On Second Thought

When I found a hard lump under my right breast a few weeks ago, I thought back 15 years ago to when I lived in America and didn't have health insurance. I live in Italy now, and while I haven't always been a fan of government health care here, I am certainly relieved that it is an option. My experiences with socialized medicine have not always been positive. When my youngest son was just days old, he suffered a respiratory emergency and ended up in an emergency-ward incubator in a Rome public hospital. The experience was dreadful: I was disappointed with the anachronistic approach toward mothering and the lack of communication from the medical staff. (Story continued below...)

I'm sure those problems still exist in many public hospitals in Italy, but people commenting on my son's story noted that it was much the same in American cities, where sick people were footing the bill. In my son's case, he was treated immediately and we did not have to wait in the emergency room even for a minute. The prioritizing system was seamless. I remember vividly seeing a man in the waiting room whose hand was wrapped in a bloody dish towel. His wife held a much smaller bloody towel in her hands. My blue-faced baby took precedent over him, and no one complained. And better yet, no one even asked for insurance information before determining whether to treat him. I still dislike the way they treated me, his mother, but my son is alive today and I didn't have to go in debt to save him.

But it never really occurred to me just how important the outcome was, at the expense of all the other atmospherics, until I found my lump. Living without health insurance in America for nearly eight years was a huge risk. Back then I was too old to ride along on my parents' health policy (they were farmers so their policy was complicated and expensive), and I made too much money to be covered by Medicaid or social assistance. I worked for a small magazine that couldn't afford to pay benefits, but I took the job because I needed journalism experience and bylines. I couldn't have afforded even the most basic coverage on my own: cash went to rent, food, and car insurance—because it had to. Like a lot of underemployed, I just hoped to stay healthy. It was before the Internet, and I couldn't Google symptoms or home remedies. When I was seriously sick, I either ignored the symptoms or borrowed prescriptions from friends. Back then I would not have had this lump checked out. I would have ignored it and simply hoped it went away.

A lot has changed since then. Not only have I moved abroad, but I also married into a private-insurance policy that works in conjunction with Italy's socialized health-care system. Many Italian residents have basic public health insurance but navigate the system using private health care when it is urgent for things like fevers and anomalies like breast lumps. (Private insurance costs a fraction of what it costs in the United States.) A basic family policy in the States, according to a USA Today poll, runs up to $13,375 a year, whereas its Italian equivalent costs roughly $1,500. Government-sponsored health care suffices for routine issues like for vaccinations or specialized equipment like mammograms or MRIs. I had my private doctor diagnose my lump and then visited a public facility for the specialized ultrasound. I had a private surgeon remove it last week.

There are at least as many private doctors within driving distance in Rome as there were within driving distance in the Midwest where I grew up. In Italy, many doctors practice in both the private and public systems and will work to accommodate a patient in a way that makes the most sense both logistically and economically. Under this system, the patients are held more accountable and must keep their own medical records with them. The biggest obstacle is that very few private doctors accept payment directly from insurance companies. Instead, private patients here have to pay up front and deal with insurance reimbursement later. But luckily, the cost for basic office visits is considerably less than in the United States. Here, I rarely pay more than $100 for a standard office visit, and annual exams like pap tests cost about $30. I often have annual checkups in America for myself and my children during my summer holidays—just to get an American medical perspective, because I am concerned that some procedures here are antiquated—and I pay double or triple what it costs in Italy. Big-ticket items like surgery or birth are not nearly as expensive as the same procedures in America and can often be reimbursed in advance by private insurance companies. Plus, hospital stays are generally inclusive. For a basic birth here, the price often includes four nights in the hospital—far longer than most people want or need to stay. Friends of mine in the United States have been booted out after 24 hours.

When I found my breast lump, I didn't even think about whether I could afford to have it looked at. Last week, it was removed by a private doctor who could accommodate my schedule on an outpatient basis. Very quickly the lab results came back showing it was precancerous, which means vigilance and frequent checkups, using a combination of private and public care. Like when my son stopped breathing, the priority is to fix the problem, not to hesitate and decide if I can afford it. I will be taken care of. And that's better, even, than the government-sponsored discount.

© 2009