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When I moved to Italy two years ago, I didn’t have plans to sign up for the national health service, as I’d been warned about a universal truth of any bureaucratic process there: One task always seems to beget another.
But the first time I got sick, the choice no longer felt voluntary. On the precipice of losing my voice, I called various doctors, all the while taking sips from my mug of tea, hoping to secure an appointment for sometime that week. What I didn’t understand — and what each office promptly explained to me — was that, without a tessera sanitaria, or a health card, they couldn’t see me. Patients were assigned in the system, and for the average medico di base, or general practitioner, this was done through the Azienda Sanitaria Locale, local administrative health offices.
So, at a certain point, the choice was made for me. Did I want access to a health care system that would likely be more comprehensive, accessible, and certainly less expensive than what I was used to in the United States? Or did I want to use the network of English-speaking doctors in Rome that were either private or catered largely to tourists, and with whom it would be difficult to develop a long-standing relationship? Framed in these terms, the question no longer seemed hard to answer.
As a student in Italy, I was not able to automatically enroll for free in the health system. For years students had paid a set fee of 149 euro to “voluntarily sign up” for the health service, but this year, due to new budgetary legislation, student fees were raised to 700 euro for a yearlong subscription.
Still, when compared with the average annual cost of health insurance in the United States, which clocked in at $8,951 for individual coverage in 2024, this felt, literally, like a small price to pay. This figure also refers only to covered workers, meaning those who receive employer-sponsored health insurance, per the Kaiser Family Foundation (KFF).
Over the past 24 years, the cost of individual health insurance in the US has gone up almost fourfold: from $2,196 in 1999 to $8,951 in 2024. These surging costs are evidenced by the difficulty the average American has in paying for health insurance: Roughly half of US adults find it challenging to pay for coverage, per KFF data from 2024, while one in four adults said they had skipped or postponed necessary health care in the past year due to costs; roughly 21% of adults also said they did not fill a prescription because of the price.
My experiences in Italy have been vastly different. I haven’t had a major health problem, but I have been able to easily get prescriptions and ask for medical advice when needed. When I call to make an appointment with my local doctor, I simply tell them my name and ask for the first available slot. Perhaps more importantly, I now value the relationship I have with my doctor, who always seems to remember me and asks how I’m doing (though the fact that I’m American surely helps me stand out).
I’ve had appointments to discuss a potentially broken foot (occupational hazard of wearing high-heeled boots on cobblestone streets in your late twenties), a monstrously swollen mosquito bite (Italy’s mosquito population is notoriously aggressive — and invasive), and the results of a blood test. Each time I left the appointment, there was no settling up at the register — because there was nothing for me to pay. It’s important to note here that I do pay for medications and clinical services, like blood and urine tests.
I didn’t move to Italy to take advantage of the country’s health care, but it turns out I would not be alone in doing so if I had. About 70% of Americans who want to move abroad are hoping that their country of choice has universal health care, according to a 2023 survey by Expatsi, an organization dedicated to helping US citizens move abroad.
When it comes to health care, the United States is an anomaly on the international stage — and it doesn’t appear to be paying off for the country. Despite spending about 18% of the US gross domestic product on health care, a higher percentage than other high-income countries with universal health care, according to research from the Commonwealth Fund, health outcomes in the US are still far worse. And compared with other high-income countries like Australia, Switzerland, Germany, Japan, and South Korea, the United States is the only one that does not guarantee public health coverage to those who live there.
Other Americans who have also moved abroad tell me their health care experiences have been largely positive, even through one of the most intense tests of the system: pregnancy and childbirth. Ilana Buhl, 31, relocated from Texas to Copenhagen, Denmark, in 2018, a long-planned move after she and her Danish husband met while she was backpacking with a friend in Europe. The process of signing up for the health system was seamless: As soon as her residence permit was approved and she received the Danish equivalent of a social security number, she was able to link that to her health care. She was given what’s called a yellow health card, which includes the name of her doctor. Most medical treatments, hospital visits, and doctor appointments are unpaid by the patient; medications are subject to payment, but those are subsidized and generally affordable.
There are annoyances with the system too, including long wait times for appointments and offices with set phone hours that span only half the day. But, Buhl notes, “If you need something urgently, you will most of the time be able to get it urgently.”
Across the region of Europe, however, this is not necessarily true. A 2023 World Health Organization report showed that, in 2019, only 23 out of 40 EU countries covered 99% of their population with health care. Roughly 19.1% of EU residents in households at risk of poverty and 12% of those not at risk of poverty said they had severe difficulties in affording medical care, per 2022 Eurostat data. And then there are the average wait times, which can be as long as 63 days in France and 77 days in Spain for non-emergency surgeries, according to the Consumer Choice Center; a similar period was 28 days in the United States. Still, across the board, the European countries examined had shorter wait times for general practitioners than in the US.
As a frequent user of Italy’s socialized health care, I can attest to the bureaucratic difficulties too. I once had to make three separate appointments for something that in the US would usually be done in one go — a pap smear, ultrasound, and gynecological visit — and these were scheduled about three months out from my call. It has taken weeks to receive a routine blood test, simply because the first time I went to my appointment, all the computers were down. Certain parts of the health care system are almost entirely private, like dentistry, and many of my friends prefer to use private specialists over public options.
Ellen Hilton, 35, moved from Connecticut to Paris with a story similar to Buhl's. Hilton had always loved the French language and culture and, at one point during her travels, met a French man and fell in love. When she moved there, in 2019, she had to send in paperwork to prove she was eligible for the health system, but the enrollment was fairly straightforward, based solely on her residency, not her work status.
“I barely used health care in the US. I never knew how to navigate it,” Hilton recalls. “I was a teacher in the United States, and I had pretty good health insurance through my teaching job, but still, I was never sure, Is it in-network or out-of-network? How much of a copay will I need to pay?”
Both Hilton and Buhl had a baby in their respective adopted country, and even as non-natives, they felt more than accommodated. Buhl has seen the many videos on social media of new mothers in the United States bringing home a new baby — along with a hospital bill totaling tens of thousands of dollars.
Hilton has an American friend who hoped her baby would come in December not January so that her deductible would have already been met. For Hilton, it’s almost like being in a different world: “I don’t even have to think about that here in France.”
