Sunday, September 9, 2012

Things don't always go as planned

In fact, they usually don't.  I had planned for another home birth.  I had also planned for the trip back to America to only last a year.  Let me back up a little...

We lived a simple, quiet life out in the wild, wild West Bank--as some liked to call it.  Felt like the last place in Israel where one could be a "pioneer" and farm a piece of land without spending three lifetimes' worth of savings to do so.  Even though the generator broke down rather often, no one had air conditioning, and the few scraggly trees kept getting eaten by an absent-minded neighbor's animals...we were out of the rat-race, unplugged, living off the land.

There was a sense of satisfaction that came from such a life.  One that had absolutely nothing to do with politics, but you can't run or hide from them.  In 2005, the 8,000 Israeli residents of Gaza were uprooted from their homes for the simple reason that they were Jewish.  Violent clashes, wounding hundreds of people in Amona, followed in the same month that Puriel was born.  We kept hearing rumors that our town was "on the chopping block."  After all, we were on the "wrong side" of the fence that was going up.

Around that time, my husband had finished his seventh year in yeshiva and mastered the practice of shechita (kosher animal slaughter).  He started talking with the school's founder, Rav Adin Steinsaltz, for guidance on how to best put his education to use.  Since he is a descendant of benei anusim, we set out for the American Southwest to help others in that same boat who are reconnecting to their heritage.

It wasn't your typical shlichut.  There was no house, job or car waiting for us; no cohesive community.  Just scattered pockets of a dozen or two people here and there, greatly lacking local educational resources.  We planted ourselves in San Antonio quite by accident after a visit that was only going to last a couple of weeks.  One year passed, then another.  I found a great job and my husband taught classes.  We bought our first-ever new car and had a nice house that sometimes slept guests in the double digits.  Gone were the days of clothes made from old bedsheets; we shopped at outlet malls now.  We had air conditioning.  The plumbing and electricity always worked.  It was quite comfortable.  A third year began.

Happy third birthday!
Puriel had his first haircut.  My baby was growing up and was already the same shoe size as his sister.  I stopped preventing pregnancy, unsure of when the next one would come but very sure that I wanted another at some point.  Within a month I had a bun in the oven.

We're going to get stuck here forever, I thought...not altogether dreading the idea.  Many Israelis go to the US for a season and stay until retirement.  The cushy life was nice, although the thought of paying $10,000 for my daughter to attend Jewish kindergarten in the coming year was not so appealing.  Ultimately, I wanted my kids to grow up in a Jewish environment with a good education and friends who share our lifestyle.  Israel still seemed like the best place to make that happen.

We're moving back--now, we decided...and started packing up the house.  A container was too expensive, even to split the cost was out of our reach since we needed some funds to land with while looking for work and settling in.  Whatever couldn't fit in our suitcases had to be sold or given away.  This would be my seventh time moving overseas and starting from scratch.  I promised myself it would be the last.

I had the worst morning sickness ever this time and subsisted off little more than soda water and matza for the entire first trimester.  Got in touch with my midwife, who warned me so severely to avoid sugar (because my last baby was big) that she said I shouldn't even eat fruit.  Something didn't feel right about that but I tried to obey, hoping this baby wouldn't top Puriel's 3.9 kg birth weight.  I dropped from full-time employment and lost my medical benefits.  Aaron became a taxi driver for the summer while I packed with two little ones underfoot.

By the time we arrived in Israel, I was finishing up my second trimester.  We lived in two temporary apartments before settling into a third.  Ended up back in Tekoa, but in the main part of the town with a few hundred other families instead of out on the edge like before.  We rented the upper floor from old friends and our kids played together everyday after school.

Back in Tekoa
In the meantime, I had no health care.  We had filled out the proper forms before leaving to suspend our national insurance payments and should have been eligible to pay the hefty fee of NIS 9,000 to get back into the system.  This law exists to keep people from leaving the country and only coming back in cases of severe illness to receive expensive medical procedures at little to no cost.  Because I had a midwife and planned for a home birth, I wasn't so worried--at first.

But something felt very different about this pregnancy.  Felt very wrong.  I hadn't been able to do any of the usual screenings or tests and started looking for a place to do basic blood work and an ultrasound.  When you give birth at home, I believe it's a good idea to make sure that there are no surprises.

Private health care was too expensive.  It would cost NIS 800 (over $200) just to get an appointment with a doctor who could order the tests (which, of course, each test had its own high price tag).  With a lot of help from my mother, I finally found a Catholic hospital in East Jerusalem, where an Arab doctor who works at Hadassah hospital runs a clinic one day each week.  His fee is a quarter of the going rate and the tests are done in-house, also at a much lower cost.

Surprise!  At 32 weeks I learned that my baby was already over 3 kg and breech, and that the reason it looked like I had twins from the outside was because of an abnormally large amount of amniotic fluid.  That ruled out a home birth for me.  But a hospital birth without insurance costs upwards of NIS 15,000 for a natural, uncomplicated birth.  If a cesarean was needed, it could end up being double that amount.  Suddenly the "redemption fee" for the insurance didn't look too bad.  But they wouldn't even let me pay it.

One trip after another to Bituach Leumi (the National Insurance Institute) left me with a different answer every time.  I kept going back, hoping for a miracle.  And one day the first of miracles came.

"Your husband is out of the waiting period," said the middle-aged woman with reddish-purple hair.  The waiting period is six months from when you return from a 2+ year absence, but almost three months after my due date.  "Did you leave and come back at different times?" she wondered.  No, we were on the very same flight as each other.  "Do you want me to fix the problem?" she asked with half a smile and the first hint of sweetness.  No, no thank you.  She even moved the kids, from being listed under my name, to being with my husband.  Now everyone in the family had health insurance again...except me.

A follow-up visit to the doctor--right after we moved into our third apartment--revealed that my tush-down breech had become a 36-week, 3.5 kg, footling breech.  What doesn't kill you makes you stronger, I kept telling myself.  But I still cried everyday from the stress of it all.  My husband was working a night-shift in Jerusalem even after our car broke down.  Then he found a local job, but they never paid on time.  Puriel was getting bullied in preschool.  Teneya was the only one who was settling in well.

The next trip to Bituach Leumi yielded a new development.  They would finally let me pay the redemption fee and come out of the waiting period early.  Better late than never, I sighed with a fair amount of relief.  But by then our savings were all used up.  We would have to use our credit card.

Bituach Leumi accepts foreign credit cards, but their payment system was down that day.  Try again after the weekend, they told me.  First thing Sunday morning, I was on the phone.  Sorry, it's still down--do you have an Israeli card?  We had just opened a new account upon returning to the country and the card had a NIS 500 limit.  Nope.  First thing Monday morning, I was on the phone again.  That's when the next miracle happened.

"What are you trying to pay for?" the lady asked me, with no amount of patience in her tone.  "You're not in the waiting period anymore."  Another glitch.  Another wondrous computer error.  I went that very same day to the clinic to get my insurance card printed.  "But you're in the waiting period," came the conclusion after nearly an hour of unsuccessful attempts to register me.  An hour more of phone calls to the main office of Maccabi and Bitach Leumi finally cleared things up.

It was official.  I had health insurance.  Slept better than ever that night and woke up the next day with a bit of spring in my step...something that had been missing for a long time.  I scheduled an appointment, curious about external cephalic version (ECV) and eager to avoid a c-section, but it would take a week to see the doctor.  A friend who had high-risk pregnancies took me in person the next day to her doctor in Jerusalem, who worked out of a clinic attached to the hospital.  He was over-booked already, but had some great advice for how to get a checkup without waiting for an appointment.

"Go upstairs to the maternity ward and tell them you're having contractions.  They'll take good care of you right away."  So that's what I did.  Turned out that baby had flipped head-down on his own and that's why walking was suddenly easier.  Hurray!  But by my checkup later that week he was breech again.  ECV was scheduled for 38 weeks and he stayed that way until the very end.

Bundle of miracles
My little bundle of miracles was born on a Shabbat morning, after 7.5 hours of labor, at the end of Hanukah.  He weighed in at 4.08 kg and had loads of strawberry blonde hair down his shoulders and back.  From all the excess water and freedom of movement, his muscles were developing ahead of schedule and he was holding up his head from that first hour.  It was like he skipped the newborn phase.  I had given birth to a month-old baby.

The land of Israel is often described as eretz hemda, a desirable land; a land that we returned to when we did because of this little boy.  We named him Hemdiya (G-d is my desire).  I added Imanuel (G-d is with us), in gratitude for the miracles that were done for us in our days, at that season.

Thursday, September 6, 2012

Free health care?

Since the ruling of the Supreme Court this summer, to uphold the health care overhaul, there has been a mix of cheers and concerns from the US population.  With it being an election year in the US, the subject is being heavily discussed and a friend asked me to expound on how the universal health care is working for us here.

I've been with and without health insurance in both the United States and Israel, as well as having been a member of three out of four of the HMO's in Israel (basic-only and supplemental plans).  Many people hear that health care is free in Israel.  Well, it's not.  But it certainly costs a lot less...

A mish-mosh of cultures and languages collided in this little corner of the world as millions of refugees flooded in from every direction with only the clothes on their backs, greatly outnumbering the local Jewish population.  The first public health fund was established by farmers during the times of the British Mandate and eventually taken over by the labor union.  Since becoming a modern country in 1948, Israel has always placed a lot of thought and effort into health care and by the early 50's the Health Ministry managed most hospitalization services while smaller clinics were expanded by "sick funds."  Membership dues were paid on a sliding scale.

The National Health Insurance Law went into effect in 1995, making health insurance coverage mandatory.  This law established the responsibility of the state to provide health services for all residents.  A standardized "basket" of health services were to be managed by the sick funds with funding from the government, the employers' health tax, employee deductions and modest co-payments (currently around $2 for the first visit to your primary doctor [$6-7 for a nutritionist or physical therapist] in each quarter of the calendar year, but there are discounts and exemptions available for welfare-based or medical grounds).

Equal status was given to each of the four sick funds and they may not bar membership for any reason, including age or health condition.  Every resident, from the age of 18, must register with one of these four funds and make monthly payments based on wages and status (for example: students pay less, the unemployed have a low flat rate, a married woman who doesn't work is covered by her husband's payment, etc.--for more details see the NII website).  Some people choose to purchase additional coverage through private insurance companies or the supplemental insurance offered through their sick fund.  With this optional additional coverage, vision and dental are heavily discounted in addition to other health services.  Annual preventative dental care for all children is free in Israel (recently extended up to age 12).

At the dentist: kids free, adults half price with Maccabi Gold
While looking deeper into the differences between health care in the US and Israel, I've come across some interesting statistics (per capita, taken from the OECD):

Total health expenditure:
Israel $2,165; US $8,233
Public expenditure:
Israel $1,254; US $3,967
Physicians per 1,000 people:
Israel 3.5; US 2.4
Annual doctor consultations:
Israel 6.2; US 3.9

Much of the health care savings in Israel are attributed to preventative health care.  Because everyone has affordable access to it, illness are prevented or treated in the early stages.  No one goes bankrupt from getting sick or looses coverage along with their job; the words "pre-existing condition" are never uttered. 

If such a young country, with such a disorganized and fractured government, can pull off a universal health care system then I'd say there is hope for the US to do the same.  Affordable preventative health care doesn't just save money, but adds years of quality life to each of us.  Israel is #4 in life expectancy in the world, with the United States trailing behind at #38.  I think the coming health care reforms will eventually help the US climb further up the list.

When I was back in the US for a while, my children were enrolled in CHIP and received vaccinations, regular checkups, preventative care and medical treatment for illnesses.  It was a relief to know that at least they were covered, but my husband and I weren't for a year and a half when we were each working part-time.  When I started working full-time, I finally had insurance but he still didn't.  I worried a lot during that time about what would happen if we/he needed serious medical care.

Don't expect the new system to be perfect though--remember that there is always waste and disorganization, in both the government and private sectors.  When we came back to Israel, we found ourselves in a "waiting period" before our health care would resume.  I was six months pregnant with baby #3 (story coming soon!) at the time and should have had the ability to "redeem" the waiting period with a payment of NIS 9,000 but was denied the chance to even do that and ended up without prenatal care.

In answer to the whole "is it constitutional to require health care payments" I have this to say:  Governments levy taxes to provide social services to the general population.  If you own a house or piece of land, you will owe taxes that go toward paying for public schools in your area.  What if you don't have school-aged children, or you send them to private school?  That's fine, but you still pay into the system so that every child can have access to at least a basic education.  From what I see, with both educational and health services, the issue is not about "robbing the rich to care for the poor", it's about ensuring "life, liberty and the pursuit of happiness."  After all, if you haven't got your health, you haven't got anything really.

Do you have questions about public health care in Israel?  Let me know in the comments section below: