As I follow the developments in the new healthcare plans for the U. S., I feel it might be time to digress from whimsical cultural observances to things more serious. I wouldn’t pretend to understand every nuance, but I can tell you all a bit about what the future of “Doctoring,” (a more precise term I believe than “Healthcare”) might look like in America.
I have been living here since 1982, and for much of this time I have been part of the churning, corroded and unpredictable machine which is Italian national “healthcare.” I pay into the program, which is a single-payer one for the most part, and I partake of it (sometimes) as needed. But what I “get out of the system” is limited, and only partially indicative of the general breakdown for most Italians.
Probably the most important detail when describing the Italian system is that no one in Italy has health insurance. Insurance is mostly purchased on automobiles, as required by law, but hardly anyone has insurance on their possessions. I know of only a few people who have their farm implements insured, and no one whose house is insured. Not one person I have ever heard of has private health insurance. But those who have a full-time job are provided for by their employers, and the sheer size of the payments that are required for legal employees leads to a) high unemployment, and b) low profit margins. As might be expected, there is a huge “under the table” market for workers. The math is clear.
This said, it would widely follow that the government provides for its citizens who are required to contribute to the system for the good of all. There is only one glitch in the set-up: there isn’t ever enough money contributed by an under-employed and aging population, and the smooth functioning of the mechanism is skewed by the propensity of the culture to allow for corruption on all levels. This is changing, slowly, but the Italian bureaucracy is an old dog indeed.
When I go to the doctor, my assigned doctor, I make an appearance any morning of the working week and sit down on one of the chairs arranged in the outer office area. I wait, as appointments are not deemed appropriate. The clock here is traditionally interpreted subjectively, and the time can be used to chat with ones’ neighbors as we wait. There are many “ifs.” If there are two people ahead of me it is my lucky day. If there are fifteen, I can cross my other errands off my list. If a representative carrying a black briefcase of pharmaceutical samples arrives, he is given precedence over all. (After all, his time is important!) If, after a cursory examination and chat, my doctor deems that I need anything other than a quick prescription, I am referred to the appropriate specialist. There are given times during the week when the specialists will be on call, some in my town, some elsewhere. If I can get an appointment with one of them in a reasonable amount of time, and I agree to drive the distance within eighty miles or so of home, I will do so. If these things cannot be accomplished, I will be advised of the alternatives.
The alternatives are consultations with experts in all fields who work in private clinics, and where appointments are always available to paying customers. They may also work in the government system, but they reserve their “special” time for their clinics where they are assured a large fee for their expertise. Every city has it private clinics where folks who have the means flock for their procedures. Some facilities are quite chic, others less so. (I once had an MRI in a converted garage.) Here you will get your results quickly, because sometimes waiting two weeks to eight months is too inconvenient, or even an unbearable prospect. Health tourism is thriving in the ex-communist countries to the East, where procedures are done on-demand, and competitively priced.
What wears down the citizenry ultimately is the lack of consistency. You MAY receive excellent care, as my son did when he broke his leg in two places a few years back. He was put in a private room, had traction and surgery, wore a cast for two months and is in perfect form today. All this for a total of less than 100 dollars. Even though my husband had to sleep on the floor next to his son for a week, it was miraculous! You may not receive excellent care, however. My mother-in-law was the victim of an accelerating downward spiral of errors, a dire house of cards which ultimately ended in her death. The only thing which might have saved her would have been if her relatives were all knowledgeable doctors. We weren’t.
My brother-in-law died of cancer due to many years of managing workers in a ”state-of-the-art” government chemical plant, where every single one of the hundreds of ex-employees and management have died from the same disease. He started his via crucis in a huge hospital with no air conditioning and eight people to a room, and progressed inevitably toward a hospice facility that was a nightmare. Yet when his family became an insufferable squeaky wheel, he was transferred to a wonderful hospice care facility with a large private room and all the amenities anyone could ask for. Both of these places were about forty miles from his home, over small, curvy mountain roads. The commute, for us and for him, was hard.
A close friend of mine was severely injured in an automobile accident many years ago, and the things I saw and had to do in that hospital still haunt me. And yet she is hale and healthy today thanks to one excellent emergency surgeon who happened to be on-call that day. Thank god she was able to avoid complications caused by infections, heat stroke, and the wrong intravenous fluids supplied to her by bewildered interns.
A hospital stay means that family members must camp out, often on folding chairs or on the floor next to the bed. Nurses are too harried to provide basic care, and toileting, bathing, bed changes and clothing are usually the responsibility of the family. And bring your own toilet paper and bottled water! I have been in Italy long enough to even begin to appreciate the constant milling about of other families in the communal rooms. There is always someone to chat with nearby…And one must never forget that a well-placed wad of Euro notes will probably get you what you need much faster.
But if you need a prescription, the system offers you pretty much anything the doctor orders for very low prices. Patients must pay a “ticket” (a token amount according to income level and category, either preventative or curative) for prescriptions, but generally the cost is low. Many will say that it is a positive thing that these medicines are “free.” Unfortunately the cost can be measured not in Euros saved, but in lack of services. Garbage not collected for weeks, unpaved roads, schools which are crumbling, antiquities falling to pieces; the notoriously disintegrating infrastructure of Italy is the price paid by citizens for their “free” healthcare. We pay, we pay. And every so often, too often, we lose someone dear to us.
In the end, what the Italian system does is provide a baseline availability of services, in varying forms, for people who don’t have extra funds to spend. Those who do have money can pay for excellent care and usually receive it. Those who don’t must rely on what is available, and sometimes that means waiting too long for a hospital bed, or suffering the ministrations of incompetent personnel. Some problems, such as ADHD, are simply deemed “nonexistent.” Older patients are often overlooked, and their suffering is seen as inevitable and therefore not treatable. Up until recently pain has been seen as a necessary part of illnesses and childbirth. (Another post…) And of course you are on your own for dental needs entirely.
I vowed that I would not give obvious advice in this post, but I can’t resist saying that we would be prudent if we observed places like Italy closely. If our reason for demanding government-provided healthcare is to render services equally to everyone, then we should proceed with caution. As with so many things, the distance between our good intentions to the ultimate outcome is paved with unexpected, and sometimes appalling, consequences.