Italy Doesn’t Need a Better National Health Service. It Needs to Move Beyond It

Scott Atlas’s lecture at the Hoover Institution made me question an assumption Italians almost never question: that guaranteeing medical care requires government to finance and organize healthcare for almost everyone.

I did not go to Stanford expecting to come back wanting to write about healthcare. If someone had told me that before the trip, I probably would have been surprised.

This August I attended the Hoover Institution Summer Policy Boot Camp at Stanford University. Hoover is a public-policy research institution based at Stanford, with a pretty clear intellectual tradition: limited government, individual liberty and free markets. The Boot Camp is an intensive residential program for university students and recent graduates, with Hoover fellows teaching sessions on economics, foreign policy, regulation, energy, immigration, healthcare and other policy questions.

I went there mainly interested in foreign policy and international security. And obviously those were an important part of the experience. But one of the lectures I kept thinking about after returning to Italy was Scott Atlas’s session on healthcare.

Atlas is a physician and the Robert Wesson Senior Fellow in Scientific Philosophy and Public Policy at Hoover. Before moving into policy full time, he spent fourteen years as Professor and Chief of Neuroradiology at Stanford University Medical Center. Much of his policy work has focused on government, markets, healthcare access and medical innovation.

His basic argument is not very complicated. Healthcare works badly when the person receiving care has very little control over the money paying for it. That can happen when the payer is government. It can also happen when the payer is a huge insurance company.

Atlas’s American reform proposals include lower-cost insurance focused more on catastrophic risks, much larger Health Savings Accounts and more direct control by individuals over healthcare spending. The idea is to make providers compete again on price and value instead of treating the patient as almost a passive user of a system.

Listening to him, I realized that in Italy we debate almost everything about our National Health Service except whether we should have a National Health Service in the first place.

We argue about funding it. We argue about staffing. We argue about waiting lists and private providers.

The premise itself is rarely touched.

I think it should be.

“Free” Is a Misleading Word

Public healthcare is not free. This sounds obvious, but our political language often makes us forget it.

We pay for it through taxation.

According to the OECD, around 73% of Italian healthcare spending is covered through government or compulsory schemes. Overall, Italy spends 8.4% of GDP on healthcare, below the OECD average of 9.3%. So my argument is not that Italy is somehow the world’s biggest healthcare spender. It is not.

My question is different.

Why should government collect such a large share of the money we spend on our health, decide how it is allocated, and then give it back to us in the form of services?

The cost becomes almost invisible this way. Nobody receives an invoice in January saying “National Health Service.” The money is already gone.

And when the service does not work, many Italians pay again.

In 2024, 9.9% of Italians reported giving up a specialist visit or diagnostic test they needed. Long waiting lists alone were cited by 6.8% of the population. In 2019, that number was 2.8%.

Things have improved recently, and that should be acknowledged. In the first half of 2026, 78.5% of first specialist visits and 84.6% of diagnostic tests monitored by AGENAS were provided within the official maximum waiting time.

But around 2.8 million bookings were still delivered too late.

This is the part that interests me.

When you apparently remove the price of a service, you do not remove its cost.

You can just change what the cost looks like.

Sometimes the price is waiting.

If I can afford it, I am not going to wait six months. I call a private clinic, take out my credit card and book the appointment.

I have then paid once through taxation and a second time to escape the system I already paid for.

I do not find that particularly universal.

A Queue Is Still Rationing

This was one of Atlas’s points that stayed with me.

When demand and supply do not match, something has to decide how a scarce resource is allocated. No healthcare system escapes that.

In a market, price does part of that job. It has problems and it obviously cannot be the only consideration in medicine. But price also communicates information. If thousands of people are willing to pay for a service, there is an incentive for somebody to supply more of it.

In a centralized system, scarcity does not disappear.

Very often it becomes a queue.

Atlas has made this argument against single-payer systems for years: governments can contain healthcare spending by limiting access to services, technology or drugs, and waiting times themselves can become a form of rationing.

Italian politics tends to treat waiting lists as a failure happening to the National Health Service rather than something that may also come from the way the system is designed.

Every time demand is too high, our instinct is the same. Put in more public money. Hire more through government. Create another national plan.

Sometimes more resources are necessary.

But at some point I think we also have to ask if the mechanism itself makes sense.

I would rather leave much more of that money with citizens in the first place.

What if We Kept the Money?

This is where Atlas’s ideas become interesting even outside America.

I do not think Italy can import an American law, translate it and call it reform. Our systems start from completely different places.

But the principle makes sense to me.

Instead of taxing me to pay for a very broad list of services and then deciding where, when and under which conditions I receive them, government could simply leave me with much more of that money.

I could use it to buy an insurance plan I chose myself. I could put it into a personal healthcare savings account with tax advantages. I could directly pay for more normal and predictable expenses. And I could use insurance mainly for what insurance is supposed to do: protect me against large, serious and unpredictable risks.

Insurance exists because of risk.

We do not insure every tank of gasoline or every oil change. We insure the car against an accident.

Healthcare has gradually done something strange. More and more ordinary expenses are paid by somebody other than the person buying the service.

And when somebody else always pays, we stop caring about price.

If I book a service through the Italian NHS, I usually have no idea what it actually costs. Nobody asks me to compare two providers. The provider does not necessarily have to win me over by giving me a better price.

In a more normal market, it would.

I would like hospitals to publish prices people can actually understand. I would like insurers competing for customers. Clinics trying to persuade me to choose them. New providers entering when they see demand that existing providers cannot meet.

And I would like to control more of the money myself.

For me this is about liberty as much as efficiency.

Helping People Who Cannot Pay Does Not Require an NHS for Everyone

Then comes the most serious objection: what happens to somebody who cannot afford healthcare?

It is a real question.

It is not, however, an argument for a National Health Service.

A country can decide to help people who genuinely cannot afford insurance. It can subsidize their coverage or provide targeted support for catastrophic costs without therefore building a system in which government organizes healthcare for the entire population.

Those are different questions.

We can debate how large that safety net should be. We can debate who qualifies and how much government should spend.

But I do not understand why helping someone who cannot afford insurance requires government to control a huge share of the healthcare spending of someone who can.

If anything, concentrating public money on people who actually need it seems more sensible than spreading it across almost everybody.

Ending the NHS would not mean closing hospitals.

It would not even mean that government never plays any role in healthcare.

It would mean that government stops being the natural buyer, organizer and financier of healthcare for almost everyone.

That is a much bigger change.

America Has Problems. Markets Aren’t One of Them

The automatic answer to all this is easy: “So you want American healthcare?”

No.

The United States spends around 17% of GDP on healthcare, enormously more than Italy. Its insurance system is confusing. Many prices are absurd and there is far too much intermediation.

I do not think American healthcare is some kind of perfect free market.

In many areas it is not particularly free at all.

There are subsidies, employer-linked insurance, government programs, regulation, restrictions on supply and prices that patients sometimes do not even know before receiving treatment.

This is one reason I found Atlas interesting. His criticism is not only a criticism of single payer. It is also a criticism of an American system where patients themselves have lost control over healthcare money.

The lesson from the United States is not “copy everything.”

It is that markets and medicine are not moral opposites.

Profit in healthcare does not bother me.

If a company develops a better diagnostic machine, builds a more efficient hospital or finds a way to perform a test for half the price, I want it to make money. That profit tells other entrepreneurs there is an opportunity. They enter, compete and perhaps do it even better.

This is considered normal in almost every other part of life.

I am not sure why healthcare should suddenly make the mechanism immoral.

Cheap Drugs Also Have a Cost

Atlas also spent part of his lecture talking about medicines, and this may be the clearest example.

Europe is proud of the fact that governments often obtain much lower pharmaceutical prices than the United States. For a government budget that is obviously attractive.

But again, an administratively lower price does not mean the cost disappeared.

A study published in June 2026 covering eighteen European countries found that higher national list prices for new medicines were associated with faster patient access. The author is careful about causality, but explicitly identifies a possible trade-off between price containment and timely access to new treatments.

Earlier research also found large differences in the availability and launch delays of new medicines across European markets.

None of this means a pharmaceutical company should be allowed to charge literally anything.

It means prices contain information and incentives.

If you deliberately make a market less profitable, you cannot be completely surprised when a company decides to launch somewhere else first.

A medicine that costs less but arrives much later is certainly cheaper for the government.

For the patient waiting for it, the calculation may look different.

Lombardy Stopped Halfway

Living in Lombardy also makes this debate more interesting because the line between public and private healthcare is already less rigid here.

Regional law explicitly treats accredited private healthcare providers as an integral part of Lombardy’s health system, and private institutions can provide services paid for by the NHS.

I think this moves in the right direction.

But only halfway.

We accepted that the hospital providing care may be privately owned. We did not really question who collects and distributes most of the money.

You can have a privately owned hospital that still depends heavily on politically decided budgets, tariffs and rules.

That is not really a market yet.

A more liberal reform would give more autonomy not only to the provider but, much more importantly, to the patient.

I Don’t Want a Better NHS

Maybe this is the main conclusion I brought back from Stanford.

For years I also thought about healthcare in the normal terms of Italian politics: How do we improve the NHS? How do we reduce waiting lists? Where do we find more funding? How much public and how much private?

I am less interested in that question now.

I do not think Italy needs a better National Health Service.

In the long run, I think Italy should move beyond the National Health Service.

I would rather have a system where most people keep more of their income, decide how to insure themselves, directly control a much larger part of their healthcare spending and buy services from providers that actually have to compete for them.

Government can intervene where it is really necessary. It does not need to sit at the center of everybody’s healthcare.

There would be problems. There would be mistakes. Some reforms would have to be changed after they were introduced. I do not know a healthcare system anywhere that does not have problems.

But I would rather have a system where the power to make choices—and sometimes make mistakes—is spread among millions of people than one where a few institutions make those choices for everyone.

The question Scott Atlas left me thinking about at Hoover was, in the end, a very simple one.

Who should control the money spent on my health?

Not the government.

I should.