Recently I find myself thinking of my late grandfather, once a strong and cheerful man. I think about how he spent his final years sitting helplessly in a wheelchair, waiting to be fed. This is a repressed memory. Perhaps we all do this — repress such memories, along with the distress and confusion that sweeps over the entire family as an elder’s treatment exacts heavy mental and financial tolls. We repress these things because, while we all want to grow old with dignity and live a long life, we worry about what kind of life we can expect to lead when we reach that point. None of us wants to spend our final years in deteriorating health in a nursing home.

The unfortunate reality, however, is that one in five seniors living in Israel requires nursing care, either at home or in an institution. What makes matters even worse is that nursing care for the elderly is an underfunded no man’s land in the current health care system. A recent study conducted by the Bank of Israel reported that per-capita public expenditure on elderly healthcare in Israel is among the lowest in the OECD. Moreover, nursing care is excluded from of the basket of services normally delivered by the Ministry of Health through the health funds (Maccabi, Clalit, et al). Instead, elderly people and their families in need of nursing care must navigate a complex bureaucratic maze comprising four different government systems (each with its own tests, rights, officers, institutions and employees), and a host of ever-more-expensive private sector stop-gaps like insurance, hospice, and nursing homes.

Bituach Leumi, for example, offers nursing care only to elderly patients living at home. Patients must disclose their income in order to qualify, and are only entitled to approximately 20 hours of nursing care per week, regardless of whether this number is sufficient to meet their needs. Many middle-class families struggle to close this gap by privately hiring foreign nursing workers so that their loved ones may continue living in their homes with dignity while they can. Those who can’t afford private live-in caregivers are either left alone or pushed earlier than necessary into nursing homes.

The Ministry of Health is responsible for more advanced patients who require long-term nursing care in a full-time facility, and demands income disclosures of both the patients and their grown children. The Ministry’s income cut-off is so low that many middle class families don’t qualify for a public bed and are thus again driven to the private sector. Even if a family qualifies for assistance, it has to pay an average of NIS 3,000 per month, with some families paying as much as NIS 10,000 per month for a bed in one of the state’s facilities.

As if the above were not complex enough, there are additional government public services provided only under in special circumstances — by the health funds (for “complex” medical situations requiring hospitalization) and by the Ministry of Social Services (for patients suffering from dementia and the like).

Wary of the bureaucracy and scrutiny awaiting them in the public sector, and knowing that they probably would not qualify for care in any event, many middle-class families in need of caregiving services turn instead to the private market. Indeed, the Bank of Israel study also reported that private health expenditures in Israel are among the highest in the developed world. The rising number of private claims has led to inflation in the prices of health services, a drastic rise in premiums throughout the health care industry, and an increasingly burdened private sector on the verge of collapse. Rises in premium costs have even forced many people to drop their insurance and forfeit the benefits toward which they had been working. Even those who manage to maintain their policies (and successfully claim their benefits) are often disappointed to learn that the benefits are only sufficient to cover three or four years, while life expectancies continue to rise.

Deputy Health Minister Yaakov Litzman has proposed a comprehensive and historic reform designed to address many of the failures in nursing care and hospitalization. By and large, the most significant change in the reform is the formal inclusion of the basic entitlement for nursing care in the bundle of rights provided by the Ministry of Health via the health funds. This inclusion is combined with many overdue changes such as the unification of the bureaucratic jungle under one reasonable roof: the health funds. Among other things, the reform also increases the number of hours for home care from 20 to 30, reshuffles the income qualifications so that patients can afford to pay for care without having to sell family assets, and excludes grown children from the state’s income qualifications.

To fund these changes, Minister Litzman’s reform proposes a 0.5% increase in the health tax — a few dozen shekels each month for the average earner. Most of the nonprofit associations and human rights organizations in the arena of elder care have expressed their support for the proposal, including retiree organizations of hundreds of thousands members. Over 30,000 people signed an online petition in its support. But the reform faces significant opposition from the Ministry of Finance, which opposes the tax increase, and from several of the current caregivers, each of which is eager to protect its own interests.

Why has it taken the public so long to stand up and demand its rights from the state? Why does this issue remain a concern only for the elderly and old organizations? Perhaps because most families in Israel who have experienced this reality prefer to forget it as quickly as possible. After all, life must go on. Or, perhaps, because those who suffer most from this situation are simply no longer able to stand up.

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This article expands on a shorter article that originally appeared in Hebrew on Mako.co.il.