Several months ago, shortly after we made aliyah, my husband slipped and fell very hard on his shoulder. A visit to Terem (the urgent care clinics whose concept in Israel was founded by the brilliant Dr. David Appelbaum hy”d, who was killed along with his daughter Nava on the eve of her wedding in a terrorist attack in Jerusalem) presented no evidence of a fracture, so he was sent home to rest it in a sling. A few months went by and it didn’t get any better; my husband was in such pain that it was affecting his ability to sleep at night.
Unfortunately for us, we still did not have decent health insurance. Although all new immigrants to Israel are given membership to the health care system in Israel the second they step off the plane, we were not considered “new immigrants” because we had lived in Israel in the 1980s. We were “returning Israelis” and the rules are quite different. There is a six month waiting period before you are accepted into the Israeli health care system, and meanwhile you must get private health insurance which in our case turned out to be very poor. It did not include any pre-existing conditions, it was expensive, and the doctors who would take the insurance were non-existent outside of the major cities of Jerusalem, Tel Aviv, and Haifa.
The “six-month rule” was instituted because too many Israelis were spending the most productive years of their lives living and making money in the US, Canada, and Berlin, and only returning to Israel at retirement age when their health care needs were greatest. The government was resentful that these returning Israelis had not been paying into the National Health Care system (called Bituach Leumi) for decades, and now they were returning and bankrupting the system with their medical needs. Hence the six-month rule.
Thankfully, the six months passed quickly for us mostly without incident (the xray was covered by the private insurance as an emergency condition), and at the first available opportunity we signed up with one of Israel’s kupot holim (health funds).
Which fund to choose? This is a valid question because they all have subtle differences. For instance, some include certain medicines in their “health basket” and others include yet a different set of medicines. So if you have a chronic illness requiring expensive medication, it behooves you to check just which specific medicines are included in the health basket of the kupat holim of your choice. Which kupat holim has the best doctors? The clinic with the most convenient hours? The ease in making appointments? How is their hospital network? Choice of specialists? How far do you have to travel? The latter question is especially important if you do not live in a major city like Tel Aviv, Jerusalem, Haifa or Beer Sheva. Where we live, there is a small clinic right in the yishuv (village) but they’re affiliated with the Clalit health fund. We wanted to join Kupat Holim Maccabi, whose clinic is 5 miles up the road – – fortunately, we have a car as buses run only every 90 minutes.
While one health fund might be great in one location, the same fund might not be so great in another. So it’s important to determine the quality of care available in your particular location. In our case, the tiny Kupat Holim Maccabi clinic for the Misgav region where we live in the Galilee happens to have excellent doctors. The family doctor has won all kinds of awards for her excellent care. Specialists such as an orthopedic surgeon, physical therapist, and ophthalmologist visit the clinic weekly. I needed to travel to Karmiel or the outskirts of Haifa for other specialists and services such as MRIs, CT scans or ultrasound, but this is only a 20 – 30 minute car ride. But this brings me to mention a very important consideration when you are deciding where to live in Israel: how far will you be from excellent medical services? Will you have a car or rely on buses? If you are retirement age or, G-d forbid, you have a serious illness that requires highly specialized treatment, frequent therapies or monitoring, it is no fun to travel hours when you are feeling your sickest to seek care, which could be the case if you live in the Golan, for example.
Each kupat holim has 3 levels of care to choose from. The cost difference is not huge between the lowest priced plan and the most expensive, so we opted for the most expensive plan, which offered additional benefits. The cost of our health insurance, called Maccabi Sheli, is approximately $145 monthly for the two of us together. Yes, you heard right: Around $70 per person for the top-level plan. To be fair, it doesn’t include everything. The particular diabetes medication that my husband takes is not part of the health basket but it’s still less than $30 per month. An ultrasound recently cost me $10. But these prices are still way cheaper than what we paid in the US, even with insurance.
For the few things the kupat holim plan doesn’t cover, you can buy private “supplemental” insurance that usually pays in 100% as a secondary insurance. This is not cheap but still way cheaper than insurance in the US. This “private” insurance will also pay for seeing physicians not in your health plan, as well as surgeries and second opinions abroad. Finally, there is long-term nursing care insurance, called “siyudi,” which works somewhat differently in Israel than the US.
The kupot holim do offer long-term nursing care insurance, but it is via a private health care insurance agency. The cost depends on what age you sign up for it. At our age (I’m 60 and my husband is 69) it is more expensive than if you sign up at age 40. The “gotcha” is that it provides nursing care at a set limit (in our case, around 3500 NIS per month per person) for a maximum of 5 years. Statistically, they reason that after 5 years requiring full-time care, you will likely be dead. Currently full-time nursing care in one’s home costs about 7500 – 10K NIS monthly (about $2500 – $3500 per month in dollars) in Israel. It is also advisable to purchase supplemental long-term care insurance privately to make up for the difference, as well as the possibility for insuring longer than 5 years. Our insurance agent tried to dissuade us from getting insurance beyond the 5 year limit as a waste of our hard-earned money, but we explained to him that since we live in Israel without family, we are literally on our own with no relatives to take care of us, so we will need to rely on professional care. In Israel, families are very close and usually care is shared by family members, so few opt for extended or extensive long-term care insurance. The supplemental long-term care insurance is not cheap by any means, but it is a fraction of what we would have paid in the US, plus the cost of private nursing care is also cheaper than the US. Caveat: it may be difficult to purchase these types of insurance in Israel after age 70 so it’s important to take care of this while you can.
But back to my husband. We made an initial appointment with our new family doctor, who proved to be every bit as wonderful as we were told. She told my husband that he was in luck, the orthopedic surgeon who comes to our local clinic on Thursdays happens to be a shoulder specialist. My husband was able to get an appointment with him for that very afternoon.
The doctor felt my husband would probably require surgery due to his rotator cuff injury, but without an MRI it would be impossible to diagnose accurately. He suggested my husband get a cortisone shot to temporarily relieve his pain and once again we were exposed to differences between the Israeli and US health care system. In America, the doctor would have given my husband the shot right then in the office and that would’ve been that. In Israel, doctors have zero supplies in their clinic offices. My husband was given a prescription for the cortisone, but there is no pharmacy at the clinic. So we had to travel 20 minutes to the city of Karmiel to fill the prescription for the injection, and then bring the vial back to the clinic so the doctor could give him the shot. Well that’s fine – – except the doctor only comes once a week to our local clinic, and the following week was a Jewish holiday and the clinic would be closed. So like speed demons we raced from the pharmacy in Karmiel back to the local clinic barely making it before the doctor had to leave for the day.
The shot provided tremendous temporary relief from pain. But the MRI revealed the damage was bad enough that physical therapy and rest would not be enough to fix my husband’s shoulder. The doctor warned us that at his advanced age, my husband may not heal well since the ligaments and tendons are no longer supple, so he couldn’t guarantee the surgery would be successful. My husband replied that even if he didn’t regain full range of motion for his arm, the surgery was worth the risk if there was a chance of relieving his chronic pain. Thank G-d, my husband is in good basic health and very physically active, so we felt he had a good chance of success.
The surgery was scheduled for a couple of weeks later. And that’s another thing: one usually hears that with socialized medicine, “elective” surgeries take months or years to schedule. This was certainly not true in our case!
We had the option of not using this doctor, and going with a “private” doctor at our own expense. But we liked this doctor; he did these surgeries regularly and seemed competent enough.
Which brings me to another point: here in Israel your perception of Israel as a land of Nice Jewish Doctors might be challenged, especially if you don’t live in a major city. Just like in America, the “best” doctors are rarely attracted to rural areas, since the pay and the equipment and facilities are less than what’s available in major cities. In rural areas you are much more likely to get doctors trained in Eastern Europe and who may not speak English, or Arab doctors.
In fact, my endocrinologist is an Arab, and couldn’t be nicer or more qualified – – I’m very happy. He’s polite, friendly, caring, knowledgable and helpful. In my husband’s case, the orthopedic surgeon was Russian.
I know many American olim shy away from Russian doctors in Israel. Mostly it’s a personality thing. In America, doctors usually discuss various treatment options with you. Russian doctors tend to be gruff, matter-of-fact, intimidating and have a “my way or the highway” attitude. This is the stereotype, anyway. It can also be frightening when you are a new immigrant facing a medical procedure and your doctor doesn’t speak English and your Hebrew is weak; it’s important to understand what is being done to you and the particulars of your care.
But while my husband’s doctor was rather forceful and had a strong personality, he truly seemed to know what he was doing. We liked him right away. And I reasoned that in Russia, where anti-Semitic policies implement severe quotas on the number of Jews accepted to medical schools, only the very best of the best Jewish students become doctors. He was going to do the entire operation arthoscopically, so there would be no large gaping incision. We felt we were in good hands, and truly in G-d’s hands.
All the way through, communication was excellent. Israel is very proficient with Electronic Health Records, and we frequently got text messages to remind of us appointments. Setting appointments was easy online. If we couldn’t handle things due to limited Hebrew, there were always “live” people to speak to who went out of their way to be patient in setting things up for us or to explain things. There were always follow-up calls checking up on us. Doctors and institutions had no trouble accessing our EHRs no matter where we were (caveat: there is no privacy in Israel!).
So on Thursday after Chanuka my husband had his surgery in a small hospital just outside of Haifa.
And while the care was great and the surgery seemingly successful, once again, there were some things that were very different from the US.
For one thing, the hospital was located in a huge shopping mall. Seriously. When we arrived at 6 a.m, we saw two male patients window shopping (the stores were closed at that early hour), walking around the mall pushing their IVs with one hand and clutching their backless hospital gowns with the other hand. The hospital was on the 3rd floor; Children’s Place and other typical clothing, jewelry and kitchen stores as well as a Cineplex and food court were on floors 1 – 2.
Another thing: when we checked in, no mention was made of cost. In the States it seems like it’s always about money. But as I sat in the intake chair, I started getting really nervous about how we’d pay for everything even with insurance (our supplemental private insurance wouldn’t pay for this surgery since the original injury occurred before we had this insurance, and it was considered a “pre-existing condition”), but realized at this late stage in the game it was too late to worry about it.
Even for what was a “minor” surgery there are risks, and I can’t say I wasn’t worried. Usually both patient and spouse utter endearments to one another as the patient is wheeled away. But instead of “I love you!” my husband, ever the geek, said, “My password is . . . ”
While I was waiting for the surgery to be over, I struck up a conversation with the person sitting next to me (Israelis always make conversation with strangers; I think it is because ultimately we feel like one big family). I asked her how I might calculate costs. She didn’t know, but just then a cleaning lady – an older woman pushing a hospital cart that contained a bucket of water and a sponja stick (mop) – overheard me and said, “Excuse me. . . um, what health plan are you associated with?” and proceeded to tell me the intricacies of how the system worked. Yes – – the cleaning lady. She also wished a speedy recovery on my husband’s behalf- but so did everyone wish us and everyone else the same, Jewish and Arab alike.
My husband was wheeled out of the operating room and I met him in the recovery room. Of course he has zero recollection of our conversation but it was truly YouTube-worthy. Although in normal circumstances he is far from fluent in Hebrew, under anesthetic he suddenly became 100% fluent in Hebrew, speaking quickly with a perfect Israeli accent. I addressed him in English but he looked at me as if he couldn’t understand. I repeated what I has said in Hebrew and he answered me in Hebrew, perfectly. In fact he was rambling on and on in perfect Hebrew. He was unable to speak English at all. As the anesthetic wore off, his perfect Hebrew disappeared and English once again ruled. I guess it means his neshama (soul) is Israeli!
How bad can things be when the first thing you’re allowed to eat after surgery is kosher chocolate pudding, provided by the hospital? The surgeon told us the damage was more extensive than the MRI had indicated, and that it was a complete tear. The entire operation was done arthroscopically so there were only five small staples and there would be no external scarring.
My husband was supposed to stay overnight, but it was clear he was doing better than expected, and they gave us the option of leaving at the end of the day.
This is where things got exciting.
It so happened that we had guests staying at our rental apartment who were visiting from America. I will call them the “Rosens” – – not their real name. Because the previous nights they’d been with us they were up till around 11:30 pm, we didn’t bother telling them we had decided at the last minute to come home the same evening as the surgery.
We arrived home around 10 pm. Unfortunately, our front door was locked and our guests had put the key in the door, so our key couldn’t open it. After I tried phoning and texting them I realized their phone was turned off. They had a busy day touring and were exhausted from a general lack of sleep, so they decided to turn in early. They didn’t hear me knocking. So there we were, my husband only hours out of surgery, on the doorstep of our rental apartment in pitch darkness, with no way to get in.
(I seem to have a talent for getting locked out of houses. Perhaps this will remind you of a similar incident I wrote about in this blog that happened to me during Pesach, which you can read about here.)
All of my windows were bolted, but I suddenly remembered that there was one window I had forgotten to lock – – the kitchen window. Leaving my husband resting on the porch, I pushed a garbage can next to the window and climbed on top of the can. With a little prying I was able to slide the window open. The window was next to the kitchen counter, which happened to be crowded with drying dishes and food supplies. I am not a small person, and this was like watching an elephant in a tutu. Unfortunately, not a graceful elephant. So in the process of climbing onto the counter, and because it was pitch dark, I managed to knock over a bottle of wine and a bottle of olive oil that were on the counter.
The noise woke up my guests. I decided to stop and be very quiet, since I felt bad I had disturbed their sleep and perhaps they would go back to sleep. This idea was nice in theory but the elephant in me knocked over a container of spices and now they were up for real.
Well, they were awake, but not up. Actually, they were quaking in their beds. They knew we were not supposed to be home that night, so it couldn’t be us. They were convinced they were hearing Arabs trying to break into our home to commit a terrorist attack.
I finally landed with a thud from the counter to the kitchen floor. Again, I tried to be quiet, but the elephant in me ran into the broom and it knocked loudly to the floor. I ran to the front door to unlock it for my husband, waiting patiently but weakly outside on the porch. Suddenly my guests’ bedroom door opened slowly and ‘Mr. Rosen” peeked out.
“Hi and surprise!” I said. “It turned out we were able to be discharged early, so we came home! But you left the key in the inside of front door so I couldn’t unlock it so I had to break in!”
“Mr. Rosen” looked pale.
“Yeah, we were in bed when we heard you,” he said. “We weren’t sure what to do. My wife finally convinced me to investigate. I was sure when I opened this door I was going to hear “Allahu Akhbar!””
I actually felt really badly that I’d caused them such a fright; but I knew this would be something that we’d laugh over someday . . . if the “Rosens” didn’t want to kill me first.
Postscript: the surgeon called us at home to make sure my husband felt okay, and offered kind words of encouragement. We also got called several times by the hospital and the kupa, just to see how he was feeling. Physical therapy was arranged and the first session was 5 days after the operation with a wonderful PT who couldn’t believe how much range of motion my husband had already. His recovery is stellar, thank G-d, surpassing all estimates (the doctor said up to 3 months before my husband could go back to work; he is already (cautiously) doing a few hours’ work at his computer at home less than a week after the surgery).
As to the bill? The surgery, hospital stay, and subsequent physical therapy are free.
We are so blessed to be in Israel, both in sickness and in health.