaches the American system in the outlays to the clients or the complexity.
All the supplemental insurances for Varda and I, plus what we pay for medications, and visits with specialists, cost us about $150 per month.
There are problems. Not all of the newest and most expensive medications are included on the list that is covered by insurance. Each year a committee of medical experts, bureaucrats, politicians, and patient advocates quarrels about what to add and how much to demand from the government treasury to cover the costs. There are not enough spare parts for all those who need replacements for their kidneys, hearts, lungs, or whatever. Opportunities are greater for residents who live close to major hospitals than in outlying areas. Not all of our physicians are geniuses, or as loving as one might wish. We do hear in the media of the unfortunate who fall through the cracks.
If the bottom line is longevity, the statistics provide some indications of success. The most recent available Israeli data show life expectancies for Jewish women to be 82 and men 79 ; life expectancy for Arab women is 78 and men 75. American life expectancy for white women is 80 and white men 74. For blacks and others the figures are 76 for women and 69 for men.
The planes are still flying. For all our aging American friends, it may be too late to benefit from all of the increased life expectancy promised by Israeli medicine. The reduced paperwork has its own advantages. But remember, most of it is in Hebrew.