Introduction

The strength of family care for frail older adults as the backbone of the informal support system is becoming an increasingly important public policy issue worldwide (OECD, 2017a, b). The global phenomenon of aging and the concrete consequences for eldercare is a shared issue, eventually affecting an entire society and it's economy. The occurrence of aging redefines our vision of the future and the quality of life. Family caregivers are responsible for maintaining the physical and mental wellbeing of the frail elderly under their care, and for routinely coordinating formal and informal community supports while preserving stability in the family (Li et al., 2015). In this respect, Israel, like many developed countries, faces the challenge of caring for a growing number of vulnerable older people through the formal and informal systems and of advancing adequate policies with the explicit objective of improving and maintaining wellbeing and durability of both the elderly and their family caregivers (Chernichovsky et al., 2017; Doron & Lazar, 2016; Iecovich, 2012; State Comptroller Special Report, 2017). The primary goal of the current study is to examine the way current legislation supports family caregivers facing the challenges of an elder aging-in-place. While previous studies have discussed family and informal care for aging Israelis (Berg-Warman et al., 2018), the legislation providing support or compensation to family informal caregivers has to date attracted only limited attention (Doron & Lazar, 2016; Doron & Linchitz, 2004).

Increases in life expectancy of more than 30 years in the twentieth century (Nash et al., 2015) and in chronic illnesses have significantly increased family care needs (Colombo et al., 2011). Despite the fact that the senior population is healthier than previous generations of seniors, the number of elderly whose activities are limited by some sort of physical or cognitive disability is growing disproportionately, because the number of very old people is growing disproportionately (Fast et al., 1999; Nash et al., 2015). Increasing efforts, accumulating resources and costs are required of family in order to fulfill care responsibilities for needy elderly (Kroger & Yeandle, 2014; Muir, 2017). It is therefore crucial to understand their impacts on family wellbeing and strength as well as how applied long-term care policies support them.

Long-term care policies in most economically developed countries currently rely on family caregivers (Horrell et al., 2015; Muir, 2017; Pickard et al., 2012), and nearly 80% of these informal caregivers are spouses or adult children (Lin et al., 2012; Wolff & Kasper, 2006). Studies indicate that this segment of society is at risk for experiencing care burdens which, in turn, undermine their wellbeing and decrease the quality of care provided (Verbakel, 2018). The financial, health and social consequences of caregiving can substantially increase the risk of poor caregiver outcomes and caregiver burnout (Fast, 2015). Literature evidence shows that growing demands for family informal care is associated with personal, health, social, and economic costs for the caregivers, which have risen dramatically over the last three decades and will only continue to increase (Fast, 2015; Roth et al., 2015). Moreover, these effects can accumulate and intensify over the course of the adult caregivers’ lives and spill over to other stakeholders, such as employers and public service providers (Fast, 2015). These circumstances underlie an emergent need to better understand factors, at the policy level, that address family vulnerability and ensure the wellbeing of family with eldercare responsibility. Despite the fact that researchers have extensively examined risk factors associated with caregiving and suggested ways to promote caregivers’ wellbeing (Chappell et al., 2015; Pinquart & Sorensen, 2011), less is known about the role of related legislation. By focusing on the Israeli case, this study attempts to understand the way current aging-in-place policies support family caregivers through legislation, beyond the long-term care insurance law (CLTCI), thereby raising the discussion on its various implications for the family’s wellbeing.

The study focuses on Israel, where a greater share of the burden of caring for the elderly falls on households compared to most OECD countries (Muir, 2017; OECD, 2016). Israel has a larger percentage of recipients of long-term care provided for by the community, not by institutions; approximately 19% as compared with only 9% for OECD countries (Chernichovsky et al., 2017; Taub Center, 2017). State authorities rely on the family and relatives to provide caregiving for the elderly, thus saving on public resources (Hasson & Dagan Buzaglo, 2019). The Israel State Comptroller has pointed to the fact that broad family informal involvement as caregivers reduces national spending on long-term care and that the state places the practical responsibility for long-term care overwhelmingly on family members, while viewing its own role as complementary (State Comptroller, 2017). Additionally, the paucity of options and access to institutional care available in the country compel a greater commitment to caring for Israel’s elderly in the community (Chernichovsky et al., 2017). Under such conditions a major burden falls on families either to fund care independently—whether by paying for care frequently provided by foreign workers or by missing work days. In many instances family members must scale back, working fewer hours than they would need or like or actually resigning from work altogether to care for their aging parents (Brodsky et al., 2011; Taub Center, 2017). Moreover, an international comparison suggests that the Israeli long-term system is inequitable and inefficient (Chernichovsky et al., 2017). Considering this salient circumstance, a re-examination of legislation contributing to the durability of family caregivers is critical (Dwolatzky et al., 2017). This brings us to an examination of the main research question: Within Israeli long-term care policy how does existing legislation support family caregivers acting as a complementary resource for the formal care system?

The present paper thus contributes to the literature focus on intergenerational family care and family wellbeing in an aging society in two principal ways: First, it responds to a recent call to compare how different aging-in-place policies support family caregivers and mitigate the negative implications of the care burden on family wellbeing and strength (Colombo et al., 2011; Kroger & Yeandle, 2014). Support of family intergenerational care by policy is of increasing importance, particularly in countries that are currently considering a reform in their long-term care systems. Acknowledging that despite differences in countries’ long-term care policies, they all apparently face challenges for securing informal care systems as a complementary source to the formal systems (OECD, 2017a, b), this paper offers a valuable lesson based on the Israeli case. The aim of supporting family caregivers necessities a broad understanding of the concrete policy and its outcomes. Second, while scholars have raised concerns about the future supply of family informal care (Pickard et al., 2012) as well their availability to provide care (Centre for Policy on Aging, 2014; Colombo et al., 2011), this study expands the discussion on these trends and emphasizes the way changing family forms and structures do not meet rising needs for care.

The paper is organized as follows: It begins with a review of policy and family care in an aging society, changing family structures and the availability of informal caregivers and the link between caregiver burden and family wellbeing. Next, it presents the scope of the problem regarding family caregivers in Israel, followed by a review of the major laws. Then a discussion is presented on what this review indicates about the policy process, the policy’s impact on family relations and a call for future research. The article closes with a brief conclusion and discussion of implications for policymaking.

Policy and Family Care in an Aging Society

Discussing the impact of providing informal care to elderly on families’ wellbeing necessitates an understanding of the actual present and past public policies in any given country. The demand for elder care services is currently being met mainly through three different types of care, where the first and common type is informal support (Gupta & Pillai, 2002). Since our aging society is exerting an enormous strain on public health and welfare systems to meet the needs of aging individuals, policymakers in many developed countries are focusing on reducing this budgetary encumbrance by promoting informal caregiving based on families and relatives’ responsibility (Metzelthin et al., 2017; Pavolini & Ranci, 2008) and reducing public expenditure for institutional care (Colombo et al., 2011; Lopez-Hartmann et al., 2012). This is also the case in countries with high public spending and low family responsibility that currently focus on shifting to more social responsibility and informal care (van Groenou & De Boer, 2016). As a result, family and informal caregivers provide as much as 80% of community care in many countries (Horrell et al., 2015). They represent the most important source of support and are essential and critical figures for maintaining frail elderly at home or in community dwelling (Berg-Warman et al., 2018; Doron & Lazar, 2016; Colombo et al., 2011; Lopez-Hartmann et al., 2012). Previous studies point to the spouse, a child or other family member as the usual primary caregiver (Brodsky et al., 2011; Chappell & Holander, 2013; Doron & Lazar, 2016). The global profile underscores the fact that the primary source of caregivers for frail elderly parents and parents‐in‐law are mostly female (Gitlin & Schulz, 2012; Lane et al., 2020; Michaud et al., 2010; OECD, 2017a, 2017b). The greater involvement of wives and daughters in care provision, including personal care, is well documented in gerontological researsch (Chappell & Holander, 2013). Across OECD countries, on average 61% of those providing daily informal care are women (OECD, 2019).

It is important to note that relying on family members for care has two distinct main social and economic advantages when examined through the public policy lens: It improves elderly persons’ quality of life by enabling them to continue their routine life in their familiar environment and community, and it saves public resources (Brodsky et al., 2011). Despite these two policy advantages, informal care at the family level, although unpaid, is not without cost (Colombo et al., 2011). As we claim, policy that leads to a reduction in caregivers’ external support is likely to intensify the negative impact of caregiving and subsequently reduce the caregivers’ wellbeing. We draw on previous studies indicating that caregivers’ external resources can be relevant for explaining the impact of caregiving on their wellbeing (Chappell et al., 2015; Gray & Pattaravanich, 2020). At the policy level, for example, cutbacks in publicly funded professional home and residential care, declines in local community services, fewer benefits for informal care provision, lack of benefits to replace lost income or cash-for-care benefits and less publicly funded support services are all related to a greater burden (Israel state comptroller, 2017). It is important to note that public spending on long-term institutional care is higher than public spending on homecare, apparently because of the steep cost of employing skilled professionals such as doctors and nurses. Care within the community, on the other hand, relies on relatively inexpensive workers (Hasson & Dagan Buzaglo, 2019). Further, since use of formal service was also associated with better psychological well-being of informal caregivers (Nakagawa & Nasu, 2011) decreases in formal services has been related to greater burden among family caregivers (Zarit et al., 2011). The discussion now turns to explaining how, under the above-presented policy conditions and due to changing family forms, caregivers of frail older adults are likely to experience stress and burden, which in turn negatively impact their wellbeing and strength.

Changing Family Structures and the Availability of Informal Caregivers

Providing family care to frail older people is a complex process in which the availability of potential caregivers, the needs of the recipient, cultural norms and expectations all play an important role (Gruijters, 2017). In the context of population aging, there are concerns about the future supply of family informal care (Pickard et al., 2012) as well their availability to provide care (Centre for Policy on Aging, 2014). Evidence indicates that changes in family structure resulted in less availability of care (Colombo et al., 2011; Verbakel et al., 2016). Studies of changing family and household composition in European and other OECD countries have reported various findings on the effects of the postponement of family formation, lower fertility rates, the rise in childlessness and increased female labor market activity in the postwar baby-boomer generations on intergenerational relations and care (Centre for Policy on Aging, 2014). Care also becomes more complicated to organize, since the more complex family relationships, trends in partnership formation and dissolution (consensual unions, lone parenthood, marriage, remarriage and divorce) reduce co-residence between generations and family support for relatives (Pickard et al., 2012).

A growing family care gap currently exists as the number of older people in need of care outstrips the number of family members able to provide it. This can be illustrated via two of the simplest measures commonly used to assess the burden of the elderly in both aging and gerontology literature: the old-age dependency and the care dependency ratios (United Nations, 2015). The former is defined as the ratio of the elderly population to the working-age population (20–64) (Bank of Israel, 2012). As the number of elderly grows in European countries (and many other developed economies) while the number of working-age residents shrinks, these societies face an increase in the old-age dependency ratio (World Bank Report, 2010). On average across all OECD countries in 2015 there were 28 individuals aged 65 and over for every 100 persons of working age 20 to 64. The old-age dependency ratio will equal 14 in 2050, and it is expected to double again in less than 50 years, reaching 58 in 2075 (OECD, 2017a, b). Next, the care dependency ratio is defined as the ratio of the population needing support with activities of daily living (ADL’s) compared to the rest of the population; specifically, how many non-hampered people are available for each (partially or severely) hampered person (World Bank Report, 2010). Scholars around the globe expect that in many countries both the old-age dependency ratio and the care dependency ratio will increase considerably (OECD, 2017a, b; World Bank Report, 2010). This will cause the dependent ADL percentage (especially those with severe restrictions) to increase significantly while the number of potential care providers, in particular potential providers of informal care/family care, decreases. Previous forecasts suggest that 1.1 million older people in England will need care from their families by 2032—an increase of 60%—but the number of people able to care for older parents will have increased by only 20%, creating a shortfall in our collective capacity to care for older generations (McNeil & Hunter, 2014; Pickard, 2015).

It is important to note that even though the care balance is being undermined, family caregivers still represent the most important source of support for people in need of care in most countries (Schmidt et al., 2016), and provide the biggest source of help for the elderly and for the sustainability of the chronic healthcare system (Criel et al., 2014). Furthermore, where change in family forms and structure does not meet rising needs for care, family caregivers face stress and burden, as explained below.

Caregiver Burden and Family Wellbeing

Caregiver burden is explained as the stress, tension, and anxiety caregivers feel and experience when faced with problems and challenges in caring for their care receiver (Chappell & Dujela, 2008). Burden results from discomfort and strain when providing acts of caring for the care receiver (Lai, 2010; Mendez-Luck et al., 2008). Family caregivers’ perceptions of such burden affect the impact of that burden on the caregiver’s life (Lai, 2010; Van Den Wijngaart et al., 2007). Previous studies have found that family caregivers who act as live-in caregivers, caregivers of people with dementia, caregivers of older adults with impairment in activities of daily living (ADL tasks) and instrumental activities of daily living (IADL tasks), and caregivers with unmet needs or lack of support, experience more burden (Kristof et al., 2017; Robison et al., 2009).

This study draws on Lawton’s two-factor model for describing the relationships between different predictors of positive and negative caregiving outcomes among spouses and adult children which demonstrates that while caregiving burden leads to more negative effects, satisfaction with caregiving leads to positive effects (Lawton et al., 1991). On the positive side, care provision has the potential to strengthen and encourage the bond between the caregiver and the person under his or her care, promote a sense of purpose in life, and raise positive emotions for the caregivers through their experience of supporting someone in need (Li et al., 2015). However, negative effects of caregiving have also been shown, since studies consistently link caregiver burden to decreased family wellbeing (Kristof et al., 2017; Ringer et al., 2016). When family members give up their time to look after family elders when they could be utilizing this time for work, household, leisure and other responsibilities, this raises many stresses and burdens (Lai, 2010; Wagner & Brandt, 2015). This stress is linked to role conflict and is related to caregivers’ needing to simultaneously balance major roles such as spouse, parent and breadwinner (i.e., employee or employer) with care for elderly relatives (Gupta & Pillai, 2002; Katz et al., 2011; Lai, 2010). Role conflict is also seen when caregivers have limited time for their children and family, possibly leading to potential psychological stress for the caregiver as well as a reduced amount of self-care and relaxation time (Ho et al., 2003). These conflicts may lead to reduced marital satisfaction, increased marital stress, physical feelings of exhaustion, and somatic responses such as disrupted sleep patterns (Gupta & Pillai, 2002). Recent analyses in European societies, using SHARE indicators of psychological and physical health and the financial situation of family members, suggest that those offering support to adults reported lower levels of wellbeing compared to those not engaged in caregiving at all (Karpinska et al., 2016, p. 10). Similarly, extensive reviews focused on the impact that providing care has on the health, wellbeing and labor force prospects of caregivers among the OECD countries have shown that caregivers face increased risk of mental health problems and may find it difficult to remain employed (Colombo et al., 2011). Caregivers also carry visible and hidden costs, including out-of-pocket expenditures, foregone employment opportunities, unpaid labor, and related costs (Fast et al., 1999; Kristof et al., 2017; Kroger & Yeandle, 2014; Ringer et al., 2016). It has been found that external resources, such as supporting policy, may alleviate the burdens and negative reactions among family caregivers during this often stressful time (Brodsky et al., 2011; Fast, 2015; Glass et al., 2016). It is therefore important to examine the extent to which existing legislation supports family caregivers. We next discuss whether this is in fact the case in Israel.

Rationale and Research Context

Family and Informal Caregivers in Israel: Themes and Nature of the Problem

Israel is faced with the challenge of providing care to a generally rapidly growing and distinctly heterogeneous older population as well as within the community (Brodsky & Morginstin, 1999; Doron & Lazar, 2016; Dwolatzky et al., 2017; OECD, 2016; State Comptroller Special Audit Report, 2017). A recent policy paper indicates that Israel’s population is aging quickly; the share of seniors in the population, especially those aged 70 and over, is projected to double by 2035.

As in other countries, population aging is largely a consequence of the decline in fertility rates, and of the continuous increase in life expectancy. In Israel, life expectancy at age 65 is gradually trending upward. Since 2000, it has increased by 2.9 years for men and by 3.2 years for women (Israel Central Bureau of Statistics, 2016): 84.7 years for women and 81 for men. Life expectancy for men is one of the highest in the world (Mevorach, 2016).

Demographic characteristics of the population aged 65 and over indicates that while Israeli society is relatively young compared with other industrialized countries, it is aging rapidly (Israel Central Bureau of Statistics, 2016; Mevorach, 2016). Data regarding Israeli aging shows that in October 2020 the population of persons aged 65 and over was about 1,093,500–606,000 females and 487,000 males, or 12.0% of all residents. Of this cohort, 40% were over the age of 75, and 12% were over the age of 85. Women constituted 62.2% of those aged 85 and over, and men 38% (Fig. 1; Diagram 1). The proportion of women to men increases with age due to their longer life expectancy. The Israeli population is gradually aging; at the establishment of the State (1948), senior citizens constituted only 4% of the population, in 2019—12.0%, and this percentage is expected to rise to 14% in 2040 (approximately 2 million persons) (Israel Central Bureau of Statistics, 2016).

Fig. 1
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Diagram 1: Persons aged 65 and over, by gender and age. Data: The Central Bureau of Statistics (Israel): Selected Data on Various Topics Regarding. Israeli Senior Citizens Aged 65 and Over, October 2020. https://www.cbs.gov.il/en/mediarelease/Pages/2020/International-Day-of-Senior-Citizens-Day-2020.aspx

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Consequently, functional impairment—which is naturally higher among the elderly—is expected to rise 16% faster than growth in Israel’s population. The changing ratio between age-groups—more people aged 70 and over, in relation to those aged 15–69—is expected to increase the long-term care challenge as well as the burden on households and on the economy as a whole (Chernichovsky et al., 2017, p. 3). Approximately 98% of the care provided to older Israeli adults is given at home, with only 2% residing in long-term care institutions (OECD, 2016). This underscores Israel’s subscription to the Madrid Plan, which focuses on aging-in-place with dignity and in the community (Doron et al., 2005). Demographically, in Israel, older people (65 years or older) constitute only about 12% of the population however, the absolute number of older people is growing, life expectancy is high and increasing numbers of people are living to an advanced age (over 85 years) (Dwolatzky et al., 2017). The percent of elderly who live alone comprises an important datum for understanding the need for receiving help from relatives and services for the elderly population: 23% of those aged 65 or older (who live in the community) live alone. The rate of elderly women who live alone is much higher than the rate of men (32% and 12%, respectively). The rate of women and men who live alone increases with age (30% of men aged 75 or older compared to 18% of men aged 65–74) (Brodsky et al., 2017).

Within this demographic shift, the parent support ratio used to approximate potential family support available to the elderly (represented by the number of persons 80 years old and over per a population of one hundred persons aged 50–64 years) (Mot et al., 2012) is expected to grow from 208 in 2015 to 295 in 2030 and 346 in 2035 (Brodsky et al., 2017). Also, the higher proportion of elderly in the Israeli population is reflected in an increase in the old-age dependency ratio, and by an increase in the proportion of the over sixty fives who suffer from physical limitations, impairing their ability to carry out day-to-day activities (Bank of Israel, 2012). Previous studies suggested that the percentage of those aged 65 and older who have physical disabilities and chronic diseases requiring constant care, assistance at home, long-term care and family or caregiver support is increasing (National Insurance Institute of Israel, 2011; Doron & Lazar, 2016). Older adults, particularly aged 75 and above and those with chronic conditions, remain independently at home in the community, but require considerable levels of family care. As a result, being an unpaid caregiver for one’s adult family member is increasingly common in Israel, as growing numbers of disabled individuals need help with major ADL tasks such as housekeeping, nutrition, hygiene, maintenance and transportation (National Insurance Institute, 2015).

Despite changes that have taken place in Israeli family structures, Israel is still a more family-oriented society than some other countries (Halperin, 2013, 2015; Katz & Lavee, 2005), and family norms in the context of caring for aging parents are strong (Katz et al., 2003). Israeli elderly traditionally tend to enjoy the support and assistance of their family members (Ayalon & Green, 2013), who usually live in close proximity and provide a substantial amount of care (Iecovich, 2012). As they age in place, the elderly rely more and more on their family’s informal resources (Iecovich, 2008, 2012). The need for family caregivers has therefore escalated, particularly for those assisting chronically ill patients (Berg-Warman et al., 2018).

With regard to gender division of informal care, in Israel, as in most countries, long-term eldercare is by-and-large informal (without payment) and more widely performed by female family members. An estimated million and a half Israelis—most of them women—serve as primary caregivers of a relative or friend who is ill, disabled, or elderly, usually while maintaining a household and career (Hasson & Dagan Buzaglo, 2019). Women constitute some two-thirds of the primary caregivers, are 55 years old on average, and typically provide 21 h of caregiving a week for an average four and a half years, all without financial compensation (Brodsky et al., 2011; Doron & Lazar, 2016). The issue of gender differences in Israel is similar to other developed countries and global studies indicate that numerous negative effects associated with eldercare are far more prevalent among female caregivers than among their male counterparts (Bookman & Kimbrel, 2011; Lane et al., 2020). An American study indicates that women not only provide more parent care than men, but they also suffer from higher costs of parent caregiving than do men (Grigoryeva, 2017). Generally, the abundant research on gender differences in caregiving for older adults emphasizes that women tend to be involved in more hours of care, provide more hands-on care and associated tasks than do men (Chappell et al., 2015). As in other developed economies, Israeli eldercare, and particularly the gender division, are of social concern, encompassing as they do substantial consequences (both positive and negative), for the well-being of families informal caregivers and their care recipients. Studies indicate that these issues of gender inequality, labor market inequities, even poverty have far-reaching implications on the larger society (Lane et al., 2020; Williams, 2012).

After considering these consequences, the discussion now turns to understanding how long-term care is distributed between the government and the family in Israel. We introduce long-term care policy within the community in light of the care deficit.

Long-Term Care Policy in Israel

Home care for the elderly is the main long-term care (LTC) service to the elderly in Israel (Asiskovitch, 2013; Katz et al., 2011). This long-term care policy, called mixed care (Halperin, 2013), includes both formal care that refers to provisions for dependent people by health and social care professionals within regulated employment relationships, and to informal care which refers to voluntary care or support given to a dependent elderly person by a family member, friend or acquaintance. In Israel, there is no strict separation of roles between the formal and informal support systems, and the formal care model supplements, but does not replace, informal care (Brodsky et al., 2011; Halperin, 2013).

Over the last three decades, the governments of Israel, like other OECD countries, have promoted initiatives aimed at maintaining the frail elderly at home longer and delaying nursing home admission (Muir, 2017). According to the National Insurance Institute of Israel’s annual report (National Insurance Institute of Israel, 2013), expenditure for long-term community care services represented 17% of public funds before the implementation of the CLTCI law in 1988. This amount increased to 50% by 1994, and today constitutes about two-thirds of all expenditures. Specifically, the proportion of individuals receiving formal home-care service increased from 2% of the total older population before implementation of the law, to 17% in 2014 (Dwolatzky et al., 2017, p. 2544). Despite this pioneer policy of the community long-time care insurance law and program that substantially increased the amount of government resources earmarked for community care (Dwolatzky et al., 2017), it gave only a partial answer for family caregivers with eldercare responsibility. Brodsky and Morginstin (1999) described the situation in Israel as extremely complex, since the increasing number of disabled elderly cost the formal care system more than it can afford to spend and caused policymakers to order less expensive care solutions by locating them in the community (p. 80). Hence, the current study focuses on community-based services, not on geriatric institutions. Numerically, about 97.9% of the elderly (65+) in Israel remain in the community (Shnoor & Cohen, 2020, p. 95), as do approximately 87% of those entitled to long-term care benefits (Hasson & Dagan Buzaglo, 2019). With this background in mind, we examine the way legislated laws support families with eldercare responsibilities alongside the community long-term care insurance law (CLTCI) and long-term care insurance program (LTCIP).

Methodology

Sources and Method

The current study employs a case study research design for investigating how laws legislated in Israel beyond the community long-term care insurance law (CLTCI) support family members who have the responsibility of caring for frail older relatives. Case study research is most often described as qualitative inquiry (Creswell & Creswell, 2017; Denzin et al., 2011). Examination of the research question draws on Yin’s (2003) suggesting that a case study design should be considered when: (a) the focus of the study is to answer “how” and “why” questions; (b) you want to cover contextual conditions because you believe they are relevant to the phenomenon under study. These key conditions fit our research question. A case study research design was chosen because we focus on legislations that could not be considered without the understanding the situation of Israeli family caregivers, the local aging-in-place context and current long-term care policy. Baxter and Jack (2008) argue that a 'qualitative case study is an approach to research that facilitates exploration of a phenomenon within its context using a variety of data sources' (p. 544). In regard to the current research questions this ensures that the issue is explored through a variety of lenses, thus allowing for multiple facets of the phenomenon to be revealed. In the same vein, Yin (2003) has suggested that the use of multiple sources of evidence in case studies permits an investigator to address a broader range of historical, attitudinal, and behavioral issues. The research question was thus examined using sources including official legislation, guidelines and institutional documents. The analysis stage is based on the requirement that the researcher must ensure that the sources and information are converged in an attempt to understand the overall case, not the various parts of the case, or the contributing factors that influence the case (Baxter & Jack, 2008).

Materials, Procedure and Document Analysis

The study employs document analysis, which is a commonly used method in case study research (Baxter & Jack, 2008) and because information gleaned from documents provides the case study researcher with important information from multiple sources that must be summarized and interpreted to address the research questions (Algozzine & Hancock, 2016). This study principally focuses on legislation and in the context of legislation analyzes, amendments, leading government policy documents (Ministry of Labour and Social Affairs Service for Senior Citizens), relevant Knesset (parliament) committee reports, official publications of the Bank of Israel and State Comptroller's reports. These materials encompass the last three decades and cover the legislative of family informal care and long-term care in Israel since 1948. This study is consistent with Merriam’s (1988) argument that documents (of all types) assist the researcher to 'uncover meaning, develop understanding, and discover insights relevant to the research problem’ (p. 118). We rely on scholarship suggesting that document analysis is particularly applicable to qualitative case studies, especially intensive studies producing abundant descriptions of a single phenomenon or program (Bowen, 2009; Stake, 1995).

Document analysis involves skimming (superficial examination), reading (thorough examination), and interpretation (Bowen, 2009). The complete process of documents analysis includes two main steps. First, the meaning of each document and its contribution to the family informal care topic is established. Six major themes were identified: (1) elder care; (2) informal care; (3) family caregivers’ legislation, benefits, subsidies and rights; (4) unpaid care; (5) community long-term care insurance law; (6) aging in place policy. Each of these six themes repeatedly appeared in the content sources. Policy documents and official reports that discuss eldercare and family care issues less explicitly were excluded from this study. Both authors have access to key documents and all material in the public realm. As a second step, information was organized into established framework, while legislation, documents and reports were compared and central themes identified.

Effort was made to avoid a common pitfall associated with case study—the tendency to answer too broad a question or cover a topic that has too many objectives for a single study (Baxter & Jack, 2008). We adopt Yin’s (2003) and Stake’s (1995) suggestion regarding boundary-setting. In this context, we implement suggestions on how to ‘bind’ a case, including: (a) time and place (Creswell & Creswell, 2017); (b) time and activity (Stake, 1995), and; (c) by definition and context (Miles & Huberman, 1994). Binding the case ensures that this study remains reasonable in scope (Baxter & Jack, 2008). Finally, by triangulating data and examining information collected through different sources, we attempt to corroborate findings across datasets and thus reduce the impact of potential biases that can exist in a single study (Bowen, 2009). Based on Stake (1995) the types of triangulation applied are data (source) triangulation, namely using more than one data source, and encompassing broad legislation since the establishment of the state in 1948 and leading policy documents from government authorities, Israeli Knesset committee reports and official publications of the State Comptroller's report over the last three decades.

Findings

Supports for Family Caregivers: Laws and Policy

The following findings are presented. First, each related legislative act is analyzed and the rights entailed to family caregivers are explained. Second, the legislative contents are organized, analyzed and summarized under three major rubrics: (a) Category, (b) Benefit type, and; (c) Eligibility (also conditions for eligibility) as introduced in Table 1.

Table 1 Summary of legislation: rights of individuals caring for an elderly family member
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In Israel, the obligation of children toward their elderly parents is anchored in law. Specifically, Israel’s strong familial culture is manifested through the Family (Alimony and Maintenance) Law of 1958, which obligates adult offspring to financially support parents and grandparents if they are unable to provide for themselves (Katz et al., 2011, p. 163). The family is identified as a primary factor with direct responsibility for its elderly members in terms of health, economic security and welfare. In fact, government offices may require families to care for an elderly relative before they agree to supply formal services (Brodsky et al., 2011). One of the family's main tasks is to represent the elderly person to service providers. In some cases, such as when a legal guardian has been appointed or power of attorney has been granted, this is defined by law. In other cases, the caregiver's role as mediator grows out of the dynamic between the elderly person, the family, and the service system.

The legal rights of family caregivers focus mainly on finances and employment and four laws govern caregiving by a relative. The legislation that defines the state’s support for family members who are the main caregivers of the elderly is presented herewith. The government’s policy for caring for persons aged 65 and older, which relies on basing the responsibility for care among relatives and especially in the community through a welfare pension, is expressed in the following laws that were ratified over the years: (1) Sick Day Payment Law 1993; (2) Section 6 of the Compensations Law 1963; (3) Section 44 of the Income Tax Law 1980; (4) Section 2(7) of the Income Tax Law 1980; (5) The Equal Rights for Persons with Disabilities Law (1998).

(1) The Sick Day Payment Law

The Sick Day Payment Law 1993 for a relative who cares for a relative affords a partial solution to absence from work due to the illness of a parent or a parent-in-law (Amendment 1995). It is important to note that the law allows employees to use up to 6 sick days per year from their accrued personal sick days due to illness of a parent or spouse's parent. This is actually the first law that was legislated with the explicit goal of directly coping with the issue of the aging of society, and with the appearance of informal care for the elderly (Doron & Linchitz, 2004) and its impact on employees’ functioning (Halperin, 2013). According to the letter of the Law, a worker whose parent or in-law has reached the age of 65 (henceforth: the parent) is entitled to up to six days a year of absence due to the parent’s illness, to be paid from his or her accumulated sick days period, on condition that the partner also works and is not absent from work as a result of entitlement according to this Law. In order to realize sick days according to the Law, it must be proven that the parent who became sick became completely dependent on the help of others for ADL tasks (as defined in Section 127, sub-Section 83 of the National Insurance Law [consolidated version] 1968), (The Knesset: Research & Information Center, 2012). However, this legislation restricts the main caregiver in the event that the parent is found in a nursing institution as defined in Section126, sub-Section 83 of the National Insurance Law [consolidated version] 1968, such that he or she is not entitled to credit his or her accumulated sick period for absence in order to care for the parent, as mentioned in Section 1 of the Law. The Law further states that two cannot be entitled for the same period. Thus, a worker whose spouse or sibling is absent from work due to the parent’s illness is not entitled to be absent from his or her work for the same issue and during the same period of time (“sibling”—another son or daughter of the parent, including an adopted child). Previously, a person was allowed to be absent from work using sick days only if the parent was 65 or older. This age restriction was canceled in the amendment to the Law from February 2014. Employees are also entitled to be absent for up to 7 days a year to care for a spouse or parent who is donating organs for a transplant.

(2) Section 6 of the Compensations Law

Section 6 of the Compensations Law (1963) deals mainly in the issue of an employer terminating the employment of a worker, and was not legislated as part of the policy for supporting relatives who afford informal care for an elderly family member (Brick & Doron, 2010). This is a broader law and refers mainly to resigning from work due to the impaired medical situation of the worker’s spouse, parents, or in-laws (on condition that the in-law lives with them and they carry the main burden of support). Workers who are forced to quit their job in order to care for their spouse, one of their parents or their parents-in-law who live with them, are entitled to severance pay and all rights of a worker who was fired from his workplace and is therefore entitled to this compensation. This means that the need to quit does not lead to loss of the right for severance pay and the financial harm due to cessation of the worker-employer relations is more moderate. Furthermore, the worker can immediately receive unemployment benefits or a reduction of days. The Law does indicate that employers must take an active part in the financial and social cost involved in children’s caring for elderly parents (Brick & Doron, 2010).

(3) Section 44 of the Income Tax Law

Section 44 of the Income Tax Law helps children who care for their elderly parents to receive an income tax benefit. However, there are stipulations for receiving this benefit—when the elderly person is “helpless” (paralyzed, bedridden, blind, insane, and so forth) or hospitalized in an institution. This policy tries to help with the financial burden of the caregiving relatives, but is partial and marginal assistance and only in cases where constant and continuous care is necessary. Children who participate in funding the hospitalization expenses in a nursing home for a parent will receive a 35% tax exemption. This will be given only if the income of the elderly person and his or her spouse does not exceed a certain threshold. It will also not be given for the entire expense, but only on sums that exceed 12.5% of this person’s income for tax purposes.

(4) Section 2(7) of the Income Tax Law

Section 2(7) of the Income Tax Law 1981 enables reception of a pension for a period of six consecutive months when caring for a spouse (who reached the age of 65 for a man and 60 for a woman) or a sick child. Thus, when a person cares for his or her elderly spouse who needs constant supervision, he or she is entitled to receive a pension without having to prove that he or she is unfit to work. This law only meets the needs of situations in which prolonged and constant care of the elderly is necessary.

In order to receive income support, the person needs to meet three conditions: (1) residency in Israel for the past 24 consecutive months; (2) the income of the person and his or her spouse does not exceed a certain sum that is determined according to age, family status and number of people in the family; (3) employment test—whether the person tried to become included in the labor market and did not succeed. Populations that are exempt from the employment test and are eligible for income support when meeting only the first two conditions include people who care for a sick relative (spouse or parent, child or adult child) who needs constant supervision, on condition that this relative lives with the sick person and cares for him or her for most of the day for at least 45 consecutive days (prior to submission of the application for income support). Eligibility is given for six months, unless the sick parent is over 65 (for a man) or 60 (for a woman). Eligibility for income support is not given if the sick person receives a special services pension or if another person is entitled to a pension for caring for this sick person.

Doron and Linchitz (2004) claim that the scope of legal support is very limited and indicate several problems that arise from the field: the Law does not meet the needs of relatives who are the main caregivers; there is no uniformity in the definition of relatives who are entitled to benefits, and the definition is relatively restricted; in most laws, the spouse and children of the elderly are entitled to benefits. Data indicate that between one tenth and one fifth of the main attendants are not spouses or children of the elderly, but rather other relatives, and 40–60% of the elderly receive help from other relatives (Brodsky et al., 2011). It therefore appears that the restricted definition does not actually meet the demands of the caregivers. For example, sons/daughters-in-law are entitled to severance pay only if they live with the elderly and pay for most of his or her expenses, and are not entitled to receive an income tax benefit (even though theoretically, according to the Procedure of the Ministry of Welfare, they are obligated to pay for the institution). An adult grandchild who helps his or her grandparent is also not entitled to any benefit.

Another problem is that the definition of the elderly’s disability is relatively strict. A worker is entitled to receive sick days only if the relative is unable to perform all six ADL tasks and is absolutely dependent on the other in these tasks (150% pension, according to the definition of the National Insurance Institute).

(5) The Equal Rights for Persons with Disabilities Law (1998)

The law prohibits discrimination against an employee for being the relative of a person with a disability. The right to equality at work originates from man’s basic right to equality and is recognized by both international and Israeli law (Alfasi, 2009). The eligibility is for any family member who cares for a person with disabilities (including spouse, parent, or child) and on whom the livelihood of the person with disabilities depends (Amendment No. 12, 2014). The prohibition of discrimination according to the Equal Rights Law also applies to anyone who was a person with disability in the past, anyone considered as a person with disability, and family members who take care of a person with disability. The employer can be sued for discrimination against an employee because of a family member with disabilities. A prohibition applies to each of the following areas: Equal opportunity in access to employment, working conditions, promotion, training or vocational training, dismissal or severance pay, benefits and payments connected to retirement.

Discussion and Conclusions

The goal of the present paper is twofold. First, to expand the discussion on the extent to which legislation alongside community long-term care insurance law (CLTCI) support family caregivers and protect the intergenerational relations within Israel’s aging society. Second, to raise the impact of care burden on family wellbeing and strength to the policy agenda. The aim of supporting family caregivers necessities a broad understanding of the concrete policy and its outcomes. Furthermore, we introduce the case of Israel’s aging society, where the number of adults requiring care and support in the community has risen dramatically, and since the burden of caring for the elderly has been shown to fall on family in the community (Dwolatzky et al., 2017; OECD, 2016; State Comptroller Special Audit Report, 2017). This article is in line with the scholarly argument that it is crucial to support this vulnerable segment through adequate aging-in-place and long-term policies, rather than to take them for granted as an inexhaustible source for intergenerational support (Fast, 2015; Pickard et al., 2012; Verbakel, 2018). Sustaining family caregivers’ capacity to help maintain older adults’ daily functioning is becoming an important policy issue (Lin et al., 2012; Muir, 2017). However, the extent to which existing legislation, benefits and rights beyond the long-term care policy are effective has attracted only limited research attention in general, and in Israel in particular (Brodsky et al., 2011; Doron & Lazar, 2016; Doron & Linchitz, 2004).

A review of the legislation has indicated, as also mentioned by scholars (Brick & Doron, 2010), that the aid supplied by existing laws is limited, mainly because their application is relevant only in extreme cases where the elderly need constant supervision or care in institutions. Their contribution to most elderly and their families is only partial. The rights afforded to family caregivers are relatively few, are limited and are all concentrated in the domain of occupational support, and this also in a limited manner. Similarly, Brodsky et al. (2011) concluded that the definition of eligibility for these benefits is narrow and is not uniformly applied. As they argue, under most of these laws, the elderly person's spouse and children are eligible for benefits, but other relatives are not, even if they take part in caregiving. Furthermore, the definition of “disability” that entitles a caregiver to miss work is strict: An employee is entitled to sick days only if the relative is disabled in all six ADL tasks (p. viii).). Namely, only if an elderly relative is completely dependent in ADL may his family caregivers miss work without having their pay docked and this only for a few days (p. viii). A gap thus exists between the needs raised in researches and actual needs, since relatives invest much time and money and lose work hours or days in order to care for their parents, but there are almost no benefits which are anchored in law for compensating them for this (Chernichovsky et al., 2017). Moreover, these limited policy supports, together with the increase in family care responsibility according to the LTC law services, may influence family relations. On the one hand, family members may cooperate in supporting the older relative, on the other hand, it may reveal conflicts between them. For example, Pinto et al. (2016) indicated that lack of family support and having to relinquish paid work to care for the elderly person may cause in-family conflict. They also found that conflicts involved difficulties to reconcile differences of opinion or financial issues. Thus, insufficient legislation may increase caregivers' burden and decrease the quality of family relations.

Most developed countries are shifting more care responsibility to the family and relatives (Metzelthin et al., 2017; Pavolini & Ranci, 2008). However, due to changing family forms, the availability and capacity of family for providing care is decreasing (Hantrais et al., 2020; Gruijters, 2017; Pickard et al., 2012). One should bear in mind that in most developed countries, the welfare systems cannot replace families’ role or provide all care needs, since they were not designed primarily for providing broad long-term care (see Pavolini & Ranci, 2008).

Recognition of the need to support family and informal caregivers in order to ensure long-term care for the elderly is on the rise in most of the developed economies in which the population is aging (Cass, 2014; Doron & Lazar, 2016; Muir, 2017). This situation has recently led many countries to re-develop policies and programs for helping family caregivers to fulfill their role over time (Iecovich, 2011; Kroger & Yeandle, 2014; Willemse et al., 2016), alleviate the caregiving burdens and stresses (see Cass, 2014). Comparatively, the Israeli governments have introduced only limited legislation amendments and there is no comprehensive public policy strategy for supporting caregivers and for moderating the negative consequences of family caregiving (Brick & Doron, 2010; Doron & Lazar, 2016; Iecovich, 2008, 2012). Simply stated, despite the community long-time care insurance law (CLTCI) legislated in 1988, that became the main social security program for elderly (Asiskovitch, 2013; Dwolatzky et al., 2017), it gave only a partial answer for family caregivers (Chernichovsky et al., 2017). As the Israeli State Comptroller recently reported, family members caring for the aged experience a heavy burden, whereas the Israeli government has not seriously addressed their needs and has left them nearly alone to carry out their responsibilities (State Comptroller Special Report, 2017). In addition, a recent study focuses on the care deficit in Israel, investigating the conditions of Israeli informal caregivers within the community indicates that the main factors contributing to the care deficit for community-based care for the elderly in Israel encompass meager long-term care benefits, a limited range of services, dependence on family members for caregiving; and the formal care system’s reliance on low-paying, untrained help, which leads to a constant shortage of caregivers (Hasson & Dagan Buzaglo, 2019). In this respect, Ranmuthugala (2009) argued that “The benefits gained by shifting long term high care to the community can potentially be counteracted by the high cost to the government of supporting the family caregivers for the rest of their lives. Ensuring the wellbeing of caregivers also means that the care recipients continue to receive the best possible care, thereby ensuring better outcomes all around” (Ranmuthugala et al., 2009, p. 620).

The conclusions that can be drawn from this review are compatible with Brick and Doron’s (2010) claim that “It sometimes seems that the State of Israel ‘likes’ to brag of laws and policies that seemingly adopt basic Jewish values of intergenerational relations, of the obligation to care for the elderly and of fear and honor to the aged. However, in practice, at least with everything related to the amendment to the family law (alimony), and taking into account the rates of poverty, distress, abuse and neglect from which elderly in the State of Israel suffer—it appears that a fundamental gap exists between the rhetoric and reality” (p. 34). This claim was also supported by the report of the National Trajtenberg Committee that was written as part of a comprehensive government initiative to examine economic and social changes. This report concluded that it is the responsibility of the government to update the legislation on sections that impart additional rights to the elderly and their families who are the main caregivers, and in parallel to supply tools and supportive services in order to enable the elderly person’s routine life in the community (Trajtenberg Committee Report, 2011). Moreover, the Report, which explained the economic and social gaps created as a result of strengthening community caregiving and family responsibility, indicates the burden that falls on the elderly person’s family as a cause for expansion of poverty. While at present, Israeli policy makers are deploying austerity measures, such a lack of investment in care infrastructure may appear illogical in hindsight, merely intensifying inequality among families and elderly.

Current Israeli policy has not taken the unpaid work among women and resultant inequality sufficiently into account. As a result of austerity policies and cutbacks in public spending on welfare and care services, unpaid care labor among women has sky-rocketed. As women increasingly participate in the labor market, with a concomitant decline in the availability of female family members to perform long-term care activities, gender difference is an important factor to consider in the Israeli case (Hasson & Dagan Buzaglo, 2019). Policy makers should take into account recent worldwide policy proposals from feminist scholars to reorganize care services and financial support (Fernandes, 2017). As suggested, this could be implemented through an expansive fiscal policy focusing on sustainable economic growth and investment in social infrastructure, particularly care services or by expanding the “green economy”, incorporating gender equality within the idea of "purple economy” (a vision of a gender-egalitarian economy giving a central place to care) (İlkkaracan, 2013). Further, both morally and pragmatically, more policy actions to support the family productive activities such as elderly care by preventing gender inequality, is inescapable.

To conclude, this paper contributes to the literature’s focus on intergenerational family care and family wellbeing in an aging society not by describing it as a problem of the family with older adults that are aging and needs help; rather by framing these phenomena as an issue which eventually affects all economies and taxpayers. Every society needs to understand the great need for a comprehensive policy to strengthen the infrastructure for eldercare. This constitutes both ethical statement and manifests an investment in our future quality of life.

Directions for Future Research

Recently, a vast array of scholars has engaged in research focusing on the global phenomenon of the care economy and, particularly on the care deficit (also known as the “crisis of care”) (Fernandes, 2017; Hasson & Dagan Buzaglo, 2019; Ilkkaracan, 2013). Tronto's (2013) work on the 'Caring Democracy' focuses on the American case of caring deficit and has introduced the declining ability in developed countries to provide quality care to meet the needs of individuals, their children, their elderly parents, and other infirm family members. Alongside this research a steady stream of studies of intergenerational relationships emphasize the importance of understanding constraints that produce greater stress and burden and their impact on family relationships and wellbeing. For the most pragmatic reasons, it is important for future research and policies to consider changes and complexities in family relationships, paying attention to family context, diversity of family structures, intergenerational relationship quality, and intersections of social statuses in an aging society to provide resources to families for reducing caregiving burdens and promoting health and wellbeing (Glass et al., 2016; Thomas et al., 2017). Future work investigating the perspectives of family members regarding the care burdens they experience when their frail-older relatives need care may also provide valuable insight for policymakers. More comparative policy analysis based on actual results is required to reveal how governments address ways to ease caregiving and diminish families’ burden through a variety of legislations and benefits. Such examination will greatly assist in the formulation of a public action plan in the near future.

Practical Implications for Policymakers

Based on a Canadian policy analysis, care provided by family members and friends contributes significantly to society and the economy (Canadian Institute for Health Information, 2010; Fast, 2015). Unpaid family care reduces reliance on publicly supported paid care, saving Canadian governments an estimated $2951 per male caregiver aged 45 or older and $2075 per female caregiver aged 45 or older (Jacobs et al., 2013). By recognizing family caregivers as complementary key roles for the formal care systems, several countries (Australia, Canada and the UK/England) are leading new policies to address the burden and difficulty of family caregivers (Cass, 2014). We also suggest supporting family caregivers by expanding laws such as subsidies, tax exemptions, income supplements, work arrangements, direct monetary support or old age allowances for caregivers. Although some of these recommendations are outside the scope of our findings, they are in line with recommendations made in previous studies (Kröger & Yeandle, 2014; Neal & Hammer, 2017).

Opposition to public support for family care is driven by fear that families will abandon their natural obligations and contribute further to the “downfall of the family.” However, evidence has shown that public supports actually only rarely displace family care. Rather, they complement it and even extend families' caring capacity and reduce the risk of institutionalization of the person in need of care (Fast, 2015).

In the Israeli case, the government’s social-economic policy in Israel has, over time, reduced investments in the fields of welfare and health (OECD Economic Survey, 2016). The poverty rates among the elderly in Israel are among the highest in Western countries, especially when compared to the OECD countries (National Insurance Institute, 2015). Exacerbation of the situation of the elderly should be prevented, in particular the situation of their supportive family. On the contrary, it is a social and moral obligation to act on their behalf.