Eighty percent of Israel's population is Jewish, the remainder are Arabs (almost all of whom are Muslims), Druse and Circassians. The Jewish population is aging more rapidly; however, the elderly among the Arab minority will also show a significant growth both in relative and absolute terms over the ensuing decades.

As a result of the National Health Insurance Law, passed in 1995, all legal Israeli residents are covered via a legally defined comprehensive basket of services for acute, rehabilitative, inpatient and outpatient services (Chinitz, 1995). The cost of most medications is highly subsidized, with only a small co-payment required. The whole system is financed through taxation, and the monies collected by the Social Security Administration are distributed via a capitation mechanism (which favors the elderly) to four sick funds. These nonprofit organizations, analogous to U.S. HMOs, are publically run and funded, and their functions and duties are defined specifically in law.

Home and institutional care are not provided through the above mechanism and budgets but by other statutory governmental bodies. Non-medical home care by licensed homemakers is provided on condition that the patient is suffering from a well-defined functional disability as measured by a public health nurse. While the recipient must pass a means test to receive free care, the ceiling is set so high that almost all but the very wealthy are eligible. At present, more than 90,000 of Israel's 600,000 senior citizens receive this type of care at home 10 to 16 hours per week (Brodsky and Clarfield, in press).

There are five levels of long-term institutional care, with the first two supervised and, if necessary, subsidized by the Ministry of Labour and Social Affairs. The next three layers of care are for more severely disabled patients and are the responsibility of the Ministry of Health (Clarfield, 2000; Clarfield et al., 2000).

Approximately 5% of Israel's elderly are in these long-term care beds (Clarfield et al., 2000), putting it about in the middle of countries that are part of the Organisation for Economic Co-operation and Development for this measure (Ribbe et al., 1997). Since this type of care falls outside of the responsibility of the sick funds and the National Health Insurance Law, patients and their families are expected to pay, on average, approximately US$2000 per month. If they cannot afford it, patients and families must apply to the Ministry of Health for a subsidy through a system similar to the U.S. Medicaid program (need to spend down, means testing and so on) (Clarfield, 2000; Clarfield et al., 2000). Since the cost of long-term care in a licensed institution is usually prohibitive given the average income in Israel, almost three-quarters of those in long-term institutional care avail themselves of this sliding scale subsidy.

One interesting fact is that, unlike in the United States, it is not just the patient and spouse who are assessed for payment, but all living children as well. Indeed, up until several years ago, even the children-in-law were obligated to contribute.

All countries have medical and social systems that have evolved through a combination of history and internal and external forces. Of interest in Israel is the extreme heterogeneity of the elderly population, almost all of whom were born abroad and come from more than 100 different countries. For many of these people, the national language of Hebrew is not their mother tongue. Beyond this, one can frequently observe a resultant clash of values and misunderstandings between physician and patient (Paltiel, 1996).

Many of Israel's elderly are survivors not only of its many wars, but of the Holocaust as well. This background offers special challenges to caregivers in a significant minority of these people, and it can be an especially difficult problem in the demented where paranoid ideation and misunderstandings relating to the intention of caregivers can arise (Lemberger, 1995).

On the positive side, for the most part, Israeli children (Arab and Jew alike) are extremely devoted to the health care of their elderly parents, especially so when the parents are sick. The emergency department "dumping" syndrome described so often in the English language literature is rarely seen here. In my experience, arranging for the discharge of an elderly patient from an acute hospital is usually easier here than in the United States, with families often willing to take on extraordinary burdens.

The elderly of Israel's Arab minority are also an interesting demographic. While the proportion of those 65 years or older is much smaller among the Arab population (3.8%) than among Israel's Jewish majority (11.5%), the absolute number of Arab elderly is expected to skyrocket in the upcoming decades (Clarfield et al., 2000). This growth will provide new challenges for a society that, up until now, has not had many elderly people with which to deal. Although the Arab elderly are relatively fewer in number, they are sicker and less functional than their Jewish counterparts. With rising wealth, literacy and Israel's universal health care system, it will be interesting to see how Israel's elderly Arab citizens fare in the upcoming decades.

As described earlier, Israel has a system of care for the elderly that is similar to U.S. Medicare, with universal coverage for acute and rehabilitation care and a means-tested welfare system for long-term institutional care. With the promulgation of the 1995 National Health Insurance Law, it was intended that, within three years, institutional long-term care would become part of the universal basket of services. This transfer was meant to increase continuity of care, as well as to provide positive incentives to the sick funds to invest in prevention, health promotion, geriatric assessment and rehabilitation (Kaye, 2000, as cited in Clarfield, 2000). Unfortunately, for various reasons this transfer has not yet occurred. Its lack constitutes the greatest single organizational obstacle to improving the health care of Israel's elderly.

Israel, a "young-old" country, is not aging as rapidly as other Western countries due to a combination of high fertility and continuing immigration of mostly younger people. Given its cultural diversity, the devotion of families to their elderly parents and Israel's nearly universal system of medical care, it will continue to comprise an interesting gerontological laboratory for decades to come.

Dr. Clarfield is chief of academic affairs at Herzog Hospital in Jerusalem and adjunct professor in the division of geriatric medicine at McGill University in Montreal. He is also chief of geriatrics in Israel's Ministry of Health.

Brodsky J, Clarfield AM (in press), An overview of home health care in Israel. Journal of the American Medical Director's Association.

Chinitz D (1995), Israel's health policy breakthrough: the politics of reform and the reform of politics. J Health Polit Policy Law 20(4):909-932.

Clarfield AM (2000), Care of the elderly in Israel: present and future. Clinical Geriatrics 8(5):29-37.

Clarfield AM, Paltiel A, Gindin Y et al. (2000), Country profile: Israel. J Am Geriatr Soc 48(8):980-984.

Lemberger J (1995), A Global Perspective in Working with Holocaust Survivors and the Second Generation. Jerusalem: JDC-Brookdale Institute of Gerontology and Human Development in cooperation with the World Council of Jewish Communal Service.

Ribbe MW, Ljunggren G, Steel K et al. (1997), Nursing homes in 10 nations: a comparison between countries and settings. Age Ageing 26(suppl 2):3-12.

Challenges of Caring for the Israeli Elderly Population