Healthcare in Italy: U.S. versus Them

About a year ago I was in the market to buy health insurance that would cover me in Italy. The insurance company required me to have a physical exam in order to pre-approve the policy, a standard procedure.  This is how I wound up at a clinic for the criminally insane in the middle of Trastevere.

“Are you sure this is the place?” I asked my girlfriend as we were wandering through the side streets, looking for the doctor’s office.

“I guess so.  It’s the right address, but…”

She was obviously thinking the same thing that I was.  The building in front of us looked more like a haunted, low-income housing project than a medical facility.  The razor wire on top of the wall is what gave me this initial impression.  There were, in fact, some hypodermic syringes scattered about the grounds, but it seemed unlikely that they had been used for their intended therapeutic purposes.

To an American expat, Italy can often seem like a country of extremes.  The extreme beauty of a Bernini fountain right next to a big pile of uncollected garbage. Prestigious universities filled with learned professors, but sorely lacking resources and adequate classroom space.  Physicians that are highly skilled, but trapped inside facilities that were already outdated when they were built in the 1950’s.  It can be hard to reconcile the juxtaposition of these contradictions, especially for someone who grew up in place where most everything is “senza infamia e senza lode.”

The Doctor is In(sane)

“The doctor will see you now,” said the nurse.

I followed her down a short hallway, ignoring the moans coming from behind closed doors.  I was led into a small room where a middle-aged man with long greasy hair was sitting next to an open window.  He was wearing a white lab coat and his left hand hung over the window sill, clutching a smoldering cigarette, which allowed the majority (but not all) of the smoke to drift outside.

With his right hand he was pecking away on an old Commodore 64 computer, although I couldn’t tell if he was updating medical records or playing Briscola.  The stethoscope around his neck gave me a sinking feeling that this character was the alleged “doctor” who was to perform my exam.  He glanced up at me momentarily and started coughing spastically as only a life-long smoker (or someone with tuberculosis) can do.  Then he proceeded to light another cigarette as he finally stood to greet me.

“Sit here,” he commanded, through a blue haze of smoke.  I could only admire his sense of economy with words.  Bedside manner was apparently not his strong point.

As I sat on the examining table, I began to scan the walls for the customary display of framed diplomas and/or specialty certificates.  I saw no such thing.  Instead, there was a complicated electrical device with wires coming out in every direction which took up most of the space in the tiny room.  A low, static hum emanated from its bowels, glowing ominously, and it looked like a prop from a Boris Karloff film.

I quickly abandoned my search for his medical credentials and sought out potential emergency exits.  He had the door blocked, but I had a clear path to the open window.  Unfortunately we were on the second floor.  Still, I had made up my mind to take my chances with the fall if he tried to hook me up to his Frankenstein machine.
I needn’t had worried.  The “exam” lasted all of four minutes, three of which were spent waiting for his coughing spasms to subside.  He asked me a few basic questions, started to take my blood pressure, but then changed his mind and just checked my pulse instead.  Apparently he was only verifying that I had a pulse, because there’s no way he could have determined its rate or regularity in the two seconds that he touched my wrist.  In any case, he promptly signed the form required by the insurance company to confirm that I wasn’t yet dead or in the act of dying.

But now here’s the interesting part: I reached the reception desk again and asked the nurse how much I owed the doctor.  She gave me an odd look, barely suppressing her laughter, and then said, “You owe us nothing, of course.  Buongiorno, americano.”

As she walked away, I turned to my girlfriend to make sure that I understood correctly.  “Nothing? Not even a co-pay or a deductible?”

“Huh? What are those?” she asked me.

Good question.  How do you explain the US healthcare system to a non-US citizen?  I was actually part of that system up until a few years ago and I still struggle to understand it.  We pay extortionate premiums, yet are still expected to contribute significant co-payments and deductibles.  Policies also have maximum annual and lifetime benefits, which at first glance might seem quite generous—until you begin to calculate the cost of one hospital stay.

And if that were all, it would almost be OK.  But the final indignity is that we are forced to constantly fight with these companies to which we’ve already paid enormous fees to prevent them from denying coverage outright. They have a phonebook-sized list of excluded illnesses.  Pre-existing conditions are never covered.  They have an army of employees who are devoted to finding reasons not to cover any given medical procedure or drug.  These folks are well-trained and have had lots of practice—you have no chance of defeating them or finding a loophole that they haven’t already thought of.

This is just what a sick person needs: to spend what little energy they have to combat against the people who they’ve paid to help them.  As I write this, I’m struck by how ridiculous it sounds, and yet I’m all too familiar with the system to think otherwise.

Healthcare in Italy

I have since seen a few Italian doctors who are nothing like the mad scientist that I encountered in Trastevere.  Most medical offices in Italy are very modest by US standards, but clean and staffed by extremely competent personnel. They don’t have leather sofas or satellite television in the waiting rooms; no valet service or complimentary pedicure while you wait.  But here’s the thing: you are treated like an actual person and not like a set of organs in possession of a wallet.  “How can we help you?” is the opening question, instead of “What type of insurance do you have?”

I have a lot more to say on this topic, but I’ll leave it for the comments section.  I’ve already taken up too space with my rant and I want to provide some useful information for expats in Italy in need of healthcare coverage.  My discussion primarily involves Americans, because if you are an EU citizen, then you’ll have different choices, although most of this information will apply to you, too.

Options for Expats

If you have a private insurance policy from the US, then technically you’re covered in Italy.  The problem is that you’ll likely have to pay up front for your care while in Italy, and then ask to be reimbursed by your US carrier.  This is good news and bad news.  The good news is that your out of pocket costs in Italy are going to be significantly less than they would have been in the US.  But of course the bad news is that you’ll have to fight endlessly with your US company who will look for every reason to not pay you back.

If you are planning to stay in Italy for a while, but less than a year, one option might be traveler’s health insurance.  These policies are quite cheap, but are not intended to provide comprehensive coverage.  In other words, they don’t cover every little thing or routine exams, but they’ll keep you from running up huge medical bills in the event of some unfortunate long-term illness or serious accident.  It’s easy enough to buy these online, and it also satisfies the requirement for your Schengen Visa.

If you’re staying longer, you may elect to purchase “expat insurance” through a foreign insurance company. The main advantage of this type of policy is that treatment is unrestricted and you can choose any doctor, specialist, clinic, or hospital in Italy.  Compared to the Italian state-sponsored system (SSN), it’s expensive, but compared to equivalent coverage in the US, it’s a steal.

This is what I did, and although Italians consider this to be an unnecessary expense, I found it to be an incredible bargain compared to what I paid back in the US and it gave me the peace of mind that I wanted.  My policy was issued by Helvetia, a Swiss company, for the low price of €1,296 per YEAR!  My former US policy cost me that much in two months, and of course it contained all kinds of exclusions and disclaimers. The funny thing is, I almost had to beg the salesman to sell me the policy. He tried to talk me into buying into the state system, thereby cutting himself out of a commission. Go figure.

Speaking of which, if you are a legal resident, you have an opportunity to participate in the national healthcare system.  This is called, voluntary subscription (l‘iscrizione volontaria) and it’s a real steal at less than €400 a year—even less than that for students and au pairs (you can calculate your exact cost here, and it can also be found on my Helpful Document page).

The only small catch is that the premium is based on the calendar year, so if you buy it in November or December, then you’ll have to renew again in January.  Just something to keep in mind.

Here is the website with all the information, in both Italian and English: Assistenza Sanitaria

A quick word or two about pharmacies and medications.  Pharmacies in Italy operate totally differently than in the U.S.—there are no big drugstores like Walgreen’s or CVS.  Opposite to the US system, in Italy OTC drugs are quite expensive while prescription drugs are either free or very cheap (provided that they were prescribed by an Italian doctor, of course).

A pharmacist must dispense almost every type of medication here, including things as simple as Tylenol.  Consequently, the costs of these items are higher. So if you take any regular meds, I’d suggest that you bring enough to cover you for the entire length of your stay, if possible.  If not, then go to the Guardia Medica and ask them for assistance.  This is the direct link for the branch in Rome: Guardia Medica in Rome

Then again, you’re in Italy, so you’d do well to observe the words of Hippocrates and just “Let food be thy medicine.”

So that’s the basic information about healthcare in Italy.  One final word of advice: don’t get sick.  But if you do, just make sure that your doctor has his credentials clearly displayed–and always know where the emergency exits are located.