The doctor will see you
Thursday, June 18, 2009 at 11:13AM 
I confess. I admit it. I’m a health care refugee. One of the advantages of being a legal resident of Italy is free access to health services. It’s not much but I’ll take what I can get.
Everyone seems to know someone who has come to Italy on vacation and has a horrendous story to tell about having to wait five days on a gurney in a hospital corridor for an appendectomy. Perhaps, but the road to hell is paved with good anecdotes. What you want to know—in a thousand words or less—is how it really works. Just give me the facts. The skinny. The inside dope.
First of all, health care in Italy is a right guaranteed by the constitution and not a privilege. The system is a mix of public and private sector financing. Interestingly, it is actually a decentralized system. According to the European Journal of Health Economics, “The set of services to be guaranteed by the public sector are defined at national level, while regions are accountable for their provision.”
Italy’s current system dates back to 1978 with the founding of the National Health Service or Servizio Sanitaria Nazionale (SSN). It is based on “universalism and comprehensiveness.” In essence, the government picks up about three quarters of the tab with approximately 37% coming from public resources and 40% from insurance contributions paid by employers (approximately 3% of gross earnings). The rest of the money comes from other private sector sources. Again, the central government sets health care policy and is responsible for enforcement, but increasingly, the onus is falling on regional and local governments for implementation of these policies.
I registered with the SSN through the Unità Sanitaria Locale di Bologna (USL) or local health service. It, in turn, is part of the Emilia-Romagna region. (Italy is made up of 20 regions.) Nowadays, you get a fancy plastic card (Tessera Sanitaria) with a magnetic strip on the back; it looks like a Colorado driver’s license. When I originally registered back in 2005, I took my Codice Fiscale (social security card) and Carta d’Identità (I.D.) to the local health service. I chose a family doctor (Stefania’s in Crespellano). Then, the employee typed all of the information into a computer and voilà. I was in.
But is everyone covered? Well, in a word, yes. If you are a legal resident who is registered with the USL, then you are covered by the nationally defined benefit package under the SSN. Again, regions have increasing autonomy, so some areas provide more services than others, but there is a minimum level of care guidelines that all regions must adhere to.
On the ground, the system functions much like a PPO does in the States; you freely choose your general practitioner from a list of local doctors who work for the USL or are self-employed and work under contract. Doctors are paid on a per capita basis determined by contracts negotiated between the Ministry of Health and practitioners’ representatives (unions). There are a maximum number of patients that a doctor may enroll. Primary care, including home visits, is regulated by this national contract to ensure “continuity.” If you are having problems that require additional care then your family doctor refers you to a specialist.
Of course, stories of dysfunction and great frustration abound when it comes to the Italian health care system; just ask an Italian—they’ll tell you more than a few stories. One of my favorite TV shows is Striscia La Notizia. It is a comedy/news program à la the The Daily Show, hosted by two Sicilian comics. It features correspondents traveling around Italy uncovering the seamier side of civic life. One of their favorite targets is—you guessed it—the health system. If you run a substandard state hospital in rural Southern Italy, Striscia might crash your party with a camera crew.
As in the rest of the developed world, the closer you are to a large metropolitan area, the better your chances of finding a level-one trauma center or a top orthopedic surgeon. Similarly, wait times for specialized care could be longer in rural, less-affluent districts. For this reason, many Italians take out supplemental private insurance. Where I live, I don’t feel the need. Several of the top hospitals in Europe are within 40 km of where I live. Moreover, our local facility in Bazzano is more than adequate.
Two weeks ago, Stefania cut her finger in the kitchen. She went to the pronto soccorso (emergency room) where the staff performed a quick triage, checked her in and showed her to the waiting room. By the time she sat down, her first name, severity of the problem (she was code green) and wait time were displayed on a large-screen TV. Fifteen minutes later, a doctor examined her. Luckily, no stitches were required. Total time: less than an hour. Total cost: zero.
Would she get this same level of prompt care in an ultra-modern hospital in Naples on a Friday night? Probably, not. Moreover, the care is not really free in Italy. You pay for it at the pump. You pay for it at work.
For example, if an employee makes 50 or 60 grand a year in the United States, the taxes amount to about 25%. In Italy, that same worker pays about 35%. However, it also highlights the apples-to-oranges argument of comparing who pays more for what in each system: Yes, Americans pay less taxes than the average European but then you have to factor in the thousands of dollars a year spent on rising health insurance premiums and other medical expenses that a typical family has in the United States.
But the cost of health care is another debate. One can argue about the relative merits of each system, but the essential difference is coverage: In Italy it is universal while in America it is not.
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