When she discovered she was carrying a child with Down syndrome, Daniela Bronstein and her family decided it would be best to hold off with plans to move to Israel. An already challenging transition, she explains, would have been made even more challenging.

So, instead of moving to Israel, the family relocated from New York to Pennsylvania, where Bronstein, in her 30s, had grown up and had a built-in support system. Her child, who recently turned 2, has benefited enormously from the Affordable Care Act (also known as Obamacare) and a host of other government programs.

But she fears these benefits could be cut by the new Republican administration, with its history of cutting government spending on social programs, and for that reason plans to move to Israel are once again in the cards.

“There is no question in my mind that if they actually got rid of those programs, we would have to leave,” she says. “And I also know we would be able to get the care that we need in Israel.”

President Donald Trump suffered a major setback in March when he was forced to withdraw his much-touted plan to eliminate the health-care reforms introduced under his predecessor. But that is little comfort for Bronstein.

“They’re still looking for ways to repeal Obamacare,” she says, referring to the program that was meant to cut the number of uninsured Americans, “and this is a major, major concern for us.”

Like many Americans, the sixtysomething Cheryl – who asked that her real name not be published – says she and her husband have seen their health-care costs rise dramatically in recent years. They would not have considered immigrating to Israel just to save on medical expenses, she says, but with her children and grandchildren already there, the added perk of affordable health care that would come with such a move makes the entire package more attractive.

“We’ve been paying a fortune for health care,” she says, “and if I find myself in a situation where the system fails for whatever reason, or with a health issue I couldn’t get taken care of in the United States, moving to Israel would definitely be a possibility.”

It would be an exaggeration to say American Jews are flocking to Israel in order to cut their health care expenses. But for those who have other good reasons to come or have always dreamed of making aliyah, Israel’s system of socialized medicine is often a tipping factor.

“Except in very specific cases, it is not going to be the main reason for making aliyah,” says a senior official at the Jewish Agency who has worked closely with American immigrants. “But the fact that Israel has reasonably priced, quality health services is a definite draw. I happen to know it’s an important issue for Americans because whenever we hold aliyah fairs in the United States, our sessions on health care in Israel are some of the most widely attended.”

Open gallery view The entrance to a branch of Maccabi, one of Israel's four health maintenance organizations. Credit: Eyal Toueg

Under Israel’s health care system, all citizens are entitled to basic medical services. The costs are covered mainly by a national health tax: Wage-earners and self-employed individuals pay 3.1 percent of their monthly salary up to 5,804 shekels (about $1,600), and 5 percent on everything earned beyond that. Women who do not work outside the home are exempt, while students, retirees and others who do not earn a fixed salary are required to pay a small fee of about $25 a month in exchange for coverage. All children are covered free of charge through the army.

In addition, Israelis pay very small co-pays for visits to the doctor and most medicines.

Services are provided through four main health maintenance organizations, known in Israel as kupot holim, which compete for patients. Beyond the basic government-guaranteed services, the HMOs also offer enhanced insurance plans for additional fees.

The Law of Return provides automatic citizenship to all Jews who immigrate to Israel. This means that immigrants are eligible for the same benefits as veteran Israelis as soon as they land in the country. As an added perk, during their first year in the country immigrants who do not work are exempt from the $25 monthly fee.

‘An added benefit’

Dr. Tanya Cardash, an adviser on health care for Nefesh B’Nefesh – the organization that promotes immigration among North American Jews – believes the Israeli system has key advantages, especially for those coming from the United States.

“From my experience, one of the most positive things is that you can’t be excluded from coverage because of a pre-existing condition, as you can be in America,” she says. “In addition, co-payments are considerably lower, both for doctor visits and drugs, and there’s no capping on the amount of services you’re entitled to. It’s not like they can tell you you can only have three MRIs a year. If your doctor in Israel thinks you need more, you can have more.”

But Cardash, a family doctor who also serves as a senior administrator at the Maccabi HMO, does not believe the more affordable health care system is a good enough reason to move to Israel. “What I would say is that you should come for Zionism or because you have family here,” she says. “Health care shouldn’t be the only reason. But once you’ve made the decision to come, it can definitely be an added benefit.”

Organizations that promote and monitor immigration from the United States do not typically collect data on how Israel’s health care system figures into relocation decisions.

“Immigration from the United States has been quite steady over the years, and the fact we aren’t seeing any major increase despite the sharp rise in health care costs in America would seem to indicate it isn’t a major factor,” says the Jewish Agency official. “What’s more, even if we did conduct a survey, it’s not likely we would get completely truthful responses.”

Like others interviewed for this article, Anne and Chuck asked that their real names not be used, out of concern that their motives for immigrating to Israel might be misinterpreted. As Anne notes, she and her husband had long dreamed of moving to Israel but had never found the opportune time until seven years ago, when they both got laid off from work and found themselves without medical insurance. At the time they were both 62 – a few years shy of eligibility for government-subsidized health care under the Medicaid program.

“We found that between our premiums and co-pays on private insurance policies, between the two of us we were paying $34,000 a year,” recounts Anne. “Since our parents were no longer alive, and we had been their main caretakers, we decided this was as good a time as any to fulfill our dream of moving to Israel. So while cutting medical expenses wasn’t the purpose of our move, it was definitely a contributing factor.”

What made insurance in the United States so expensive for them, she says, was that her husband had a pre-existing condition. “The fact you can get coverage in Israel, even if you have a pre-existing condition, is a reason lots of elderly people make the move, from what I hear,” she says.

Another factor for many retirees is the cost of medications.

Before Joan and her husband moved to Israel, several of their children were already living here and the couple would travel back and forth. Medical costs were a key factor behind their decision to eventually relocate to Israel.

“My husband is on Lipitor [a cholesterol-fighting drug], and when we were living in the United States his prescriptions cost us hundreds of dollars a month,” says Joan, in her 70s, and who asked that her full name not be used. “Here in Israel, we pay next to nothing for the exact same medicine.”

The fertility draw

Because they typically pay fewer visits to doctors and hospitals, younger people may not find Israel’s health care system to be as big a draw. There is one service it provides, however, that for some young couples trumps all other aliyah considerations: fertility treatments. Israeli citizens are entitled to free in-vitro fertilization treatments for the first two children, up to age 45, amounting to a huge financial incentive – worth tens of thousands of dollars, if not more – for women experiencing difficulties conceiving. For many, it’s a good enough reason to pack up and move.

Many do not end up staying, though, and as one doctor (who did not wish to be quoted by name) notes: “There is considerable abuse of the system: People apply for citizenship, they get treatments at the expense of Israeli taxpayers, and then leave.”

Israel has long played host to a large community of Jewish-American expats, many unsure of their long-term plans and not quite ready to exercise their right to citizenship in the country. Increasingly, the ability to gain access to affordable, quality health care is a decisive factor in such decisions.

Jen, a thirtysomething who asked that her actual name not be published, was one such case. After arriving in Israel on a student visa to pursue graduate studies, she found a job and applied for a work visa. After renewing the work visa several times, she figured it would be just as easy to apply for citizenship. “As I saw it, one of the main benefits was getting proper health insurance,” she says.

Jen has since married and given birth in Israel. The experience has strengthened her resolve that she made the right decision. “I had some complications and needed to be on extended bed rest,” she relates. “Being here in Israel rather than the United States saved me tens of thousands of dollars.”

Bob, in his late 20s, who also requested that his actual name not be published, was in a similar situation. While living in Israel on a work visa, he turned 26 and was then no longer eligible for health insurance under his parents’ family plan in the United States. Affordable health care, he says, was one of the reasons he ultimately applied for citizenship. “I would say it was a secondary factor in my decision,” he says.

Despite all its advantages, Israel’s health care system also poses considerable challenges for Americans brought up in a different medical culture. While most doctors are conversant in English, not all medical support staffers are, often creating difficulties and confusion. Hospitals tend to be understaffed, requiring family members to put in their own shifts, watching over patients, helping them get in and out of bed, spending the night, feeding and showering them, and so on.

And while Israel’s health care system has kept up with the 21st century for the most part, there are still areas where it lags.

“I was shocked when I came here and discovered that all communications with the clinics were done by fax,” remarks Anne. “Who even owns a fax machine these days?”