My Adventures in Socialized MedicineComments
A year ago today, I went to get a flu shot and inadvertently kicked off a medical odyssey that took up nine months of my life and ended up requiring surgery. It also gave me a more comprehensive view of the Israeli medical system, and I thought I’d write up my experiences and hopefully give you a sense of what dealing with socialized medicine is like.
(TL;DR: everything’s fine; it wasn’t cancer. Also, the following essay contains discussions of a gynecological nature, if that’s a big deal for you.)
But anyway, this starts with a flu shot. At the medical center near my home, flu shots are administered by nurses. But I prefer to use the center near my office, partly because it helps me avoid morning traffic, but mainly because it’s next door to a fancy bakery where I can reward myself for my virtue with coffee and a pastry. At that center, flu shots are administered by doctors. When the doctor on flu duty that day swiped my card and called up my file, she observed that I hadn’t done a routine kidney function test in a while, and promptly handed me a pee cup. If it had been a nurse, I might have tried to beg off, but a doctor’s authority was more persuasive, so I grudgingly did my business and went on with my day.
Before we continue, a few paragraphs on how the Israeli medical system functions. As we’ve talked about more than once on this blog, there’s more than one way for healthcare to be socialized, and the Israeli system is a kludge that combines elements of single payer, free market competition, and even privatized medicine. The reason for this is that, like a lot of Israeli institutions, the medical system predates the state itself. Zionist organizations arranging group immigration in the late 19th and early 20th centuries provided a lot of services for their members, including “health funds” into which members would pay and receive payment for care when necessary. The descendants of those funds are what Israelis use for healthcare today.
Israelis are born into their mother’s fund. It is possible to switch funds (though the fund you apply to isn’t obliged to accept you). But what’s important is that your fund can never kick you off. The base level of what the funds are required to provide, and the fees they’re allowed to charge, is set by the ministry of health, but most funds offer higher tiers of service in an attempt to attract members. In addition, funds compete for members by offering better facilities and more services (alternative medicine is a big focus here, as are dental care and eyewear).
The health funds receive most of their funding from the ministry of health, which in term gets its budget from state taxes. I’m in the 35% marginal tax bracket, and about 10% of my gross salary goes to health taxes. But before I started working I paid a flat rate of a hundred shekels a month (~$28.5) and received the same services. The ministry of health also administers what’s called “the health basket”, the list of medications, treatments, and medical devices that are subsidized by the state (which is to say, by money it transfers to the health funds) and to what level. The health basket is decided on by committees of doctors and ministry officials, and updated yearly.
The health funds function as a sort of mini-NHS towards their members. Up to a certain level, all medical services are handled within the fund’s facilities. This includes GPs, obviously, but also certain specialists, lab services, simpler imaging services such as ultrasound and x-ray, and even minor surgery. Within the health fund, the necessary precondition to receiving care is the referral. A member approaching their GP may receive a referral for tests, or for a specialist appointment, or for physical therapy. That referral represents the member’s right to access a service.
It’s worth noting that while the financial motivations for keeping most services in-house are obvious, the funds do contract out some of their medical work, to private clinics and hospitals. But the process for members is the same at all locations—make an appointment, swipe your card, present your referral, and you’re good to go. There’s a co-pay for specialized services, but it’s usually added on to the direct debit by which the fund’s regular fees are paid, so billing is invisible to the patient. (To get a sense of the co-pay rates: GP visit, 25 shekels or $7.13 per quarter; specialist visit, 29 shekels or $8.27 per visit; ultrasound test, 34 shekels or $9.7 per test. A lot of services, such as blood tests or nursing services, don’t even have co-pays.)
Obviously, past a certain point it’s no longer financially viable for each of the health funds to maintain its own separate system, which is where the public health system comes in. For these services—which include obstetrics, surgery, hospitalization, higher-complexity imaging, oncology, dialysis, and many others—the health funds pay the hospitals for providing them to their members. To access these services, a patient requires, in addition to the referral, something known as a “commitment” (or, in the old Israeli bureaucratic parlance, a Form 17). This represents the health fund’s commitment to pay the hospital for the service in question. The way it’s supposed to work (but doesn’t always) is, you present your health fund with a referral for a service they don’t provide, and they supply you with a commitment. You then present that commitment to the hospital, and at that stage your part in the billing process is concluded. This includes commitments which are, by their nature, undefined. If you arrive at a hospital for surgery, for example, your commitment covers all the services you might require during your stay, according to your medical needs and the discretion of the doctors treating you.
Finally, in addition to the health funds and the public health system, Israel also has a robust private medical system. Most middle class Israelis have supplementary health insurance that covers things like private surgery, out-of-network specialist appointments, and organ transplantation abroad (because Israel, being a small country, has a severe shortage of transplant organs). But a lot of these private hospitals also have deals with the health funds (some of them are even partly-owned by the funds). So it’s not unusual to be able to go to a private hospital using your state insurance.
What you end up with, then, is a system that is both heavily regulated and has a degree of competition baked into it. It’s far from perfect, and we’ll talk about some of its flaws later on, but it is, almost accidentally, an extremely robust way of doing things.
Anyway, back to my urine. The kidney function test came back anomalous (spoiler: my kidneys are fine) so my GP referred me to a nephrologist. He sent me to do every test known to man, including a cardiac stress test (administered at a private clinic), several ultrasounds (at my health fund’s ultrasound clinic the next city over), and some lab tests (at the medical center near my house). All came back normal, except that one of the ultradsounds showed a potential anomaly around my liver (my liver is also fine). The nephrologist kicked this back to the GP, who sent me for an abdominal CT (at a private hospital, part of a chain co-owned by my health fund). At this stage, as you might imagine, I was ready to swear off the entire medical profession, but then the CT revealed several massive cysts on my ovaries (and by massive, I mean 5-10 centimeters each).
I have a condition called PCOS, or poly-cystic ovary syndrome, so ovarian cysts in themselves are not surprising. What was concerning was that one of the cysts was not obviously a cyst (in fact, the original CT report called it “an elliptoid structure”, which would have been cool if it wasn’t inside my abdomen). My GP then sent me for a vaginal ultrasound (those are super-fun, by the way; it’s totally fine that women in the US are forced to have them before they can get an abortion) which revealed a “semi-solid structure, with calcifications”. A second, more sensitive ultrasound revealed blood flow towards the cyst, and a blood test showed that my CA-125, a marker associated with ovarian cancer, was slightly elevated. At this point, I was starting to freak out. (To reiterate, it wasn’t cancer.)
My gynecologist is out of network for my fund, but one of the advantages of going to her is that she’s a department head at a local maternity and gynecology hospital which, though nominally private, does have an agreement with my health fund. So I was able to get a referral to a well-regarded onco-gynecologist that was covered by my fund, and a surgical date within two weeks of meeting with him. Again, because this particular hospital works with my fund, all I needed to do when checking in was present a referral and my card, and that was it as far as billing was concerned.
The surgery itself was both not very fun and weirdly funny. Anxious as I was when they wheeled me into surgery, I couldn’t help but be amused at how the surgical team’s solicitousness and correctness clashed with their obvious goal, to truss me up like a piece of meat and render me unconscious so they could begin their work. Though we had hoped to leave the ovary with the problematic cyst intact, in the end the surgeon decided to remove it completely. The surgery was laparoscopic, which helped with the recovery—I was barely moving in the days immediately after the surgery, and at about 80% back to normal within a week. In the end, no matter how many medical advances we make, invasive procedures are never going to be painless or hassle-free, and what makes them tolerable is the kindness and compassion of medical professionals.
There followed a month of me quietly freaking out over my certainty that the pathology was going to come back positive. I wasn’t afraid for my life—if it was cancer, it seemed to have been caught early—so much as I was afraid that I would have to spend the next year fighting for my life. It ended up being something much less dramatic, however, a Borderline Ovarian Tumor, a type of tumor that is not cancer, but does spread if it isn’t removed, and for which the recommended treatment is only surgery, with no radiation or chemotherapy. What this means for the future is regular monitoring of the state of my remaining ovary (more vaginal ultrasounds, yay) and possibly a preventative appendectomy (or, as my surgeon put it, “if you have abdominal surgery for any other reason, tell them to take it out while they’re in there”; readers, I am not going to tell any surgeon to do that). All in all, a rather anticlimactic ending to an ordeal that took over my brain for the better part of the year.
To bring this back to the more general discussion of healthcare, here are the points I’d like to leave you with:
1. Get your flu shots, people. They might be more helpful than you imagine.
2. People with ovaries: pay attention to that general area. When I realized that I had ovarian cysts I looked up the symptoms, and realized that I had been experiencing them (and ignoring them) for more than a year. And while in my case there was no risk to my life, BOTs can spread through the reproductive system and even to the intestines and the bladder. I could have ended up needing more invasive surgery, losing my fertility, or suffering severe impact to my quality of life. That was all prevented by early diagnosis.
3. I want to stress that my experience with the Israeli medical system should by no means be taken as comprehensive or even entirely representative. In many respects, I am an extremely privileged consumer of that system. I’m young, generally healthy, and able-bodied. I’m educated and computer-literate and able to navigate the various websites and phone menus required to make appointments and schedule tests. I have a car, so I wasn’t reliant on Israel’s groaning public transit system to get to my various appointments and tests, and I work the kind of job where no one bats an eye if I show up late or leave early for a medical appointment. (For that matter, the only reaction I got when I announced that I would be taking three weeks’ medical leave was “feel better”; that’s what they’re required to do by law, but we all know that weaker workers have their rights ignored all the time.)
But by far the greatest advantage I had when dealing with a medical issue was where I live. The center/periphery divide in Israel affects access to many types of government services, and perhaps none more so than medical care. The health funds are required to provide a certain level of care, but there’s a lot less oversight when it comes to ensuring access—having enough GPs that patients can easily make an appointment, for example (and GPs, as you’ll recall, are the gateway to nearly all other services within the system), or easily accessible medical centers. The problem is only compounded when you leave the health funds’ ecosystem. From where I write this post, I am within half an hour’s drive of three world-class public hospitals, and at least half a dozen top-notch private ones. People who live two hours’ drive north or south of me, however, sometimes have only one hospital to go to, and in some cases not even that. The fact that I was able to access specialists, tests, and finally the surgery itself with the speed and ease that I was isn’t a universal experience for Israelis. And even though I paid the same for surgery at a private hospital as I would have in a public one, my privilege is reflected in the fact that that hospital was there to be paid in the first place. A patient outside of Israel’s central region might not have had that option.
4. You may have noticed the one part of the medical system that my odyssey skipped—the public hospitals. These are the focal point of a major crisis in the Israeli medical system, with professionals warning of an imminent systemic collapse. Quite simply, the hospitals are being starved of both budgets and doctors (which are, in themselves, a form of budgetary starvation; if a department needs ten doctors and is only assigned five, the level of care will obviously suffer). It’s understood that waiting times for non-urgent surgeries will be immense, and people who have the option (either because they have private medical insurance or because, like me, they live near a private hospital that has a deal with their health fund) often go private for those sorts of procedures. This creates a vicious circle, because the people abandoning the public medical system are exactly the ones whose voices are more likely to be heard when protesting government indifference and budgetary starvation, and the further those processes progress, the more motivation that echelon has to abandon the public system. You could easily end up with a two-tier system, even as the country officially remains a universal healthcare provider.
5. When Americans discuss healthcare policy, the focus tends to be on catastrophic illness and injury and “who will pay for it?” (even though, as we were discussing just the other day, a lot of the time the problem is “how much does it cost?”). But as I think my story demonstrates, the role of a medical system is not simply to step in with payment in case of a catastrophe, but to provide all-around, comprehensive care. The Israeli health funds place a tremendous emphasis on prevention and early diagnosis, which improves outcomes, as seen in my case (and, along the way, reduces spending). In addition, there’s a great deal of communication between parts of the system that happens above the patient’s head. The original anomalous kidney function result was sent straight to my GP; when the tests I was sent to by the nephrologist threw up results outside of his expertise, he sent a message to my GP to look at them; and when the final ultrasound of the tumor showed vascularization, the technician alerted basically everyone in my medical file, and then called me several weeks later to make sure I had pursued the issue. I don’t get the sense that any system on offer in the US incorporates that approach, which feels essential to meaningful improvement in medical outcomes. I understand why the focus in the American healthcare conversation is on money, but that feels to me like just one aspect of the problem.
6. By the same token, it seems to me that a lot of the problems Americans face when accessing healthcare are rooted in bad, not to say predatory, practices by healthcare providers that you’re going to have a tough time rooting out. The phenomenon of checking into a hospital for an approved procedure only to find out that anesthesiologist was out of network, which has been cited here in the comments on more than one occasion, is simply inconceivable to me. It feels like an outgrowth of the very fact that patients are involved in medical billing at all. If you have an insurer and they approved your procedure, it should be their job to hammer out the payment with the provider, not yours. That’s obvious in the health fund system, but I’m not sure how you inculcate that sort of thinking in the American one.
7. Finally, it’s important not to downplay the potential dangers of a socialized healthcare system when it comes to vulnerable populations and services that may be considered controversial. In Israel, for example, abortion is included in the health basket, but in order to access it women must get the approval of a committee, which can often be a humiliating ordeal. And while medical marijuana is nominally legal here, the current health minister has done everything in his power to undermine the distribution system, leaving hundreds of patients without their medication. In the UK, meanwhile, an ongoing anti-trans hysteria has made accessing gender confirmation services extremely difficult for many patients. I don’t think Americans appreciate the fact that an integral component of a socialized healthcare system is that the government decides what treatments you can and can’t get. I know that private insurers do the same thing in the US, but it’s worth considering how the addition of political pressure can affect the outcome.