Biden is wrong: A single-payer healthcare system is not the problem in Italy

An unpredictable stretch.
An unpredictable stretch.
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The whole of Italy has been on lockdown to control the spread of Covid-19 for more than 10 days now.

The regions of Lombardia and Veneto are at the epicenter of the crisis and have been dealing with the epidemic for much longer than that. Hospitals there are overrun. There is not enough space in intensive care units (ICUs), which are necessary to treat about 10% of those infected with the disease. The situation has been compared to a war.

During the latest Democratic presidential debate earlier this week, former vice president Joe Biden used the Italian example as evidence that Medicare for All—which is supported by his main competitor for the presidency, Vermont senator Bernie Sanders—is ineffective. “With all due respect for Medicare for All, you have a single-payer system in Italy—it doesn’t work there,” Biden said, referring to the coronavirus epidemic.

But while the Italian healthcare system is near collapse in the areas worst hit by the pandemic, the reason has nothing to do with its single-payer system. Healthcare budget cuts made to respect austerity measures weakened the system, which found itself unprepared to deal with an unprecedented emergency of the size of the Covid-19 pandemic. A privatized healthcare system wouldn’t have fared better in the same circumstances—in fact, evidence suggests the opposite is true.

ICU shortage

The shortage of beds in ICUs is the most urgent concern right now for hospitals in Italy. Many have called it a structural problem: Compared to other European countries, Italy has fewer hospital beds in general, and ICU ones in particular.

Looking at this data it would be easy to make the leap that the problem is, indeed, Italy’s single-payer system. With the exception of Germany, the US has many more ICU beds than countries with universal healthcare coverage.

But outside of this current emergency, the number of ICU beds in Italy is not an issue.

“On average and in normal times, ICU in Italy is used to its 50%-60% capacity,” Rosanna Tarricone, a professor of healthcare management at Bocconi University in Milan, “with seasonal peaks up to 80%-90%.”

Tarricone says that while it’s important to make international comparisons to get a sense of how Italy fares in relation to other countries, there wouldn’t be arguments for increasing the number of ICU beds outside a once-in-a-lifetime emergency like the Covid-19 pandemic.

Italy, she says, tends to be below the European average when it comes to resources and investments in healthcare, and yet “its outcomes are amongst the highest despite the lack in investment.”

Italians, in fact, live longer than most other populations, and normally require fewer ICU beds. It just so happens that the combination of having that older population and less space in ICUs has played a role in making the country more vulnerable to this particular outbreak.

Not a private concern

The public health system didn’t invest more in ICU beds because it didn’t need them. It has always provided a basic level of coverage throughout the country, even in less populated areas—because guaranteeing the service is the goal of government care.

Private providers would have been less likely to guarantee such coverage. Having to distribute their resources in a way that makes financial sense, they would have had no justification to invest in intensive care units that would probably go mostly unused.

According to a study published in 2015, while the US has a higher overall concentration of critical care beds, they are not equally available across the country in proportion to the need. Because the ICU supply is handled by private health providers, it responds to market competition rather than the actual needs of the population. Therefore, the study found, beds are concentrated in populous urban areas where competition is higher for speciality hospitals. More rural areas, on the other hand, have less access to ICU care.

This is why a higher number of ICU beds in the US does not necessarily correspond to an overall larger availability of all kinds of hospital beds. The US is now in fact having to scramble to free up emergency hospital capacity to deal with the expected surge in case, including by using hospital ships.

Looking at numbers of hospital beds more generally, Italy actually ranks above the US:

While most Italians rely on government-provided healthcare, the country also has a private system.

Private health providers in Italy operate in two ways: Part of their services support the public health system, and can be accessed by citizens without extra costs as an alternative to government providers; the rest is for those who wish to get private services (without, for instance, waiting lists or having to share rooms in hospitals) and are willing to pay out of pocket for them.

Altogether, private hospitals and clinics account for a significant part of the overall offer: Out of about 1,000 facilities in Italy, almost half are private (mostly in partnership with the public system).

But, similarly to what happens in the US, only a few large private structures—in big urban cities, where demand is higher—provide critical care and have ICU beds. “For the most part, private hospitals are small structures specialized on longterm care,” Tarricone said.

The cost of critical specialities is scarcely viable for private providers, and a publicly funded system is key to provide essential services even where it’s not necessarily financially sustainable—a luxury private providers don’t have.

The actual shortage

Ultimately, according to Tarricone, the lack of ICU units isn’t a structural concern for Italy—it’s only a problem in this situation. “To what benefit should we have an excessive number of intensive care [beds]?” she asks.

The real problem in Italy is the austerity measures demanded of it in the aftermath of the European debt crisis almost a decade ago. Those measures required cuts in healthcare spending, which reduced the total number of hospitals and clinics (from about 1,200 in 2007 to 1,000 in 2017), and perhaps even more importantly the number of healthcare personnel.

New hires in particular were limited, which has left Italian healthcare personnel not only stretched thin (pdf, p.10), but older as well. More than half of the doctors in Italy are over the age of 55, and therefore at risk during the current coronavirus outbreak.

In Lombardia, too, investments have been made on partnerships with private providers—that often lack critical care capacity—rather than on strengthening the public health system.

It’s because of these measures that the system is ill-equipped to handle the current emergency.

The US, were it to switch to a single-payer system, doesn’t necessarily have that same problem. While Italy’s public investment in healthcare is about 6.5% of the GDP—close to the European average (6.6%), but below the better performing countries such as Germany (9.5%) or France (9.3%)—the US’s investment is a lot larger (14.3%), which would help insulate it somewhat from economic trouble.