No, Italy Is Not the Case Against Medicare for All

No, Italy Is Not the Case Against Medicare for All

No, Italy Is Not the Case Against Medicare for All

The Americanization of Italian health care plays a part in the country’s disastrous coronavirus outbreak.


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Democratic and Republican pundits have no shortage of bogus talking points to discredit calls for Medicare for All. The “How will you pay for it?” refrain was central to the (apparently successful) bipartisan attempts to isolate the Bernie Sanders campaign.

A memorable recent incarnation of this effort came when Democratic nominee Joe Biden weaponized the Italian health care system—which has been besieged by one of the world’s most lethal outbreaks of Covid-19—against universal health care during the March 15 Democratic presidential debate. “With all due respect to Medicare for All,” he said, “you have a single-payer system in Italy. It doesn’t work there.”

There’s really nothing a European like me enjoys more than listening to US politicians rant about the mythic “endless lines” and inadequate levels of care we face in our single-payer systems.

Before moving to the United States, I had never once worried about accessing the health care I needed. As for our waiting lines, nothing compares to the struggle to find an American doctor that will simultaneously take new patients and accept my insurance, or the endless process of disputing inflated bills and going back and forth with the web of insurance companies and private-sector middlemen that are somehow involved at every stage of even a simple procedure.

The Democratic front-runner’s position here is actually far to the right of Italian far-right spokesperson and former prime minister Matteo Salvini, who wouldn’t dare attack the public system right now. In fact, he recently committed his party’s members to donate a portion of their salaries to support it.

Here’s what Biden’s comments completely elide: When Covid-19 reached Italian shores, it found a country in the midst of a private-sector transformation that has been turning the country’s single-payer health care system into an Italian version of Biden’s beloved “public option”—and putting millions of people at risk in the process.

The callous slashing of public funding undertaken by all Italian administrations since the 1990s and the parallel proliferation of private clinics have left the country with fewer health care personnel and hospital beds, and longer wait times.

These cuts, along with similar attacks on public expenditure in education, pensions, and social security, have been coupled with a dramatic restructuring of labor relations that has left a significant portion of the Italian workforce struggling with increasingly precarious forms of employment on one hand, and the threat of unemployment on the other.

What does this mean in a time of pandemic? Stripped of paid leave and unemployment benefits and unable to afford missing a day of work, people have been going to work sick. Sound familiar?

Since the situation in Italy turned critical, many researchers have identified reasons for the disproportionate devastation of the country’s outbreak (20,465 deaths as of April 13): demographics (a higher elderly population), timing (the identification of patient zero on February 20 followed an unusual upsurge in hospitalizations for cases of severe pneumonia misattributed to the common flu), and the haphazard implementation of the lockdown (which unwittingly encouraged affected individuals in Lombardy to flee, dispersing the contagion nationwide).

Crucially, Italy ramped up its testing capacity early on, testing more people than any other European country until very recently. The United States lagged behind: By March 9, the Italian government had tested over 53,000 people and imposed a near-complete national quarantine, while the States had only conducted 4,183 tests. This was back when Donald Trump was still cynically tweeting about how this coronavirus was nothing more than the flu.

Inconsistencies in testing capacity have made it difficult to compare the relative rates of contagion by country, but as the scope of the threat becomes clearer and countries—including the United States—attempt to rapidly expand their testing, Italy is starting to look like less of an outlier than originally thought.

The skyrocketing rate of infection in Italy is not, as Biden would have it, stress testing or disproving the efficacy of universal health care. The chilling fatality figures do not in and of themselves offer any evidence that the country would have fared better had its system been run by the private sector. In fact, Italians have rallied behind the single-payer system on social media, and even the most hostile news outlets have come to recognize that its ability to coordinate a national reorganization of health care personnel and facilities might be all that stands in the way of full social tragedy.

To be sure, Italian authorities’ mistakes were legion: They failed to take prompt action during the window available once they learned of the outbreak in China and didn’t provide the public with adequate guidelines on how to slow the contagion—e.g., avoiding the ER or a GP’s office if you presented symptoms—until it was too late. But these failures have very little to do with the public nature of the health care system, and very much to do with the fatal ingredient in the cocktail of tardy responsiveness and at-risk demographics: a decade of austerity policies. Since the turn of the century, and more aggressively after the global recession of 2008, the Servizio Sanitario Nazionale (SSN), Italy’s universal health care system, has undergone continuous spending cuts and rounds of privatization.

The “Americanization” of the SSN has been ongoing since the 1990s, when Italy joined the European Union. But the 2008 global financial crisis acted as an accelerator, and when the recession really hit the country in 2011, the ensuing financial panic was quickly used as political leverage to impose a range of structural reforms aimed at reassuring financial markets over the soundness of Italy’s debt. It was a case study in Shock Doctrine.

The Piani di rientro, policies aimed at containing health care expenditure across the country, became the fundamental instrument through which the then-decentralized network of regional health care services could be re-centralized under the unifying agenda of austerity. These financial recovery plans put regions with high deficits under the scrutiny of the Ministry of Health and, for the first time, the Ministry of Finance—turning the delivery of health care into an issue of financial stability.

In concrete figures, these plans have amounted to the cutting of €37 billion from the SNN since 2010. Between 2008 and 2017, a hiring freeze led to a decrease of 42,800 health care personnel—particularly doctors and nurses. Those at work are asked to clock longer hours for less pay. In the meantime, the number of hospital beds has drastically declined, from 3.9 per 1 million people in 2007 to 3.2 a decade later, according to OCSE data. That’s far lower than the European average of five, though this has also been curtailed from 5.7 in 2007. The United States’ is 2.8.

A study published as recently as last month shows how between 2004 and 2014 these policies worked really well at reducing costs. They also had the “inadvertent” consequence of increasing the rate of “avoidable deaths” by 3 percent.

Despite the impoverishment of people and medical facilities, Italy’s national system is the system that is now handling the pandemic. And what are all those flourishing private clinics that were supposed to save us all from the inefficiencies of the public sector doing? Pretty much nothing, at least until they are forced to, as many reports coming out of Italy have shown.

In fact, the Italian government had to step in by means of an emergency decree, the “Cura Italia,” to allow regional governments to request publicly subsidized private clinics to make some of their personnel, beds, and equipment available to the public sector. And of course, this is not free of charge: Private facilities will be compensated for 100 percent of the costs of such “inconveniences”—at a much higher rate than what taxpayers would be paying if the same services were provided directly by the public sector. This, on top of other contributions they already receive from the state to begin with.

As the number of victims of Covid-19 has risen to over 17,000 in the span of just a month and a half, Italians wonder how different the situation could have been had hospitals been provided with adequate staffing, beds, and equipment. As the number of cases in the States skyrockets and health care workers face shortages in supplies and personnel, Americans should brace themselves to ask the same question.

If there is anything to blame for this catastrophe other than the virus itself, ask an Italian. Many of us have been saying it all along: Austerity kills.

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Katrina vanden Heuvel
Editorial Director and Publisher, The Nation

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