No child is deprived of his right to health care services?

R is the son of a single-mother migrant worker from the Ukraine. He is 16 years old and attending tenth grade in a central Israel high school. As many of his age, R gets supplementary income by waiting tables, and these days he is starting to prepare for his first matriculation exams.Recently, he has been complaining of headaches and increased fatigue during the day, which worried his teacher. Through an inquiry, she was amazed to discover that although R has been living in Israel since the first year of his life, he doesn't have, and never has had, medical insurance, and so the only medical care he is entitled to is restricted to emergencies.

R is not alone. Out of 8000 non-resident children living in Israel today it is estimated that over half of them, about 5000 children, have no medical insurance and are therefore not entitled to any medical treatment, except for emergencies and only after they suffer a dangerous deterioration in their condition. From here on we will review the issue of medical care accessibility amongst children of no status, we will try to understand how is it that children like R live amongst us without access to medical care, and we will suggest ways to correct the current situation.


The United Nations Convention on the Rights of the Child and its application in Israel 

In November 1989, the UN General Assembly signed the Convention on the Rights of the Child. This convention wished to express the general consent in the world that “the child, by reason of hisphysical and mental immaturity, needs special safeguards and care". The UN Convention for the Rights of the Child (UNCRC) acknowledged that the rights of children deserve special attention and states that states parties "shall respect and ensure the rights set forth in the present Convention to each child withintheir jurisdiction without discrimination of any kind, irrespective of the child’s or his or her parent’s or legalguardian’s race, colour, sex, language, religion, political or other opinion, national, ethnic or social origin,property, disability, birth or other status" (article 2.1 of the convention). Article 24.1 of the convention explicitly states that every child, of whatever status, has the right "to the enjoyment of the highest attainable standard ofhealth and to facilities for the treatment of illness and rehabilitation of health".

The state of Israel has ratified the UNCRC in 1991. As a major step in the implementation of the convention in Israel, and with the intention to promote the right to medical care among non-status children, the Ministry of health has issued an arrangement with 'Meuhedet' in 2001. This administrative arrangement depends on insurance fees paid by the insured child's parents and a Ministry of Health matching budget, and it is supposed to provide a framework that will ensure children currently present in Israel will receive the same medical care as children insured under the national health insurance law, regardless of the 'legality' of their stay in Israel (article 1.4 of the arrangement). And now, 14 years after its first application, it is estimated that only 40% of non-status children are insured under the 'Meuhedet' arrangement. What is the cause of the gap between the vision of the arrangement and its actual implementation?


Arrangement voluntarism and cost

P was born in Israel to a family of low social stat. Early in life he was diagnosed with severe developmental delay, and he suffers from cerebral palsy and epilepsy.  His parents understood that he needed continuous monitoring in a child development facility and medications, and so insured him with the 'Meuhedet' insurance plan. However, their financial situation forced them to cancel it. They are also unable to pay for the medical care P needs, or for his medications which he has to take on a daily basis.

One of the major barriers preventing the implementation of the 'Meuhedet' arrangement for all non-status children is that it is voluntary: imposing full responsibility, both for joining and for paying the insurance fees, on the minor's parents. This is in contrast to the national health insurance law which entitles Israeli children the right for health services, regardless of their parents' duty of payment and registration.

Imposing this responsibility on the non-status child's parentsbecomes even more problematic once you consider the fact that the good wishes and intentions of many parents might shatter in the face of the harsh reality of their lives in Israel. The 'Meuhedet' arrangement requires expensive fees, about 200 shekel/month for a single child and almost 400 shekels for two children or more, and there are no exemptions or discount rates available for indigent parents. For the non-status population in Israel, which consists of many single-parent families, such payment requirements become almost impossible. These people can barely make a living, and many times they are deprived of work permits, which make the insurance fees yet another burden they cannot handle, even if they wanted to.


Children not born in Israel

A, 18, arrived in Israel in 2007, after crossing the Egyptian border with his family. A suffers from kidney failure and needs dialysis. In spite of his illness his family did not purchase him health insurance due to its high cost. However, even if A started paying his insurance fees today, he would still have to wait the entire qualifying period for his dialysis treatment.

The State Comptroller's report from May 2013 regarding the treatment of minors without civil status in Israelstates that "the government did not set a clear policy regarding the treatment ofminors without civil status residing in Israel, which cannot currently be returned to their home countriesor other countries". A's case can serve as an example. Children who were not born in Israel and wish to be included in the 'Meuhedet' arrangement are required to wait six months from registration until the insurance takes effect, in which time they are left without insurance coverage even if they are in need of crucial medical treatment to stabilize their condition. Furthermore, the arrangement states that in the case of children who were not born in Israel, the insurance will not cover medical conditions which started prior to their entrance to the country. These two conditions are especially harmful to children of refugees and asylum seekers who arrived in Israel with their parents after escaping government persecution in their home countries.


Arrangement exceptions

M is a migrant worker from the Philippines who married an Israeli citizen. The couple had three children who are now 5, 3, and 1 year old. M and her husband are unemployed and so cannot afford a lawyer to help them through the process of attaining legal status for their children. As a result, the three children are left denied of access to health services and care.

Even though the 'Meuhedet arrangement is supposed to provide health care accessibility to the entire non-status children in Israel – "irrespective of race, color […] national, ethnic, or social origin […]whether the child's or his parents' or legal gurdians'"– in practice Palestinian children living in Israel are excluded from the arrangement, as well as solitary minors, and children of 'mixed' couples where the father is Israeli and the mother is foreign. In principal, these children can gain legal status by their father's citizenship. However, in order to achieve such status they are required to go through a long and expensive process in which their father's paternity is proven by a paternity test. In the waiting period until the long-awaited status is achieved the children are left without insurance coverage.


Arrangement alternatives/Suggestions for improvement

It appears that despite the good intentions, all the conditions and stipulations that are included in the 'Meuhedet' arrangement conflict with the spirit of the UNCRC. In fact, the arrangement imposes on non-status children the consequences of their parents' choices, and effectively adds another obstacle to their already harsh living conditions in the form of denied accessibility to available health care services in Israel.

According to the UNCRC, "States Parties shall undertake all […] measures for theimplementation of the rights recognized in the present Convention […] to the maximum extent of their availableresources." Many believe that depriving non-status children of health services is a purely financial matter. In fact, limiting accessibility to health care often leads to increased spending by the health services in Israel. This is because lack of basic child health care can often lead to deterioration of their medical condition and to emergencies which lead to long hospitalizations and complicated treatments. In most cases, the state is the one who pays for these hospitalizations and treatments.

It is obvious then that the alternative – that all non-status children will have medical insurance – is healthier both for these children and for Israeli economy. How, then, can we guarantee that "no child is deprived of his or her right of access to […] health care services" regardless of his/her legal status, parents' decisions or financial ability?

These days are the last of the 'Meuhedet' arrangement and the Health Ministry is working to draft an improved tender aimed to address the barriers and problems presented above. This is a good time to reflect and consider another alternative, better than any this or that correction to the arrangement. This alternative is to apply the national health insurance law on the entire population of children living in Israel, irrespective of their parents' status and without discrimination compared to resident and citizen children. Such a worthy step does not even require an amendment to current legislation if we consider article 56(A)1(d) of the 1994 national health insurance law. This article explicitly states that "the Health minister is allowed to set special arrangements with regards to HMO registration and routes of providing health services to those who are staying in Israel and are not insured under the current law with the extent and conditions that he/she shall set". It seems the time is right for such a step, which will bridge the gaps between the spirit of the UNCRC and reality in Israel with regards to health care services.


Written by Dr. Zoe Gutzeit (PhD), project coordinator in the Migrants and Status-less Persons department at Physicians for Human Rights.