Since it looks like the issue of “socialized medicine” is going to play a major role in the upcoming Presidential campaign, I thought I’d share my experiences of how an actual socialized medical system works.
Basic System Features
Italy has a national health system, similar but not identical to the one used in the UK, France and Spain. Other European countries, including Germany and Switzerland (and the ACA, for that matter) use a government-regulated insurance approach.
In Italy, all citizens are automatically enrolled in the national health system. Legal Italian residents who are citizens of another EU country are also entitled to use the health care system under EU reciprocal agreements. Legal residents from other countries are allowed to buy into the system. Premiums are income-based, and range from 400 to 2700 euro per person per year.
Coverage is comprehensive, and includes things like rehabilitation services which are often treated as supplemental services in the US. There are no deductibles, and for new registrants, there are no exclusions for pre-existing conditions. Public system doctors do not make house calls, but the system does provide transportation for the elderly or others in frail health who are unable to get themselves to a treatment facility.
Co-Pays and Other Costs
Coverage includes an unlimited number of visits to your primary care physician, without co-pays.
There are co-pays for certain items like annual blood tests. Co-pays are subject to a statutory maximum, currently 46 euro (about $50), but depending on the test can sometimes be less. Co-pays are waived for those on limited incomes, or for those in certain medical categories like cancer survivors.
Co-pays also apply to consultations with specialists. If you get a referral from your primary physician, and are willing to take the next available specialist, you pay 46 euro. If you make the appointment on your own, or you want to see a specific doctor, you pay 100 euro (about $110).
There are no co-pays for emergency room or hospital services.
Mammograms are free every two years. If you (or your doctor) want them more frequently, you can schedule them, subject to the standard co-pay.
Drugs prescribed for active conditions (e.g., antibiotics for current infections) are free. You generally need to pay for drugs that are prescribed for long-term conditions, although prices seem to be heavily subsidized. My statin costs 6 euro a month, for a local-manufactured generic product. Ted’s blood pressure medication is similarly reasonably priced.
Painkillers are less widely used here, whether by prescription or OTC. When I broke my wrist a couple of years ago, I was sent home with a 2-week supply of prescription strength Tylenol (500 mg). I understand that in the US many people in my situation are given opiates.
My sense is that doctors here use painkillers for pain reduction, not pain obliteration — increased pain is a symptom they don’t want to mask. There are drug abuse problems in Italy, but there doesn’t seem to be an epidemic of opiate abuse, which often starts in the US with a prescription – maybe there’s a connection.
When you are enrolled in the system, you select a primary care doctor who is generally your point of entry. If you don’t like your doctor, you can change without cost or penalty (although you will have to wait in line at the administrative office).
The system is administered locally. Within each region, there are smaller administrative areas which ensure that most of your medical care will be provided for by practitioners close to where you live. In our case, our primary care physician is a 10-minute walk from our house. Our primary hospital and emergency room is a 10-minute drive from our house, or 20 minutes by bus (served by three bus lines). Within walking distance from where we live, there is a satellite center for blood tests and immunizations, so you don’t have to go all the way to the hospital. There is also a small private hospital within walking distance where you can get some services at additional cost.
Although your primary care physician is located in your area, you can actually go to a public system doctor anywhere in the country. If you want to see a knee specialist in Perugia or a heart specialist in Rome, you are covered, subject to co-pays and availability. If you have a rare condition and the only available specialist is in another city, the system will cover your train ticket.
The system is set up for efficiency, which is not necessarily the same as convenience for the patient. If you are very sick, or have a medical emergency, you will be seen quickly, for example only a few days between cancer diagnosis and treatment. On the other hand, if you go to your doctor with an important but not urgent medical problem, you will probably sit for 2 hours in your doctor’s waiting room. Most primary care doctors here practice individually, with at most a nurse assisting.
(As a point of reference, I understand that in the UK you can make appointments with your primary care physician, but you might have to wait a week or more if your matter is non-urgent. I’ve also been told that in the UK appointment no-shows are a big problem, which may be why the Italian system operates this way.)
Waiting times for non-urgent specialist consultations, or non-urgent medical procedures, like “extra” mammograms or colonoscopies, can sometimes be months long. If the appointment is truly non-urgent (e.g., you want a second medical opinion to confirm a prior medical conclusion) you may not mind the wait. And you can sometimes get an appointment quicker if you are willing to go to another doctor in the region, which can be an hour or two away. Or you can go to a private doctor.
Private System as Supplement
One of the most interesting features of the Italian medical system is the way you can go to a private doctor or a private hospital on a one-off basis, even though you are covered by the national health care system. This is not the case in the UK (or the US for that matter), where you are either in the public system or the private system, but you generally can’t utilize both systems at the same time.
So, for example, if you want a colonoscopy, and don’t want to wait months for a hospital appointment, you can make an appointment for the same procedure at a private hospital, generally with a much shorter waiting time. Similarly, if you want a specialist consultation in weeks instead of months, you can pay for a private doctor.
Private facilities also provide services for the public system on a contract basis. A friend of ours had minor surgery at the local private hospital, which was fully covered by the public system. Private facilities also provide diagnostic services for the national health system on a space available basis. (I’m not sure how the economics of this works, but I think this system acts both as a safety valve for the public system and as a mechanism that allows the private facility to be fully utilized).
There are also some doctors who have both public and private patients, with shorter wait times (and higher fees) for the private patients.
The reason why this back-and-forth between the public and private systems works is that the costs, even at most private facilities, are very reasonable The cost of a mammogram from a private doctor, for example, is 80 euro. A consultation with a private surgeon is 150 euro. And the cost of a colonoscopy at the private hospital was 130 euro. (When they quoted me that price, I actually thought I had missed a zero, since the cost of the procedure in the US can be $3,000 or more.) These costs are not only reasonable for us as Americans, used to paying staggeringly high prices, but they are also within the means of middle-class Italians.
My sense is that most people in our area use the public health system for most of their medical needs. People in certain situations might use private doctors for primary care. People with chronic medical conditions, women expecting a baby, or working parents with small children, for example, often prefer the convenience of being able to make an appointment.
With respect to major medical services, though – surgery, broken bones, treatment for cancer or other serious illnesses – it seems that most people, rich or poor, use the public system.
Private insurance is available, and is generally not costly, but in my region, at least, it seems that few people use it.
Quality of Medical Care
The quality of the medical care is difficult for me to judge, given that I am not a doctor. But the doctors seem attentive and well-informed to me. In cases where I have had the same procedure done both in the US and here, my experience here was better. (I had a colonoscopy in the US where they overdosed me on the sedative, and I was out for several hours after the procedure was over. Here, I was given the correct dose and was only out for 20 minutes).
I have also noted that many procedures done by physician assistants or nurses in the US are done by doctors here. In the US, when a test is done by a medical tech, the technician is often prohibited by law from discussing the results of the test with the patient. In Italy, when tests are done by doctors, they write up and discuss their results with you in real time. When I had a mammogram at a private facility, the doctor personally reviewed the results of my scan with me while we viewed it together – this has never been the case in the US.
Another thing I like about the Italian medical system is that your results, whether in a public or private facility, are typically immediately available and are your property. When I had the mammogram, for example, the doctor wrote up the results and handed them to me, along with a CD. (The concept of electronic medical records doesn’t seem to have caught on here yet, except within hospitals). This puts the responsibility on you for maintaining your personal medical records – you often see people in doctor’s offices carrying around thick folders with their medical history. But it also means that if you change doctors or move to another region, you don’t have to struggle to get copies of your medical records.
As with many of the public services in Italy, quality varies by region. Even though the quality of care is theoretically the same in every region, the quality of the administration, the number of facilities and available doctors, varies a lot. Tuscany and Umbria are generally regarded as having the best systems, but all of the northern and central regions, including the Marche, where I live, are pretty good. Rome has some of the best doctors and hospitals, but administration can be chaotic. In the South, though, the quality of service in the public facilities is not as good, and it seems that those who can afford it purchase private insurance.
Doctors are not well paid here, and many younger doctors have decided to practice elsewhere. This is a problem, as many older doctors are now approaching mandatory retirement.
The possibility of practicing privately also draws some of the doctors away from the system. As the price points I noted above indicate, the profit potential for practicing privately is not huge. And many doctors prefer not to have to deal with money. But this brain drain has had an effect and over time an insufficient number of doctors may start to affect the overall performance of the public system. This has already happened with respect to eye doctors and dentists – these services are theoretically provided by the public system, but so many doctors in these areas have gone into private practice that in effect these services have been privatized.
As noted above, once you are enrolled in the national health care system, there are no additional costs or deductibles beyond co-pays for certain non-urgent services.
In particular, there are no co-pays for visits to your primary care doctor. And primary care doctors here typically don’t have advice nurses or receptionists who act as gatekeepers deciding whether you are sick enough to warrant the doctor’s time. As a practical matter, then, you decide when you want to see your doctor. You may have to sit in the doctor’s waiting room for a couple of hours, but generally speaking, if you want to see your doctor on a particular day, you can.
And although there can be long waits for non-urgent conditions, those waits tend to disappear when you are really sick. In the US, the quality and the timeliness of the care you get is often based on how much money you have, or the quality of your insurance. Here, it is based on how sick you are.
Another benefit to having a national system is that care is coordinated.
Last year, a local friend was stricken by a serious auto-immune disease that causes temporary paralysis in the extremities. He had a particularly difficult case, where his lungs were paralyzed for several weeks and he had to be put on a ventilator. After 45 days in the intensive care unit of the local public hospital, his condition had improved enough to start rehab, and he spent several months in a specially designed residential rehab facility. Now he is home again, and a physical therapist visits several times a week. All of this care, from hospital ICU to special rehab to at-home physical therapy, was coordinated by his doctors, who decided when to move him to the private facility and when he could go home. And all of it was covered by the national health system.
In the US, the health care delivery system is often fragmented. Hospital services might be covered under one part of your policy, while rehab services come under another, with different deductibles and policy limits for each. The costs of a serious auto-immune disease in the US can be staggering, and rehab services in particular are often not fully covered. It’s the kind of medical condition that can lead to bankruptcy in the US. That doesn’t happen here.
The Italian medical system has its faults. Primary care doctors can be overburdened Waiting times for non-urgent procedures can be long. But the peace of mind that comes from knowing that a serious medical condition won’t take all the resources you have is priceless.