NAELA's sixth international delegation traveled to Israel in June 2017. Led by NAELA President Hyman Darling and his wife Meryl, the group of 11 delegates and four guests started with a meeting with long-time NAELA member Israel ("Izzi") Doron, a law professor in the Department of Gerentology at the University of Haifa; his associate who heads the elder law clinic at the University; a law student; and Carmit Toledano, a lawyer with the Association of Law in the Service of the Elderly. (
See “
Elder Law in Israel,” by Kathleen Kienitz, CELA, in the November/December 2015 NAELA News.)
Professor Doron provided us some demographic background on elder law in Israel. The elder law concept is fairly new in Israel, a country smaller than Vermont with a population of about 8.6 million, 11 percent of whom are over age 65. Men receive an old age pension at age 67, women at age 62. The life expectancy for men of 81 and the life expectancy for women of 85 are among the highest in the world. The Israeli birth rate is three children per woman, which is significantly higher than the European birth rate of fewer than two children per woman. As a result, Israel's population is growing from within, rather than from immigration. Families stay in contact and live close to each other. Due to the slow growth in new housing construction, often three generations live together. This results in a better informal support network of family than found in other countries.
The Courts and Elder Law Israel
The legal structure in Israel is quite different from the U.S., as there are secular courts and religious courts. There are four religious court systems: Jewish, Islamic, Christian, and Druid. All marriage and divorce cases are heard in the religious courts, with litigants filing in the court of their religion. (We weren't clear about which court you select if the husband and wife are of different religions.)
When the Ottoman Empire ended in Palestine in 1915, Britain took over the area. Israel was established in 1948 and decided to keep British common law as the basis for its legal system, but there remains some influence from the Ottoman Empire. Israel has the distinction of having the highest ratio of lawyers to people.
Law students enter law school from high school, usually after their mandatory military service (three years for men, two years for women). Law school lasts 3-½ years, and then students must serve a one-year internship. The law school has 150 students per year, for a total of about 525 students. Presently, Israel has about 10 elder law attorneys, with only one in private practice, according to Ms. Toledano.
Long-Term Care a Shared Cost
The national health program covers long-term care, and average cost of care in a skilled nursing facility (SNF) is $4,000 per month. The Ministry of Health pays for care in a SNF, and requires that the children help subsidize the cost. Many seniors purchase long-term care insurance, which can cover three to seven years of care. The estimate is that only 4 percent of seniors are in SNFs, as most are at home.
There is a look-back period of 5 years for gifts, so if a parent gave money to a child, that child must use the money for the parent's care. Ms. Toledano feels that the government will expand the program with the Ministry of Health to cover the cost of long-term care for everyone in the future, without a subsidy from the children, by raising the health tax (which is now 100 shekels a month or more depending on your income). The exchange rate is 3.5 shekels to the dollar.
The Ministry of Welfare provides up to 18 hours a week of care at home, which can be provided by a family member. Two seniors can pool their hours and receive 36 hours a week of help.
Israel, as with other nations, is facing a shortage of in-home caregivers. Most home caregivers are migrant workers and their working conditions do not comply with Israeli law on time off, etc. A migrant worker must live in Israel, and is supposed to have 36 continuous hours a week off. Migrant workers cannot work as nannies or au pairs.
On another stop during our visit, we met with Yifat Solel, the chief lawyer for Ken la Zaken (Yes to the Elderly), and the chair of the Cooperative Alliance for Social, Economic and Environmental Justice. She is pursuing a class action lawsuit against a long-term insurer who decided not to renew long-term care policies for retirees of a company that went out of business. The claim is that the policies were defective because they weren't long-term and didn't provide care. These long-term care issues are global. Ms. Solel gave us slightly different information about the number of hours of home care available, and said that children of a person in a SNF must contribute to the cost of care, whether living in Israel or abroad.
Elder Law Clinic
Ms. Toledano told us of a case the elder law clinic pursued all the way to the Israeli Supreme Court. Their client, a woman, needed some help at home after the death of her twin sister, her caregiver, but the Ministry of Welfare refused to pay for it. The Ministry of Welfare placed her in an assisted living facility with a secure perimeter, although she didn't have dementia. She had no family to help her -- no children, no spouse, no nieces or nephews. The Israel Supreme Court ordered the Ministry of Welfare to pay for her care at home because she didn't wander and couldn't be forced to live in an assisted living facility. She's now at home with a home health care worker.
Ms. Toledano said that many of the Hotline calls to the elder law clinic are about money. If the elder calls, it is most often because the elder was fired or denied a pension. They have also received a question about placing a nanny cam in the parents' home or at the care facility where the parent lives, and the elder law clinic has raised the issue of the patient's privacy rights.
Housing for Seniors
We met with Steve Zecher, who created an organization called Co-Housing Israel (CHI), to design and build a community for aging residents as an alternative to an assisted living or residential facility for the elderly. There are about 159 co-housing communities around the world and Steve is looking for the best ideas from each of them. Usually the land cost is 8 to 10 percent of the total project cost, but land cost in Israel is high, and will be 30 to 35 percent of the project cost. With this initial challenge, Steve has 30 current members in the CHI project who are working to build a cooperatively owned building with apartments of 450-900 square feet. Steve said that the particular challenge in Israel is finding land, because 30 percent of the land in Jerusalem is owned by the Catholic Church or the Greek Church, and 95 percent of the land in the state of Israel is owned by the government.
Ministry of Health Geriatric Services
We met with Iris Rasooly, MD, MPH, who heads the geriatric services in the Ministry of Health. She gave us an overview of her role in policy making for the elderly in the community. She noted that the Ministry of Justice recently changed the laws of competency, guardianship, and patients' rights, which resulted in the health care proxy going from a two-page form to a 20-page form. She sees this as a major setback, because patients and health care professionals do not want to work with the longer form.
She related that the Ministry of Health funds 75 percent of the long-term care, with a means-based co-payment by the spouse and children of the patient. She was pleased to report to us that the Ministry has increased its visits to SNFs. It was visiting each facility twice a year, for a total of 600 visits a year, when there was a scandal over abuse secretly filmed by an employee of a SNF. Now the Ministry is doing 100 visits per month, with each visit taking a full day because it looks at eight different areas of the facility.
Other Visits
We travelled to Masada, and to the Dead Sea. We had a tour of Arab East Jerusalem with a representative from Ir Amim, an NGO focusing on present day issues. We visited Yad Vashem, a world center for Holocaust research, education, and commemoration.
We met with the CEO of a consortium of 56 organizations that works on behalf of Holocaust survivors. Their average age is 85-86, and they face the same issues as any aging group -- longevity, livelihood, and loneliness. In addition, they have more health challenges and often no family to help. This work is very personal to him, as his mother was a survivor of Auschwitz.
No visit to Israel would be complete without a visit to some of the many religious sites. We visited the Baha'i Gardens in Haifa and spent the night at a kibbutz on the Mediterranean Sea. On our way to Jerusalem, we visited Nazareth, where Jesus lived, and toured Bet She'an National Park, an archaeological excavation of more than 400 acres. The city on the site was originally established by the Egyptians in the 16th to 12th centuries B.C.E. We visited the Western Wall, the Dome of the Rock, and the al-Aqua Mosque.
Israel faces the same issues as we face here in the U.S. One example is whether the Ministry of Health will pay for the latest medical procedures. This is decided by a committee each December. The decision affects all four HMOs in Israel, as each receives funds based on the cost of the new procedure and the anticipated number of patients who will receive it.
Every country the NAELA delegations have visited - Cuba, China, Iceland, Ireland, and the Netherlands -- is facing similar issues: a larger percentage each year of the population is over 65, more people in the over-80 age group than ever before, more people needing assistance, more and better medical technology allowing people to live longer, and usually a shrinking population of the under-25 age group. Israel is unique thus far in that its birth rate is higher than many countries. The hope is that this may lead to better and longer care at home.