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Analysis

In pandemic’s shadow, health coverage decisions move from doctors to politicians

Netanyahu and Gantz’s refusal to pass a state budget means the expert committee that chooses which new treatments to add to the national insurance plan cannot do its job

Haviv Rettig Gur

Haviv Rettig Gur is The Times of Israel's senior analyst.

Illustrative photo of doctors in an operating room at a hospital in Jerusalem. (Yaakov Naumi/Flash90)
Illustrative photo of doctors in an operating room at a hospital in Jerusalem. (Yaakov Naumi/Flash90)

For the second year in a row, the government’s inability to pass a state budget means that the high-level committee that chooses which medical treatments will be covered by national health insurance, and which won’t, must make its decisions in the dark.

Where in the past it was doctors, economists, and health fund representatives who gathered each year to make the difficult decisions about what to include in the ever-expanding so-called “health basket” of subsidized technologies and treatments — and thus which patients to help and which to pass over — this year it may be the politicians who make those decisions.

The government has now operated without a state budget law for 11 months, and no budget bill is on the horizon for 2021. That means the so-called “health basket committee,” as it meets over the next two months to choose which new treatments will be available in 2021, will be choosing among some 880 new medicines and technologies requested by physicians, desperate patients and pharmaceutical companies — without any sense of the funds available to them for doing so.

“As of today, there is no budget,” Prof. Joshua Shemer, head of the Assuta hospital network, a former surgeon general of the IDF, and this year’s chair of the committee, warned in an interview with Channel 12 after the committee’s first meeting on Wednesday. “We don’t know how much money stands at our disposal, but we are starting to work and I very much hope we will be given a proper budget. I am in touch with the prime minister and the finance minister.”

Decisions over nationally subsidized health services are notoriously ambiguous and difficult because funding is always limited. Some decisions are easy: replacing an old treatment with a proven and improved one. Others are hard. The committee must often choose between improving the lives of many and saving the lives of a few. It must decide, in hard numbers, how much the healthcare system will spend on extending the lives of the terminally ill, knowing that that money comes at the cost of other treatments for other patients. It must decide which treatments should be subsidized to ensure access for all, and which, given scarce resources, should be allowed to remain expensive and inaccessible for many.

Then-deputy health minister Yaakov Litzman, then-finance minister Moshe Kahlon, then-health basket committee chair Prof. Zeev Rothstein and then-Health Ministry director general Moshe Bar Siman-Tov at a press conference discussing what will be covered in 2020, at the Health Ministry on September 1, 2019. (Yonatan Sindel/Flash90)

Here is a policy arena that offers only dilemmas. Yet each year, the committee’s 18 members — doctors, economists, ethicists, scientists and representatives of Israel’s four health insurance funds – must sift through hundreds of treatments and technologies, rank them by cost, medical effectiveness, and potential benefit to public health writ large, and deliver simple, concrete decisions to the government. (The committee is technically only an advisory body, but in practice its decisions are treated as set government policy.)

Take this year’s 880 requests, which include treatments for heart disease and diabetes, as well as blood diseases, cancers, new preventive screening measures, and more. To fund all the requests would cost more than NIS 3 billion ($880 million) per year, according to the Health Ministry, six times the budget made available to the committee last year.

That gap forces the committee to make some hard policy choices. Should it use its limited funds to join the fight against the COVID pandemic, which might mean favoring treatments that tackle risk factors like heart disease? Or should it do the opposite: focus what resources it can muster on those parts of the health system — on the many desperate patients — whose cause has fallen by the wayside as attention shifted to the coronavirus?

The budget framework poses similar overarching questions. More money could favor more expensive treatments, which often grow cheaper by broader adoption. Less money could mean the committee limits itself to preventive measures and inexpensive innovations.

And because Israel’s political class has been unable to pass a state budget, the committee is now starting its second year in a row of deliberations without the ability to intelligently make those choices.

Illustrative: Some 40 doctors and patients demonstrate outside the Sheba Medical Center at Tel Hashomer on December 20, 2009, where a meeting of the health basket committee is scheduled to be held later in the day, calling expanded dental coverage for children. (Roni Schutzer/Flash90)

In September 2019, the committee began its deliberations for additions to the 2020 allocation, hoping and believing that then-health minister Yaakov Litzman’s promise of a NIS 750 million ($220 million) increase to the budget for covered treatments would come through.

At the last minute, a week before the end of 2019, a special stopgap budget of NIS 500 million ($147 million) was passed — less than Litzman promised, but a similar amount to the previous year.

But the lack of a budget framework for a second year has made the committee’s work much harder. A year has passed; a pandemic has swept over the healthcare system like a tsunami, consuming its resources and driving vast deficit spending by the government. There is still no state budget for 2020 and none on the horizon for 2021 as Prime Minister Benjamin Netanyahu tries to avoid carrying out the rotation deal he signed in May with Defense Minister Benny Gantz.

So the committee must again try to do its work in the dark.

The first meeting of the health coverage committee’s deliberations for 2021, held at Sheba hospital in Ramat Gan on Wednesday, offered the first signs that the lack of a budget has fundamentally changed the way the committee operates.

Sheba Medical Center (Photo credit: Sheba Medical Center)
Sheba Medical Center in Ramat Gan. (Courtesy)

The very fact that Shemer, the chairman, gave an unprecedented interview to Channel 12 the day the committee’s work got underway is one such sign. The committee’s deliberations are secret and its public statements rare, in order to allow members to speak openly about the painful decisions that lie before them. Journalists can watch the deliberations, but only under strict rules. Quoting anything said in the committee’s meetings is prohibited.

Shemer’s interview broke that traditional veil, and for good reason. Previous chairpeople believed their role was to facilitate a thoughtful debate on medical policy and reach difficult decisions about new treatments. Shemer now sees his role as lobbying for the budget his committee needs to properly do its work.

“Last year, the prime minister said that the budget will rise to 750 million shekels,” he told Channel 12. “I am expecting this to happen [this year]. We saw this year how billions were invested in coronavirus patients. We expect some of that for other patients as well,” he said.

The pivot from a body doing medical triage to one that lobbies publicly for its budget is a fundamental one. It turns the committee from a medical policy advisory body into a de facto political organization.

Last week, Deputy Health Minister Yoav Kisch (Likud) was asked by MKs how much money would be set aside for the increase of covered treatments for next year.

Likud MK Yoav Kisch at the Knesset on January 17, 2018. (Hadas Parush/Flash90)

“The issue of the budget is still being discussed,” he said. “We intend to act to ensure that the health basket will not be hurt, and will include at least 500 million shekels.”

But the committee’s members aren’t so sure. Few health budget decisions are now being made in the Health Ministry, as the pandemic response overtakes other considerations and cannibalizes other health priorities.

In the end, Shemer said, the committee will do its work with or without a coherent budget framework. But unlike previous years, he warned, in the end it won’t be the committee that determines what is covered and what is left out.

“We will make the ranking even without a budget, but someone else” — the very cabinet ministers and MKs who have refused to set a budget framework, despite the harm done to the public service by that disregard — “will have to decide on the cut-off.”

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