JERUSALEM — The lack of affordable health insurance in the United States is one of the top issues in that country’s presidential campaign (along with Iraq and the economy). As I write this entry, nearly 50 million Americans have no access to health-care.
For the ten months prior to my move to Israel, I was one of them.
I developed bronchitis shortly after I moved here. Luckily, I was able to use Israel’s universal health coverage since I am a dual citizen. Still, I had never used Israel’s system before, so I did not know what to expect. In the end, the experience revealed the positives and negatives of the free-market and universal health-care systems.
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After I realized that I had developed something more than a simple cold, I walked five blocks to the local health clinic (pictured above). After registering at reception, I sat in line to wait. There were roughly fifteen doors, and behind each of them was a small doctor’s office. I sat down to wait at Door Number 13. (I’m not kidding about the number.)
When it was my turn, I went inside and sat down. I glanced around the room, and I was shocked to see the condition of the place. The machine that measures blood pressure looked like it was many years old. The stiff bed on which patients can lie down was ragged, and the thin, white sheet on top was torn, and it looked like it had not been changed in days. The air-conditioning unit was rusted and broken.
Well, I thought, at least I had a simple condition. It would be easy to get the diagnosis, get some antibiotics, and then go home — right? Wrong.
The doctor was a Russian immigrant whose only other language was Hebrew. I spoke very little Hebrew, and the only other language I knew was French. The resulting exchange probably looked like it was from a bad movie. Here, in English, is what I told her in Hebrew:
“I have bronchitis. It is bad here (pointing to my chest). Yesterday it was not bad here (pointing to my forehead). Today it is a little bad there. Today I do this all the time (pretending to cough). Yesterday I did not do this.”
After hearing my symptoms, the doctor motioned for me to rise and take off my shirt. She listened to me breathe, and then she printed out a piece of paper. I took it to the reception desk, and the woman there told me that it was a referral to another clinic just down the road. I did not need to pay anything. (However, it was 1 p.m., and the next clinic was not open until 5 p.m. Since when do hospitals close?)
As it turned out, I needed the authorization from the initial doctor in order to get significant care at a major clinic. (I presume that the major clinics need initial authorizations so that people do not waste a public resource’s time with minor headaches or cases of hypochondria.) The second clinic was amazing: modern, clean, high-tech facilities. And, best of all: There was no line! I had an X-ray taken, and the diagnosis of bronchitis was confirmed. The doctor wrote a prescription, and I was out of the door in twenty minutes. I did not need to pay anything.
But before I continue the story, I need to mention one other occurrence at the second clinic. For years, I’ve had a minor, reoccurring condition. (I’ll spare my readers the details.) Every time that I needed to get a prescription to treat the issue, I needed to go to the doctor. He would take a test, and he would then send it to a laboratory to be analyzed. The laboratory would send the results to my insurance company, and then they would approve the prescription. The whole process could take weeks.
While I was at the second clinic in Jerusalem, I decided to see if I could get the prescription in addition to the antibiotics for the bronchitis. I told the doctor the name of the medicine, and she wrote the prescription right there. She had specified a two-week quantity of the medicine, but I asked her for one month’s worth. She wrote a new prescription, and then she handed it to me. And that was it.
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But the story does not end there. After spending a morning and early afternoon at two clinics, I still needed to get the medication. After all, I felt horrible — and all of the running around was doing little to help. The receptionist at the second clinic asked me if I knew where a pharmacy was located, and I told her that there was one a few blocks from my home.
I walked to the pharmacy, and the pharmacist told me that I would need to pay full price for the medicine. What? As it turned out, that pharmacy did not take my specific insurance group. (Although Israel has national health insurance, each person can choose from several specific programs.) I needed to walk fifteen minutes down the street to a pharmacy located in a different mall — my insurance, he said, would be accepted there.
I walked to the mall, entered the pharmacy, and waited in line. After a brief argument with a woman over whether she was next in line, I finally gave my prescription to the pharmacist. He filled it, and then he walked to his computer to finalize the transaction.
He also told me I would have to pay full price. I was too tired — and livid — to keep arguing. I had been in clinics and pharmacies for hours.
I called an Israeli friend of mine, and she spoke to the pharmacist (in Hebrew). As it turned out, my insurance group had not updated their computer database that is accessed by private pharmacies to say that I was a member — even though I had registered more than a week ago. My only option at that point was to pay full price. So the pharmacist recommended that I purchase individual pills to take over the next two days until my insurance was straightened out. So I bought four antibiotic pills for NIS 32 (roughly $8).
The next morning, I walked back to the very first clinic that I had visited (pictured above). No one had even bothered to tell me that a pharmacy was located there! I received both prescriptions in full — but I did have to pay more than I would have done in the United States. The total came to NIS 320 (roughly $80). Israel’s national insurance covered half of the cost, so I had to pay NIS 160 (roughly $40). This was twice as expensive as prescriptions generally cost in the United States, where co-pays are usually $10 to $20 per medication.
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My story, of course, is not typical of countries with universal health insurance. Since this was my first time using the Israel’s health care, I was completely lost. No born-and-raised Israeli would have needed to go through such a hassle to receive something as minor as antibiotic pills for a case of bronchitis. I just did not know how to navigate such a complex system.
However, I did observe enough to see its positives and negatives. Yes, Israel’s universal health-care program is frustrating, time-consuming and bureaucratic. (It’s just like waiting in line at the Department of Motor Vehicles in the United States.) And some of the facilities are not the most modern.
However, the fact remains that I did receive the basic care I needed — although I did have to pay a little more for medicine. A person in the United States without health insurance would never receive care for bronchitis. Still, the fact also remains that Americans with health insurance receive care in the United States that is usually better and quicker. (I’m not counting the times when insurers dictate what remedies people can receive, as in the personal example I described earlier.)
As a result, there are pluses and minuses to each system. However, the core issue still remains: Which is the best means to have a healthy population? In general, there seem to be two options (based on my experiences in the United States and Israel):
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Everyone receives health insurance, but the quality of service is moderate for everyone and prescriptions are a little expensive; or
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Those who acquire health insurance receive excellent care and cheap prescriptions, but those who do not have it receive nothing at all.
Which one would you prefer? The former is universal health-care, while the latter is a free-market system. Conservatives like Keith Burgess-Jackson support free-market systems and argue that no person should be forced to pay for another’s health care. Liberals generally argue that everyone has an inalienable right to health care. Who is correct? As frequent readers know, I tend to be a conservative on fiscal issues. So it may be surprising that I favor universal health-care, and that I do so out of economic, social and philosophical considerations.
First, the social and philosophical ones. Burgess-Jackson’s argument falls apart when one compares it to another public service: Fire departments. If I accept his point, I should protect my house against fire, my neighbor should protect his, and I should not be forced to pay to protect his house. This is ludicrous. Society, of course, has a common interest in preventing fires, so society pools its resources together through taxes. It is society’s responsibility because fires can spread one from house to another. However, the effects of a lack of health care also spread throughout society. In economics terms, it is a mistake to treat health care as a consumer good. It is preferable to let the market determine the price of televisions; no one needs them to survive. But everyone needs health care. It is irresponsible to let the markets control everything in society.
Second, the economic considerations. In the United States, most people receive medical insurance through their employers. Every penny that businesses spend on insurance for their employees is one that they cannot spend on wages, investments, capital, and research. When the government provides health insurance, businesses are more free to spend money on these items and do what they usually do best: Grow the economies in which they are located. A healthy society is a productive one, so the economy improves when everyone has health insurance.
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The reality is that people with health insurance tend to favor free-market health care because the quality of the service is better, and people who lack insurance usually favor universal health care because it is sometimes the only way for them to acquire coverage.
But what system benefits society the most? I would argue that it is best to guarantee that all people have a basic, moderate level of health care rather than for some people to have excellent care while others have none at all. In the latter example, the presence of people without health care increases the likelihood that disease will spread, that people will be less productive, and that more people will be unhappy. All of these are less likely to occur when everyone has a certain level of assured care.
Perhaps that’s why Israelis generally live nearly two years longer than Americans.
Later: The debate over health-care reform in the United States and Economic Reasons for National Health-Care.