The W.H.O. ranked Italy as the 2nd best country in the world for overall healthcare in 2020. On paper, it looks pretty good. Here’s some reflections after living here.
Greg Hopkins is retired and moved to Italy from the US 5 years ago. Surrounded by beauty. Grateful to have escaped the matrix. Fascinated by our collective evolutionary journey. He regularly writes in 'MEDIUM'. Greg Hopkins @gregphopkins medium.com
As I write this, I’m frustrated. I just walked to the local health center in a downpour, carrying vials of urine samples, only to be told, quite cheerfully, I had missed the window for the collection of lab samples by ten minutes. In two days I will go back, because they’re closed on Tuesdays.
Last Friday, I didn’t have the prescription from the doctor and didn’t know about a form that was needed, so back home I went. A few days prior, at the start of this escapade, I had stopped by the pharmacy to get the collection vials. A doctor called to verify which kind they needed. Despite the emphatic si si, va bene that indeed I was getting the right kit, I was sent back because they needed a different kind.
In Italy, especially as a foreigner, these types of fruitless excursions are common. Maybe I’m getting cynical, but I fully imagine the next time I go to the health center, they will say, “Oh, these are too old. You’ll need to start over.”
After a couple of years living full-time in Italy, descriptors of the Italian Health System that come to mind include: Frustrating, confusing, contradictory, disjointed, and just plain odd.
Really excellent care and high-quality facilities exist amidst the haphazardly organized healthcare landscape in Italy. You just have to figure out how to navigate through the maze. Long waits and miscommunication come with the territory.
General Facts about National Health Care in Italy
SSN, Servizio Sanitario Nazionale, is the National Health Care Service in Italy. Overall guidelines, basic benefits, budgets, and reform initiatives are established by the central government. Health care is decentralized among 20 regions that deliver primary, secondary and tertiary services as well as preventive and wellness campaigns.
The health centers in each town are called ASL (Azienda Sanitaria Locale). Each ASL has a nurse on staff who can collect blood and urine samples for lab work. ASL also collects annual fees for SSN for those who need to pay, and they assign primary care doctors. Primary care doctors write prescriptions for nonurgent procedures and medicine.
The numbers say that overall, health care is good. Average life expectancy in Italy in 2017 was 83.1 years — second only to Spain (in the EU). Heart disease, strokes and lung cancer are the leading causes of death, partly due to the fact that 1 in 5 adults smoke daily.
Italy has the lowest rates of preventable and treatable causes of mortality in the EU — despite spending less than the average per capita on health care.
Free health care is not free. My wife and I are full-time legal residents living on pension income. The cost for SSN is €2,200 per year, or about $2,600. This fee is fairly close to the per capita expenditure for health care, which was about €2,400 in 2017. Though we do pay income taxes in Italy, for some reason this does not reduce the amount we pay.
About three-quarters of healthcare costs in Italy are publicly funded through taxes, with a quarter being paid out of pocket. Cost-shifting to a greater percentage of out-of-pocket fees increased after 2009 to offset budget shortfalls.
Besides co-pays, most people also incur costs for private appointments to get around the long waits. Confusingly, many doctors who work for SSN also maintain a private practice. Usually you can get an appointment fairly quickly, for reasonable costs of around €125 to €150. There are many elective procedures, such as osteopathic care, that are not covered that require seeing a private clinic.
Co-pays for a blood panels and routine lab work run about €60. A sonogram is around €23. Overall, pharmacy costs are about half of what they are in the US. The US has the highest average cost for prescription drugs in the world.
Major surgeries and treatment in hospitals is covered by the national health care plan. Nobody is going to lose their house or go bankrupt because of a heart attack or prolonged illness.
Urgent care is covered by insurance. I had an ear infection, for example, and seeing a doctor twice for this cost nothing. I am currently seeking treatment for a enlarged prostate — common among men over the age of 55. Thus far, for a couple doctor visits, tests, and scans, costs have been less than €100.
Dental and vision are not covered by insurance. Dental is cheaper and quite good. A crown costs about €500. Getting a couple cavities filled runs around €120. A new pair of glasses with frames and a checkup can cost from €300 to over €700, depending on the frame and the type of lenses.
All medical costs are deductible from taxes. There isn’t a high threshold for medical deductions like in the States.
Downsides of Healthcare in Italy
Waiting several months for procedures is normal, with some exceptions. Average wait times for cataract surgery in 2019 in Italy was quite good at 25 days. However, wait times and cancellations have gotten worse with Covid.
Last night an Italian friend said he knew a poor guy who had been walking around with a catheter for a month. His prostate had completely shut off his ability to urinate. He was still waiting for treatment.
I am authorized to receive Green Light Laser therapy for an enlarged prostate, covered by the SSN, and I’ll be surprised if I am seen in less than ten months. To get the preliminary tests completed — normally done in a visit or two — it’s taken me six months.
Communication and guidance is greatly lacking. The right hand usually doesn’t know what the left is doing. When I arrived for my last appointment with a urologist in the town of Sondrio, my appointment was not on the books. The results of a sonogram and a diagnostic test I had completed were not online — nor was there any record of me. The doctor brusquely redid the sonogram and scribbled some notes down on a piece of paper. Doctors do not seem to know what’s covered by the national health service or even what procedures are available.
Electronic health management for things like prescriptions and record keeping don’t seem to exist, despite a much ballyhooed 2016 initiative called the Digital Health Agreement. There is no online patient portal with charts, appointments, and messages from doctors. Prescriptions are written by hand and records are kept in personal file folders and carried to each appointment by the patient.
As a foreigner, figuring things out is a process of groping in the dark and learning by trial and error. There are some online guides, but these rarely answer the question at hand. The assigned general practitioner doctor can offer good guidance, but you can’t count on it. My GP doctor said the other day that “green laser was not covered by the national health service,” while it clearly says it is on the website featuring Italian doctors trained in the procedure. The notion of hand holding the patient and shepherding them through procedures is not a norm here.
There can be real consequences from the swirling ambiguity. I have tinnitus in my left ear because an infection went on far too long before I received treatment. Coming from the states, I simply had no idea that the first course of action was to go to the emergency room. Here, the emergency room is more like a clinic rather than the chaos, long waits, and high costs typical in emergency rooms in an American hospital.
As far as I know, there aren’t basic annual exams. At my age, it would be nice to have a proper cardio exam to see how my heart is functioning, and a general evaluation to see if anything of concern is lurking such as skin cancer. This layer of preventive medicine might exist, if I knew how to ask the right questions or perhaps if I paid extra. But it’s a thicket of unknowns.
Summary and Conclusions
By comparison to the U.S. health system, Italian health care is pretty rag tag and haphazard. Most hospitals are old and rundown to the point of being dilapidated — nothing like the spotless, palatial medical campuses in the US filled with new equipment. There are many good doctors here, but navigating the system and getting in to actually see somebody is not easy or fast.
That said, health care in the US is way too expensive and often not very good. My last employer was paying $1,200 a month for coverage for my wife and me, and our yearly out-of-pocket costs ran around $2,000 or more. Holistically-oriented doctors and most preventive care was either not covered at all, or only covered at 50%. I lived a mile from a large hospital, but it was not included in my insurance coverage. For routine lab work I had to drive about 10 miles on a gridlocked freeway.
The sketchy and confusing medical coverage in Italy forces me to rely on myself to keep well. Regular exercise, a healthy diet, and self-care using home remedies are my primary plan. Overall, I’m stronger and healthier than I was five years ago. And, paradoxically, I’m more relaxed about health care. The obsessive worry around seeing the doctor is less prevalent in Italy.
Today, I feel pretty good. Nothing hurts too bad. That’s my check-up. Now, time for a bike ride, and maybe some weight lifting later today.
OECD/European Observatory on Health Systems and Policies (2019), Italy: Country Health Profile 2019, State of Health in the EU, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels. Link to publication.
Healthcare in Italy: the 2020 guide for expats and travellers. Link to website
Access to the National Health Service by Non-EU Nationals, a gov.it publication, Link to website
World Health Organization, publications about healthcare in Italy, Link to website
For an informative and entertaining series of articles on personal experiences with health care in Italy (and a knee operation that had to be redone), see the blog Nancy Goes to Italy.