Painful Exclusion: The costs of denying asylum seekers access to healthcare services in Israel, and a proposal for a remedy
A decade has gone by since the first African asylum seekers arrived in Israel. Still, the Ministry of Health has failed to formulate a comprehensive policy to regulate their access to health services. The following report details the costs of this failure - the health, moral and economic cost of the lack of healthcare policy for asylum seekers. It then offers an alternative: a sustainable solution for that population that includes a state-sponsored insurance arrangement.
Israel is now home to almost 40,000 African asylum seekers, mostly from Eritrea and Sudan. The State of Israel recognizes the mortal danger they face should they return to their countries of origin, and therefore protects them against expulsion. Beyond this protection, however, these people lack any civil status in Israel, and accordingly remain without regular access to health and welfare services, except in emergencies.
Over the past few years, there has been a gradual change in the Ministry of Health’s approach, as it has begun offering partial, specific solutions for asylum seekers. As described below, however, these are far from sufficient, leaving many individuals without appropriate healthcare. Private insurers offer a limited range of services and exclude coverage for “pre-existing conditions”. As a result, even those who do have private policies are often not covered. The ministry’s Gesher Mental Health Clinic in Jaffa, the only clinic in Israel offering mental health services to asylum seekers, is overloaded and cannot offer mental health treatment to all those in need among this population. Finally, the few services offered by the state at the Terem Clinic for Refugees in downtown Tel Aviv are limited, and do not really meet the needs of chronic patients, patients who need follow-up treatment and rehabilitation, those who require surgery, oncological and other complex treatments. Consequently, asylum seekers have no choice but wait until their health deteriorates and their life is in danger, in which circumstance they would be eligible to emergency hospital care.
This systematic neglect of the health of asylum seekers takes a heavy toll from their health. This situation, however, affects not only the asylum seekers themselves, but is also very costly, ethically and economically, for the entire healthcare system, particularly the hospitals that must bear the burden of emergency care for asylum seekers and cover for the lack of a universal solution for this population. As suggested by the report, despite some investment by the Ministry of Health in limited solutions, totaling some 40 million NIS in 2016 alone, the hospitals continue to bear the high costs of emergency treatments in the form of bad debts. The report reveals for the first time that over 2013-2016, these bad debts reached a total of more than 157 million NIS; in 2016 alone, the total was 36 million, with the Tel Aviv Sourasky Medical Center bearing almost 23 million NIS in bad debt.
The sorry state of human and economic affairs revealed in the following pages suggests the need to develop a comprehensive healthcare solution for the asylum seekers in Israel. This solution involves moving from their exclusion towards their inclusion in the public health system; from partial, ad-hoc and specific solutions as a humanitarian response to immediate needs towards a just, equitable and sustainable solution that recognizes their basic right to health and dignity.
This proposed policy change requires activity on several levels. On the first level, the proposed change requires abandoning the specific solutions in the form of dedicated clinics and private insurance policies in favor of a comprehensive and egalitarian state insurance arrangement for asylum seekers. Studies conducted in other countries indicate that insurance arrangements for documented and undocumented migrants significantly reduce the cost of providing them with health services. The model presented in this report seeks to apply the existing model for providing health services to minors without civil status (currently provided by the Meuhedet health fund) also to adults, with the required adjustments. Based on this model, most asylum seekers will be required to pay a monthly insurance fee of about 150 NIS, with the Ministry of Health covering the remaining amount. In return, they will enjoy access to the basic service range provided to Israelis through the health funds under the State Health Insurance Law. As shown in the calculation presented below, the investment required by the ministry to ensure the success of this move is negligible - some 20 million NIS beyond the present investment in treating uninsured migrants, or an addition of 0.052% to the annual health budget. Moreover, it is a wise investment, particularly when we take long-term risks and other considerations into account.
On the second level, the proposed change requires preparation by healthcare providers - the medical, paramedical and administrative staff in the health funds and hospitals - to provide healthcare for the population in question, including linguistic and cultural mediation. As described by the report, here, too, a modest and judicious economic investment - using interpreters and cultural mediators rather than expensive equipment or human resources - can reduce the hidden costs for the healthcare system.
On the third level, the proposed change also requires working with the asylum seeker community itself, to raise its awareness and familiarity with the Israeli healthcare system. Operating on all three levels thus requires the cooperation of the Ministry of Health, the medical community and healthcare providers, as well as civil society organizations, and particularly those assisting asylum seekers. In many senses, the text below is a call for such cooperation.
The Ministry of Health is already aware of the hopelessly dissatisfactory level of the existing treatment solutions for asylum seekers. Until now, however, it has failed to formulate a real policy to remedy the situation. According to senior ministry officials, their hands are tied, since now more than ever, as the Ministry of the Interior acts to deport asylum seekers and dissuade others from arriving, the Ministry of Health is prevented from improving the living conditions of these inhabitants. But perhaps now is precisely the time for the Ministry of Health to take into due account the broad range of independent considerations directly relevant to its mandate - including medical and ethical considerations related to individual and public health, as well as long-term economic considerations - and formulate a sustainable health policy for the community of asylum seekers living among us. Now is the time for the ministry to make a stand and provide full and equal health services to that community, to alleviate their distress rather than add to their suffering.