Life in the Time of Corona

2020-03-22

For the past week and a half, we have been under lockdown here in Italy because of the CoronaVirus.

The outbreak started in northern Italy, quite a ways from where we are living.  Cases are still concentrated in the northern provinces of Lombardy, the Veneto and Emilia Romagna.  The hospitals in Lombardy in particular are some of the best in Italy, with top flight doctors and high quality medical care.   This virus is survivable, for most people, with proper medical treatment.  But when a hospital is running at 200% capacity, with 10-20% of the medical staff either infected or under self-isolation for possible infection, not everyone will have access to proper medical treatment. Overwhelmed hospitals will have to make battlefield-style decisions about who to treat.  So now the whole country is under lockdown, to prevent hospitals from getting overwhelmed.

Everyone over 75, anyone with compromised immune systems, or anyone with symptoms, is being asked to stay home.  Others may go out for matters of “necessity”- shopping, medical appointments, walking the dog, looking in on an elderly relative.  Food stores, pharmacies, and stores selling cleaning supplies and household items (not sold in pharmacies here) are open, as are banks and post offices.  Medical facilities are open, but most doctors offices (doctors tend to practice solo here) are closed except by appointment for urgent matters. Dentists are likewise available only for emergencies.  Garbage pickup continues (although the recycling center is closed) and police and fire departments are fully operational. All other businesses – bars and restaurants, coffee bars, clothes stores, movie theaters and concert halls, barbers and hair salons – are closed for the duration.  There is no equivalent of DoorDash here – although a few restaurants have organized delivery services, it has been strictly on a one-off basis, and I get the sense that most people are cooking at home.

We have a number to call if we get sick, and someone will assess our symptoms.  I understand that people are being advised to stay home unless they are having breathing difficulties.

Italy has a national health care system, but the system is administered locally.  There are three public hospitals in our two-county administrative area.  For the moment, they are trying to restrict patients infected with the virus to two of those hospitals, with the third being used for other medical services.

It helps a lot that Italy has a single-payer health care system.  There are no payment or insurance coverage issues, and the system can allocate patients among hospitals to maximize their resources without worrying about which hospital has contracts with which insurers.

Pharmacies remain open, and as far as I can tell there are no shortages of the kinds of medicines many people take on a routine basis.  I think that’s because not only brand-name but also generic drugs are made in this country.  Pharmacies seem to be willing to refill long-term prescriptions even if they are technically expired.

We’re fortunate that just about everything we need for daily life is within a 15 minute walk of our apartment.  The only destination we might need to access by car is the hospital, and we’re not planning to go there if we can help it.

Ascoli is a town of about 50,000 surrounded by agricultural land.   A lot of the food we eat on a regular basis – fruits and vegetables, chicken and lamb, pasta and grains, sausage and cheese – are produced within 2 hours of here.  We have 6 local bakeries, some of whom grow their own wheat, and a local coffee roaster.  San Benedetto, about 1/2 hour from here, has one of the largest commercial fishing ports in Italy, with wild and farmed seafood from the Adriatic.  “Local and sustainable” isn’t just a slogan here – it means short food supply chains, which is particularly important in a time when long distance transportation may be perturbed.

We haven’t seen the kind of panic buying that has been reported in the United States.  The shelves are fully stocked.  Even if a particular item (bleach, gelato) is not available on a given day, it will generally be available on your next visit.  Stores have implemented a limited entry system to keep people from congregating inside.  Our local supermarket moved the ticket machine from the deli counter to the front door, so you take a number and wait outside until it’s your turn. It’s the most organized line I’ve ever seen in Italy.

Italy is a democratic country, so at least up until now the government has tried to rely on voluntary compliance rather than a heavy-handed police force.  If you go out, you are supposed to carry a self-certification form stating your errand, but I’ve never been asked for one.  I’ve read that the police have issued thousands of citations in various parts of Italy, but voluntary compliance here seems really high.  The demographics here are kind of unusual – a lot of families with children and a lot of older people, but relatively few single people in their 20’s, who have to go elsewhere to finish their education or find jobs.  It probably doesn’t hurt that the latter days of World War II and its immediate aftermath, which were a time of great privation for Italy, are within the living memory of many of the older people here.  Some of the older folks have been through hard times before – and at least this time nobody is bombing them.

It’s kind of remarkable how quickly you can get used to a dramatically different way of life.  At breakfast, we discuss what we are going to do that day, as always.  But the number of options is severely limited.  Instead of “Let’s go to the beach today,” or “Let’s pop up to Venice for a few days,” it’s “Who gets to go to the store today?” Some days neither of us goes out at all, which is weird.  We’ve been reluctant to take walks, since the legal status of doing so is uncertain and errands generally have to be done solo.  But today I went down to the creek behind our house for about 20 minutes and didn’t see another soul, except for a guy walking his dog.  So I figured that was alright.

I’ve long been a student of medieval history, and accounts of plague outbreaks in medieval and early modern Europe, and how communities dealt with them, have always fascinated me.  I never dreamed, though, that I’d be living in them.

Italy took too long to enact these drastic measures, and as a result we will probably have to stay on lockdown longer than originally anticipated until we can flatten the curve of new cases.   For our region, though, which wasn’t as strongly hit as the north, the restrictions may have come in time.  We’ve seen more cases, but nothing like the horrible numbers being reported up north.  We’re not out of the woods yet by a long shot.

For those of you living in the US, please take my advice. This is not “just another flu.” These restrictions are not a hysterical over-reaction.

The world will be different when we emerge from this.  But we don’t know yet what kind of world that will be.

 

 

 

 

 

The Italian National Health System

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.

System Administration

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.

Issues

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.

Major Benefits 

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.

On Being Recognized as an Italian Citizen

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During the months of planning for our move to Italy, I discovered that I was, under Italian law, actually an Italian citizen.

Under the law of the United States (and, as it happens, the Roman Empire), citizenship is a matter of geography.  If you are born in the United States,  you are a citizen of the United States, regardless of the citizenship of your parents. In some European countries, however – including Italy – citizenship is a matter of ancestry.  If your father or mother was an Italian citizen when you were born, then you are an Italian citizen, regardless of where you were born.

My grandfather emigrated from Italy to the United States in 1912.  Since my father was born in 1917, before my grandfather became a naturalized American and renounced his Italian citizenship in 1924, that means my father was an Italian citizen (although I doubt he ever knew that).  And that means I have been an Italian citizen since birth, although until recently I didn’t know that either.

Since this type of citizenship operates automatically, and not by choice, under US law I can “recognize” my Italian citizenship without giving up my US citizenship.

As you might imagine, going through the recognition procedure requires collecting quite a lot of paper — not all of it easily obtained decades after the events.

I thought locating my grandfather’s Italian birth certificate would it be difficult, but it turned out to be surprisingly easy.  Although he was born in a tiny town in the Abruzzo, a forward-looking city administration had actually put its old documents online, which meant they were easily searchable.

My father’s birth certificate was more problematic.  Although he was born in the US, his birth certificate was filled with spelling errors, including my last name.  My father was born at home and my grandfather likely went to the city records office to obtain a birth certificate.  My grandfather spoke English with a heavy accent, and county clerks in any event didn’t know much about Italian names in those days.  I was told that I could have the document corrected if I could provide a baptismal certificate.  Using Google, we located a church in the Arthur Avenue area of the Bronx which appeared to be only a few blocks from where my father was born.  Sure enough, they were the right church — they provided my father’s baptismal certificate, which spelled my last name correctly, and we were then able to get the city of New York to issue a corrected birth certificate.

As it turned out, though, I couldn’t change my father’s first name. My father was christened Antonio although he went through life as Anthony.  Apparently teachers in those days didn’t have much patience for “foreign” names and arbitrarily changed them to something more “American” – something that thankfully wouldn’t happen today.  We were able to resolve that problem, too, by getting an “also known as” certificate from the state of Florida, where my dad lived for the last 30 years of his life.

We also needed to provide a copy of my parent’s marriage certificate.   That wasn’t so easy either.  My parents hadn’t had a church wedding – all I knew was that they had eloped.  An older friend suggested I try the records of Elkins Park, Maryland, which she said had been a favorite destination for eloping couples in the 1950s.  Bingo.

After we collected all the documents, we had to have them verified using apostilles (basically an international notarization form) and then translated.  We took these documents to the vital records office here in Ascoli, where the woman in charge reviewed the documents, then sent request letters out to the various Italian consulates in the US verifying that they had no contrary information.

This whole process took months.  Once my application was approved, though, things moved amazingly quickly.  I went down to City Hall and had my birth and marriage “registered” in the town records.  The town hall used special oversized paper which hasn’t changed much since the Middle Ages (although they use printers now instead of pen and ink).  Within a week, I had a new Identity Card, identifying me as an Italian citizen, which basically entitles me to live (and work) anywehere in the EU.  My new status also enables Ted to apply for a “carta di soggiorno” (essentially, a [ermanent green card which doesn’t have to be renewed every two years).

Why did I do this?  There are no tax benefits — Italy taxes legal residents essentially the same as Italian citizens.  The main benefit is administrative.  Like many European countries, Italy is now tightening up its requirements for foreign residents.  Non-residents have to renew their permessi di soggiorno  (visas) every two years, and the language requirements and hard to define “integration” requirements seem to be getting tougher.  We could most likely pass the current tests, but who knows what new requirements may be coming down the pike? And it is easier not to have to worry about dealing with the Italian bureaucracy any more than is necessary.  This way, we can come and go as we please.

And I now have two passports!  I feel like an international money-launderer.