Adapting the Israeli national health insurance law to the 21st century– a report from the 19th Dead Sea Conference

Passage of the National Health Insurance Law (NHIL) in 1995 marked a turning point in the history of the Israeli healthcare system, ensuring sustainable, high-quality medical care to all eligible Israeli residents. Over 100 amendments have been made to the law over the years, yet additional adaptations are required to ensure the law’s relevance in years to come. In honor of the 25th anniversary of the passage of the law, the 19th annual Dead Sea Conference brought together prominent figures in the Israeli healthcare system for a discussion on “25 Years to the NHIL: Suggested Changes and Adaptations”. Key topics discussed in the conference were regulatory aspects related to the healthcare system, administration of medical services, and financial aspects pertinent to the NHIL. The following meeting report summarizes the insights and recommendations from this conference.

OP230 How Legitimate Is The Process Of Updating the Benefits Package In Israel? A 20 Year Overview

IntroductionThe National Health Insurance Law enacted in 1995 stipulates a minimum list of health services (benefits package) that the four health plans in Israel have to provide to their members. The recommendations on which new technologies or new indications for existing ones should be added every year to the benefits package, subject to a predetermined budget, are made by a public committee that evaluates and prioritizes candidate technologies according to their clinical merit, economic (mainly budget impact), social, ethical and other aspects. We assessed the legitimacy of this coverage decision process over the past 20 years.MethodsThe legitimacy of the process was assessed by adherence to the conditions outlined in the accountability for reasonableness (A4R) framework. A4R defines four conditions for legitimate and fair healthcare coverage decision processes: relevance, publicity, appeals/reversibility, and enforcement. We reviewed the changes made in the coverage decision process over the past 20 years and examined whether these changes have changed its legitimacy.ResultsOur analysis suggests that despite several changes made over the years in the process for updating the benefits package, for example, increase in transparency, introducing a structured appeal process, it only partially fulfills the four A4R conditions. In order to accomplish these goals more fully, several widely used considerations such as cost-effectiveness analysis and incorporating views from patients should be included. Additionally, this decision-making process should become even more transparent than it currently is.ConclusionsThe annual process of updating the benefits package in Israel where hundreds of technologies are “competing” with each other for coverage under a pre-defined budget is unique and not without merit. This process has been operating in the same pattern with only minor changes made since 1999. The main barriers for fulfilling all A4R conditions may relate in part to the large number of technologies assessed each year within a short time frame. Several changes in the process including the assessment of societal values, involvement of diverse stakeholders including patient advocate groups should be made to improve its legitimacy.

Two-year supervised tooth brushing program evaluation in preschools in Southern Israel

Background Dental care for children was included into National Health Insurance Law in 2010 and eligibility age went up gradually to 18 in 2019, providing universal dental care. As a part of dental care reform, community based preventive School Dental Services were extended to preschool children. School dental service (SDS), funded entirely by the State, was extended to younger ages providing supervised tooth brushing module. The national supervised teeth brushing program (STBP) was first implemented in 2015-2016 amongst 3-4 year old children attending 600 nurseries in Israel. Due to the program’s success, it was gradually extended to more nurseries in low socio economic regions across the country, reaching 2200 settings in 2019. The objective of this study was to assess dental health among preschool children participating in the program during the last two years, comparing to those who did not. Methods Participant and non-participant kindergartens were randomly selected in Jewish and Bedouin Arab towns in the Southern district matched according to SES level. DMFT index measuring mean number of decayed, missing and filled teeth was recorded among preschool 5 years-old children. Results 283 children were examined, 157of them Jewish (86 participants in STBP, 71 non-participants) and 126 Bedouins (59 vs 67 respectively). Mean untreated carious teeth (d) was 1.15 vs 1.8 for Jews and 3.22 vs 3.9 for Bedouins. Percent of treated teeth within total caries experience index (f/dmf) was higher in tooth brushing group: 37% vs. 29% for Jews and 23% vs. 8% for Bedouins. Key messages Supervised tooth brushing shows favorable effect. Less carious teeth and more treated caries were recorded in STBP group.

Bureaucrats, Politicians, and the Politics of Bureaucratic Autonomy

Bureaucratic actors are located at the center of social policymaking. The chapter illustrates the relevance of conflicts of interests between fiscal bureaucrats and social bureaucrats and politicians, showing that where these conflicts are intense neoliberal reforms may be blocked or muted, at least for a time. The two case studies were selected to illustrate variation in the roles played by state bureaucracies and to cover key domains of social policymaking. The child allowances scheme demonstrates that the level of social policy politicization is influenced by changes in a program’s rules of entitlement, and that in turn the level of politicization determines whether and how bureaucrats are involved in policymaking. The National Health Insurance Law shows how bureaucratic actors may respond to a highly politicized change in the institutional arrangement of a social policy field by shifting the locus of decision-making to the bureaucratic arena, where powerful bureaucracies dominate policymaking.

Privatization Through Centralization in the Israeli Health Care System

This article addresses a policy paradox that characterizes many health care systems and the Israeli system in particular, that is, the existence of two parallel yet seemingly contradictory policy trends: reducing public financing for health care services while increasing governmental involvement in health-system management. The authors characterize this process as privatization through centralization; that is, to control welfare-state expenses and be able to reduce them, the government must first control the funding and management of welfare-state mechanisms and organizations. They develop a theoretical rationale for explaining this policy paradox and demonstrate it through analyzing the legislative changes that followed the legislation of the National Health Insurance Law in Israel.