Is public care for citizens, residents, or taxpayers?
Where do countries draw the line on who's included in "universal care"?
It’s fascinating to talk to people about who they believe deserves healthcare financed by taxes. Americans living in European countries with public and private systems frequently make a point of how they pay for private care because they didn’t contribute to the local public system. This suggests a belief system where people who have put in their 40 credits over 10 years have the right to the public health system, like we do for US social security benefits, while others have not earned that right.
It’s important to note that people’s stated beliefs about who deserves care are different depending on how we approach the topic. Asking if foreign residents should use the public system often gets a resounding NO while asking if everyone deserves access to healthcare gets a resounding YES from the same people.
For the record, I started asking about this because Americans living abroad make such a point about not using the public system because they didn’t pay into it. The way they felt the need to work this into conversations and publicly declare that they don’t use the public system1 caught my attention, particularly because some of these same people say they moved to Europe because they wanted the right to healthcare. They absolutely support universal healthcare. They want the right to taxpayer funded care, but don’t think it’s morally correct to exercise this right unless they are legitimately unable to afford to pay. Which is how Medicaid works in the US. Only, since everyone has the right to taxpayer funded care, they can make their own determination of when they can afford to pay and when they need to rely on public care.
Part of why this caught my attention is that there is no such discussion in Canada, where Americans simply register for provincial insurance as soon as they’re eligible.2
In Canada, care is provided by private institutions and usually paid for by public insurance. In Portugal and Italy, public and private care is generally provided by separate institutions. However, medical professionals often work for both and the public system contracts out care to private institutions, while private institutions send patients to the public system for certain types of care.
What really piqued my curiosity was when I discovered that the right to public care in Portugal and Italy was tied to citizenship, as well as residency. Portuguese and Italian citizens who live abroad could access free care in their country of nationality. So, wasn’t about paying into the system, since non-resident citizens don’t have tax obligations in either country. Both countries also have citizenship by descent, making children of citizens born abroad citizens.
Italy recently put limits on how many generations back you can register a birth abroad (something Ireland and Germany already had), while in Portugal you can claim your nationality as long as you can come up with documents proving you had a Portuguese ancestor. So, theoretically, someone with a Portuguese great-great-great-grandparent could use the Portuguese public care system for free.3 Given the cost of care in the US, the cost of traveling to Portugal could very well be worth it.
It took me several years to realize this, because when someone mentioned it I assumed they’d simply not declared their non-resident status to the health authorities or that the registration office was lax on asking for proof of address. I finally looked it up and realized that my assumption was wrong. Both Italy and Portugal have recently placed highly controversial restrictions on access of non-resident citizens from using the public system for free.
In 2024, Portugal decided that non-resident citizens would be made “inactive” in the public system. Technically, all legal residents have the right to public care. In reality, the immigration authorities are years behind in processing residency paperwork and made a blanket announcement extending the validity of all residency documents. People with expired (but still valid by decree) documents and those who’ve been granted residency but not given resident cards are being refused registration in the public system and being asked to pay.
This is when I noticed that politicians campaigning in Portugal are still promising that they’ll ensure all citizens have a family doctor. I wondered if it was just my lack of fluency, but no:
“Ventura also criticized the public health system, arguing that it unfairly prioritizes immigrants over Portuguese emigrants (source).”
So, for many in Portugal, healthcare is a birthright transferred by blood.4 It has nothing to do with where you were born or where you pay taxes. Perhaps this is because healthcare is a constitutional right in Portugal.
Two political parties are currently campaigning to restrict the ability of residents who aren’t citizens to access to public healthcare. One proposal would require non-citizens to be tax payers for five years before becoming eligible for public healthcare.5 They’d also like to see it become significantly harder to become a citizen.
In Italy, I understand that the constitution only includes the right to free healthcare for the indigent, so they have the constitutional right to the equivalent of Medicaid in the US.
Italians are now automatically de-registered from the public system by the tax authorities when they become non-residents. Being de-registered doesn’t seem to matter, since all citizens remain entitled to free care during visits to Italy, with the idea that it’s for emergencies but without any actual requirements restricting it. This allows family doctors to be reallocated among tax residents, without blocking citizens from accessing care.
There is a proposal to allow non-resident citizens to remain enrolled in the public system for an annual fee of €2,000. Debate around the law reveals beliefs on who deserves publicly funded care:
“Di Sanzo highlighted several rejected amendments, including exemptions for retirees who already pay taxes in Italy, students with little to no income, and a sliding fee scale based on earnings. Also controversial is a clause requiring retroactive payments: if someone pays the €2,000 one year, skips the next three, and then re-enrolls, they must pay for all missing years.”
Italy’s immigration authorities similarly have administrative struggles causing many legal residents to lack valid residence cards, causing difficulty accessing public care they are theoretically entitled to.
Canadian citizens living abroad are not eligible for public coverage.
Americans enrolled in Medicare are able to use their coverage while in the US, even if they’re living abroad. As far as I know, US citizens living abroad are not entitled to any other sort of public care in the US, since the programs all require proof of residency.6
Years ago my mind was blown when I read about a woman who was sent to jail for enrolling her child in a neighboring school district with a better school system. When I went to find her name I discovered there are several cases. I imagine this contributes to our belief that using a public healthcare system in a country we’ve recently moved to is tantamount to theft. The article I read originally was about Tanya McDowell, who served five years in prison.
In Portugal, most expats who opt out of public coverage still enroll in the public system (getting a user ID number) and obtain private insurance. In Italy, you cannot opt out of public coverage if you’re eligible. In both countries, it’s simple enough to receive care at private facilities and not use the public system. Unless you’re in an ambulance or diagnosed with certain conditions, which private facilities don’t treat.
I’m not entirely sure if it would be an option to have private insurance in Canada if one qualified for provincial coverage. In Canada, there are categories of temporary residents who don’t qualify for provincial coverage, so there are insurance plans available (in addition to the more common supplemental insurance plans, which build on provincial coverage, rather than serving as an alternative). A quick search suggested that in provinces that don’t provide public insurance for foreign students, insurance is arranged through the university or a provincial fund for students. Comprehensive insurance plans are available (and required) for International Experience Canada (aka working holiday visa) participants. The question is if these policies would be invalid if held by Canadian residents on another permit category.
Like the debate on funding for gender confirming care, I imagine that the amount of money spent on this is insignificant in terms of total healthcare spending and therefore doesn’t warrant a public debate. I’m interested in the question because of what it suggests about the complexities of who we feel deserves access to public healthcare.
Or adoption.
Presumably, this would not apply to citizens of other EU countries or Portugal would be in hot water with the rest of the EU.
Medicaid and SSI are cut off if you are outside of the US for more than 30 days.
This was fascinating! Thank you