Circles of Exclusion: The Politics of Health Care in Israel

1 The Israeli Health Care System

1 The Israeli Health Care System An Overview A group of old men meet everyday in the waiting room of one of the Israeli sick funds. Day after day, they gossip, talk politics, argue, and joke. One day they all realize that they haven’t seen Moshe, one of the regulars. Astonished and worried, Yaakov asks Pesah, “What happened to Moshe? Why didn’t he come today?” “Well,” Pesah, replies without the slightest irony, “Today he is not feeling well. He’s really sick.” As with many jokes, this one reveals much about the institutions it seems to mock—in this case, the sick funds in Israeli society, especially during the country’s first four decades. In Israel, sick funds were designed not only to deliver health care services but also to serve as a cornerstone in the construction of the Israeli’s sense of belonging to a new society. The strong links among the sick funds (especially the Kupat Holim Clalit and the Kupat Holim Leumit sick funds), political parties, and workers’ organizations gave them a central role in the configuration of individual and collective identities and in the distribution of political power and resources in the newly The Israeli Health Care System 17 developing state. These political and cultural affiliations have also been part of the definition of who belongs and who is excluded in Israeli society. Today, Israelis receive their health care from a public, single-payer system . Four public, nonprofit health organizations—called “sick funds”—are responsible for the provision of health care services. In what was from its inception a fragmented system, whose diverse institutions have little vertical or horizontal integration, actual health care services are provided by several institutions: the sick funds themselves, state hospitals, city hospitals, and hospitals belonging to nongovernmental organizations (NGOs). The current configuration of the Israeli health care system has been reshaped by the contradictory combination of a privatization process that started in the late 1970s and the legislation of the National Health Insurance law in 1994.1 The fact that the Israeli health care system is both public—that is, inclusive—as well as exclusive and fragmented is a result of the way it developed during the Ottoman period, the Mandate period, and the period after Israel became a state in 1948 in which health care, like all other social and political institutions—was dominated by the Histadrut (General Workers ’ Union). The fundamental influence on the Israeli health care system has been—not surprisingly—the conflictive process through which the state of Israel emerged. Thus, critical to any understanding of how the system works today is a consideration of Israel’s history—particularly its Zionist roots. Zionism was a reaction to centuries of prejudice and persecution that Jews faced in the Diaspora. In the late nineteenth century, Theodore Herzl, a Hungarian Jew, believed he had found a solution to the persecution of the Jews in Europe and elsewhere. Since even the most enlightened European countries exhibited periodic outbreaks of anti-Semitism, Jews, Herzl argued, should accept the inevitable. As the revisionist historian Avi Shlaim has written , “Assimilation and emancipation could not work because Jews were a nation. Their problem was not economic or social or religious but national. It followed rationally from these premises that the only solution for the Jews was to leave the Diaspora and acquire a territory over which they would exercise sovereignty and establish a state of their own” (Shlaim 2001, 2). Herzl’s Zionist vision was a product of the emergence of nationalism in Europe. For romantic nationalists, a people—whether Italian, German , Hungarian, Russian, or, in this case, Jewish—constituted an organic unity, bonded by blood and cultural links. What the Jews, like other nation ’s clamoring for their own state, lacked was a homeland in which they 18 Circles of Exclusion could build separate Jewish political, economic, and cultural institutions that allowed them to freely express this connection. What they needed in short was a Jewish state. Herzl himself was not committed to creating that homeland in Palestine. Uganda and even Argentina were briefly considered . But the pull of the biblical land of Israel proved too strong for many to resist, and Palestine—a place that was, Zionists insisted, “a land without a people for a people without a land”—became the location of choice. This formulation, of course, ignored the existence...