Public healthcare: rights can be the death of us

Public healthcare is not free. It has already been paid for. Indeed: prepaid.

It is paid for in taxes, pay packets, contributions, VAT, in that tax burden which reached 42.5% of GDP in 2024. That levy also funds the National Health Service: public healthcare expenditure in 2025 was put at around 141.5 billion euro; in 2026 it is forecast at about 148.5 billion. More than 6% of GDP. Not a peripheral item, but one of the great pillars of the state’s cost.

Then reality arrives, and reality almost always takes the form of a waiting list. You fund the public system, then book a private appointment. You pay for the SSN [Italy’s National Health Service], then pay the diagnostic centre. You contribute towards the right to treatment, then buy insurance or reach into your pocket to avoid waiting months.

This is where the word ‘right’ begins to crack. Because a right paid for twice is no longer merely a civic achievement: it becomes a legitimate question.

What does this promise really cost the taxpayer? And what would taxpayers receive if they could keep at least part of what is now absorbed by a system often unable to treat them within a timescale matching their actual needs?

This is not a question against healthcare. It is a question intended to save healthcare from itself.

Article 32 of the Constitution safeguards health as a fundamental individual right and a collective interest. A lofty, noble, necessary formulation. But law is living matter: born in a particular time, evolving through history, obliged to confront reality. Today the question cannot be avoided: is that reading of Article 32 still sufficient in the face of an overtaxed state, structural waiting lists, rising expenditure and an ever wider pool of beneficiaries?

We live by rights, certainly. But rights can be the death of us when severed from duties.

A national community is not a moral cash machine. It is a pact, an alliance, an act of mutual trust. First you contribute, then you claim. First you belong to that pact, then you gain full access to its benefits. The National Health Service was built by generations who worked, paid in, went without, maintained hospitals, trained doctors, funded facilities. It is not a natural endowment. It is national patrimony.

For this reason, full ordinary access to the SSN should be reserved for citizens and, cautiously, for those who can demonstrate a long and proportionate contribution history. For everyone else: emergency care, protection of minors, essential maternity care and public health always guaranteed; but ordinary services through compulsory insurance, a specific contribution or reimbursement at cost.

Today, instead, a foreign national with a valid residence permit can register with the SSN; care may also extend to legally resident dependent family members. That is the law in force. But precisely because it is in force, it can be debated.

The question is not denying treatment. It is restoring proportion.

If a single income opens stable healthcare access to a large household, while the average Italian family is now small, who bears the difference? Who pays the gap between what is contributed and what is received? Is this still solidarity, or a form of public charity administered with other people’s money?

A serious state must have the courage to distinguish: emergency care yes, public health yes, full rights only within a real belonging that includes contribution.

The rest is not humanity. It is accounting recklessness. And recklessness, sooner or later, always presents its bill.