Insanity: The ‘full-paying patient’ scheme in Italy

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The old – and perverse – idea that if you want a good cure, you need to pay for it is creeping back, says Silvia Vignato. Is this progress?

 

In Italy, there is a state-run, tax-funded universal health care system in which every citizen is entitled to the same level of care regardless of his or her actual contribution in taxes. The tax system is such that, in salaried jobs, taxes are deducted at source.

To me, this means that each month, roughly 300 euros is cut from my salary (1.900 € net) and sent to National Health. I never see that money. It disappears into the State and makes me feel that we are all safe – and entitled to protection.

This sense of security is not something old. When I was a child, in the late 1960s, my mother would say that if you go to National Health, you are likely to receive poor treatment. In her view, you needed to pay for good doctors to take good care of you. You preferred to go to private clinics rather than to public hospitals, where the poor go.
 
The change in feelings towards National Health occurred in the late 1970s. In 1978 a law was passed that stated that you did not need to be a worker to be granted free treatment. Being a citizen was enough. At the same time, an effort was made to secure the best practitioners and equipment for the public health system. Good practices became wide-spread. This is why citizens, not only the poor, started turning towards National Health with a sense of trust and entitlement. Like me, who grew up by it.

Actually, in Italy, medical care is not 100 per cent “free”. Whatever the needs, and unless you belong to special categories (e.g the elderly, chronic patients, pregnant women), you pay what we call “il ticket”, a quite mysterious percentage of the total price of the medical – up to 36 € for each procedure. It can add up to quite a sum, but it is still widely accepted.

Talking of good practices and trust is also a delicate matter. Trust is not equally spread throughout the country. You do have places in Italy where the National Health works better than others – the devolution of power from the State to the regions has opened many doors for vast bags of corruption, and in many a region the public structures are obsolete and overcrowded. But Milan, the city where I live, is not supposed to be such a place. Milan is supposed to be a well organised,  corruption-free area. You pay your taxes, you get your services.

“If you are in a hurry, you pay for it”

In January 2010, I realised I had a gynaecological problem. Getting to see a specialist through the National Health is complicated, so before considering it I actually waited until I was really not feeling well and not getting any better spontaneously. Mind you, I was not dying, I was simply sick.

On 13 January, I finally went to see my GP and told her that I needed to see Dr So-And-So, the gynaecologist who had me under her care, and that I thought I needed a swab test. The GP wrote out the prescription for both the visit and the test and I went home. You do not pay for your GP; she gets a salary for seeing patients, so until then, I still held my trust in free care.

I then dialled the unique number for reservations in Milan, and asked for my appointment with Dr So-And-So.

The girl on the other end of the line told me that the first available date was 24 April.

I argued that I was sick, but of course, she could not do anything about that; she is just hired to give out dates through her computer.

If I accepted seeing any gynae-cologist available in the whole area of Milan, one who is less busy than Doctor So-And-So, I could get a visit on 20 March, she said. To speed it up, I needed a different prescription with the word “Urgent” stated on it, she said.

So I went back to the GP, queued up again and asked the doctor to write out two new prescriptions to state that it was “urgent”.

But the GP said she could not do that because I was not an urgent case; “urgent case”, according to her understanding, means you are dying.

I argued that it was not true. I had an infection which needed to be addressed urgently, even though I was not (so I hoped) dying.

“Well, if you really want to be seen in a hurry, you pay for it!” she said.

I thought she was joking. Was it a luxury, then, to be cured of something banal but nevertheless quite nasty? So I pleaded again.

“Call the hospital where your gynaecologist works and book a private visit, if you really want,” she insisted. Then she got angry: “What, you want to be visited when you want? You should thank God that we are in Italy and you only wait three months for a visit! In other European countries, you wait much, much longer.”

I was appalled. She was lying. So I told her it is not true that in France, where I lived for 10 years, you wait such a long time. I am entitled to be cured when I need, I asserted.

But the power was with her. She refused and I was out on the street, furious – and sick. So I called the hospital, and indeed, I could book a visit within a week in the hospital itself with Doctor So-And-So for 96 € plus the cost of the swab, 36 €.

Paying 132 € is not unaffordable for me. It is still quite a bit, though. It should not happen twice in a month. Moreover, it is especially bitter to pay such a sum if I consider the monthly 300 € which I pay to finance the salaries of both my GP and the hospital gynaecologist. Do I want to be cured or to be right, I wondered. I felt guilty to be putting financial considerations above my health.

Dubious alternatives

I had a choice, though. How come I sort of knew what the problem was with me? I had searched the Internet for forums where the symptoms I had were described. I looked up statistics showing that 30 per cent of women suffer from this particular bacterial infection, so why not me. Of course, I had also read clear warnings about the need to cure it thoroughly lest it becomes chronic and leads to other major ailments. In the end, I did exactly what you are not supposed to do: a do-it-yourself, Internet-based self diagnosis and therapy. And what I feared would happen, happened: I was not correctly cured and the infection came back again.

Before leaving for my fieldwork in Asia, I felt awful. I then submitted to the system, using another tool of power instead of money: personal networks. Somebody I know in the university knows somebody in that hospital. I had my visit and examination at once and for free, without paying “il ticket” and bypassing those who were either booked three months earlier through the Unique Number or paying under the full-paying patient scheme. I got my medicines and felt better. I had played it dirty, though. I could do that. The feeling that each month I pay taxes for everybody to be safe had gone.

I live in a very popular part of the city. What happens to a migrant waitress, or to a 17-year old call-centre kid, or to a part-time cashier in the supermarket if they suffer from the infection I had (it affects 30 per cent of adult women)? They earn 800 € per month and do not know people in the university hospital.

Like me, they learn from being told by the GP that being cured when you need to be cured is a luxury. Feeling well itself is a luxury; even in minor ailments like this one, if you cannot pay, you endure pain, sickness, and maybe worse consequences. Like me, they learn that if they want an immediate cure, they can look up unqualified healers: they can search the internet, buy other traditional medicines, consult a healer. Or just do nothing.

Unlike me, they cannot choose to go with the system, even though I feel bad about it.

It is a powerful device. It creates a difference exactly where you are supposed to be all alike – before sickness and pain, and it creates it in the name of the State and inscribes it in the most intimate parts of a person: her body, her inside. It also engenders mistrust towards the State at a very immediate, intuitive level of perception.

The old – and perverse – idea that if you want a good cure, you need to pay for it is creeping back. Is this progress?

Silvia Vignato is an Italian anthropologist with an interest in Southeast Asia.

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