Editor’s note: This commentary is by Joseph Patalano, Ph.D., a clinical and consulting psychologist who lives and practices in Burlington. He has over 35 years of practice in medical, hospital, health agencies and private practice in Massachusetts and Vermont.
Travel, especially in Italy, has been a passion for many years. The “kids” are grown and finished with college so there is more time and finances for that now. Last year while traveling I began to experience some medical symptoms after hiking to yet another beautiful walled fortress, on a mountain, in a small town near the sea in southern Italy. The hike was not terribly rigorous but it was a long slow slog uphill on a very hot day. We started early, to avoid the heat, but these days the summer’s heat is more intense in Europe. I began to experience some numbness in my legs that seemed to be radiating. I also felt numbness in my arms, nausea and intense fatigue. These are the symptoms we are often warned about for cardiac and stroke and I was concerned. True to my gender I kept the concern to myself. My wife and I, with several rest stops in the shade, made it back to our place. Long story short, the symptoms persisted and we visited the emergency room of the local hospital.
On arrival at the hospital I reported my symptoms, using my meager Italian language skills and considering the medical staff”s meager English, we communicated reasonably effectively until an English-speaking doctor could be located. After establishing that I was an American tourist, there were upper body scans, brain scans, EKGs, blood work, etc. The care was professional and welcoming. The physician noted that, considering my last name, I must have family near Naples. When I indicated that my father’s family were from Ischia, he noted that he too had family there. We were paisanos. After the examination was complete the doctor requested some identification and I handed over my U.S. passport. He copied the information and indicated that, if there was anything concerning in the test results, he would want a neurologist to review the data. He wanted another brain scan in 24 hours to ensure that no insidious process was going on. He told me that there was not a neurologist in his small hospital and if necessary the hospital would transport me a few towns away, in an ambulance, to see a neurologist there. He assured me that the ambulance would return me to the hospital so that I would be in close proximity my Airbnb. He also noted that I could stay in the hospital for the 24 hours or go home and return the next day. He also said, with a knowing nod that the food would probably be better at home. I chose to go home.
Through all of this I was concerned about cost, as I had no idea if my U.S. health insurance covered my medical expenses in Italy. I asked the doctor how much all of this assessment and treatment would cost. He looked at me with an amused smile and said that it would cost me nothing. Further, he reported that he had signed me up for the national health program and that from now on, everywhere in Italy, my records would be available if I had further medical needs. I was astounded. He went on to inform me that he was a medical doctor not an economist and that if someone needs medical care, it was his job to provide it for me and that cost was not an issue. Luckily all tests came back fine and I had my second brain scan without incident or cost.
It strikes me how different this medical experience was from the way that health care is handled in our country. The first person a foreign tourist would see would be the screener from the billing department, which would be the largest department in the hospital. There was NO billing department in the Italian hospital. The patient would be queried as to how the services were to be paid for. (This would be done later if the medical presentation was so acute or unstable but would be a high priority for the hospital, ASAP) There would be enormous numbers of forms to be filled out solely for the purpose of billing and assigning payor responsibility. If there was no discoverable paying source the patient would be billed on the spot or would be treated as an indigent. if unable to pay, services would be the minimal necessary. I have worked in the medical care system for most of my career and I can tell you that billing departments and associated insurance reps are the largest and most powerful departments. Clinicians have to vie for space and resources with the endless numbers of bean counters. All the forms and bureaucracy are to facilitate two goals. One that maximum payment is made to the institution providing the medical service. The second goal of much of the paperwork is more sinister. The second goal is “clarify” the responsibility of insurance carriers and give them the data they need to decline covering services. That’s right, in contrast to the Italian system which prioritizes personal health care, the U.S. health care system puts gigantic resources in finding ways to get the delivering institution paid and minimizing coverage responsibility of insurers. Insurance companies, including, “nonprofit” insurance companies, make money by maximizing the price of their policies and minimizing payout. Someone takes care of the provider (in most cases takes care of the provider’s employer). Someone is taking care of the insurance company. Who is looking out for the patient? That was not a concern in Italy. In Italy everyone pays for their health services in their taxes. When they are sick they get treated with no interference and some might say predation by insurance companies, who contribute nothing to health care but drain billions out of it for their profits. In the case of nonprofits they drain billions to allow the huge management salaries and multimillion golden parachutes to reward the administrators.
On a later trip to Italy I spoke to a surgeon. We shared a train compartment. He was traveling to Palermo to work with another surgeon, to learn a new surgery technique. We began talking about health care and I asked him if he could make more money practicing in the U.S. His answer surprised me. He said some doctors do come to the U.S. and indeed they make more money than him. He noted, half in jest, that he could probably kept busy doing surgery on the tens of thousands of people who are shooting victims in the U.S. Seriously, he said, he loved the U.S. and has traveled there several times. He said in Italy they take almost 50% of his income in taxes. That may seem like a lot but, he said, his education, including his medical education was paid for. His children’s education is paid for. His family’s health care and medicine is paid for. His retirement is paid for. He has two months a year of paid holiday plus he has virtually unlimited medical eduction opportunities. He drives a BMW! He can travel anywhere in the national health system to do a variety of medical duties. He can teach and do research. The system has so much medical data from all care delivered in the country, there is a wealth of research opportunities. Best of all he said, he gets to live in Italy! Don’t get him wrong, he said, there are many problems to be solved, there are instances of poor care, there are all the problems inherent is a big system but the bottom line is that we are all in it together.
Italy is not alone. Most of the Western world has similar, although varied, health care systems and the health care systems enjoy tremendous popularity. A few things stand out in comparing the U.S. health care system and the one that I encountered in Italy. First, in Italy and in Europe, there is a commitment to quality health care for all. Second, the Italian system is comprehensive, includes, medical, dental, prescriptions and vision. Medical resources are easy to access and they have minimal expensive bureaucracy. Cost per capita is much less than the inefficient U.S. system. Savings of scale allow for inexpensive purchasing of meds by the government and patients.
The US health care lobby would have us believe that European health care is rationed, there are long lines and the health care is inferior but none of that is the case. Health care is rationed everywhere including here. In the U.S. it is rationed by private insurance companies who look out for their own interests and profit. European health care systems enjoy superior medical outcomes compared U.S. model. Not only are medical outcomes better, but the system is easier to access for patients, which saves lives and allows for earlier intervention. Duplication and waste in the health care bureaucracy is significantly reduced.
It would be easy to think of the health care in Europe as idealized and a panacea but that would be a mistake. Health care is complex and ever changing and there are no easy solutions for the thorny problems involved. One simple improvement, however, would be the adoption of a Medicare for All system that is phased in over four years and improved to allow for comprehensive health care, including dental, optical and pharmaceuticals that represent a large part of our current medical treatment. It would cover all at reasonable standard of care. It would get health care out of the commodity business and have a single focus on caring for its patients. It would be comprehensive and access would be made easy. It would be civilized.
There is currently a bill proposed in the U.S. Senate by our own Vermont senator, Bernie Sanders. The bill would go a long way in addressing the issues outlined above. This approach deserves consideration and a fair hearing by all of us. I hope that someday those who travel to our county and indeed those who live in it, will be treated with the same care and dignity that I found so many miles away in Italy.
