When Italy’s vaccine rollout began in January, Kenda was proud to be a resident here, believing that “my adopted country was going to take good care of me”.
Four months later, she calls her vaccination experience “a gut punch”: “To learn that they are actually putting me at the end of the line, if in the line at all, has felt like a betrayal.”
She and her husband Scott are American retirees living in Liguria who took out private health insurance when they first arrived, partly to simplify the bureaucracy and partly for emergency coverage when they visited the US. They’ve been told by their insurer that their policy doesn’t cover vaccination against Covid-19, while multiple conversations with the local health authority – by email and in person – have all concluded the same way: if you’re not registered with the Italian public health service, there’s no way to book a jab.
READER QUESTION: Do you need a health card to get vaccinated in Italy?
If that is indeed the case, Kenda says, Italy should have said so clearly from the beginning: “Had we heard that message at the end of last year when the vaccine plan was rolling out, we would have then chosen NOT to renew our private health insurance for 2021 (paying for a year in full) but we would have absolutely signed up for the Italian system.”
The Local has heard from foreigners all over Italy who share her frustration. It’s especially acute among people in their 60s and older, who are watching others in their age group or even younger get vaccinated while they’re unable to secure an appointment.
There’s no rule in Italy that says foreigners can’t be vaccinated, in fact the opposite: since the beginning of the campaign, the Italian Medicines Agency AIFA has said in its official guidance that “all people will be vaccinated who are present on the Italian territory”.
In practice, though, only people who are enrolled in the public health service are being allowed to book a jab. Italy has valid reasons to run its vaccination campaign via the public system: it wants Covid-19 vaccines to be free of charge; the majority of its population have their health records stored in public databases; and people who are enrolled in the public system have paid some form of social security contribution to get there.
But the goal of the campaign is maximum coverage, and yet the process has not been designed to handle exceptions. That means those who are outside the system – in some cases, not by any choice of their own – are losing out on a place in the queue.
The issue can affect Italian nationals too. Christina, who was granted Italian citizenship through ancestry in September 2020, was told she would receive her tessera sanitaria – the Italian health card that shows you’re registered with your regional health service – at her address in Sicily. More than six months later, she’s still waiting.
Without the tessera, she has been unable to book a vaccination using Sicily’s registration website, which like every other region, requires you to enter the number of a valid health card issued in Italy. “It may take some time to sort out this issue and finally obtain my card. In the meantime, I am of the correct age to qualify for the vaccination, and I want to have it as soon as possible,” she told The Local.
Others report problems that could affect anyone living in Italy, regardless of nationality. “My tessera sanitaria expired during the first lockdown of 2020 and shortly after the lockdown finished my partner and I moved from Campania to Lazio for work purposes,” says Ben, a teacher in Rome.
He hasn’t had the chance to renew the card yet and he’s still officially resident in Campania, since his landlord has not supplied the paperwork he needs to change his registered address. Meanwhile Lazio’s vaccination website won’t accept his old tessera sanitaria number. “The only response I’ve got from anyone is to renew the card and try again. Although with regional travel being limited that’s easier said than done right now,” Ben says.
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Though the process may not deliberately disadvantage foreign residents, they are more likely to be outside the Italian health system, since unlike Italian nationals they do not automatically qualify to access it but instead have to meet certain criteria, and/or pay an annual fee to opt in.
Several people told The Local they had decided to join the Italian health service for the first time, even if it meant paying extra or giving up other forms of healthcare, in the hope of getting vaccinated in good time.
That didn’t always fix the problem. Donald Helme and Dale Perry, a couple in their 70s who until the pandemic lived between Le Marche and Ireland, say they “caved in” and signed up for Italian public health care, renouncing access to the Irish system in the process. After paying the fee and getting a provisional tessera sanitaria while waiting for the electronic version to be issued, they found they were still unable to book via the registration website – while a phone helpline only offered a recorded message directing them back to the site.
“It is amazing that having got the tessera (because they insist on it!), having got the numbers, there seems to be a gap through which the actual website booking process allows us to drop,” Donald says. “We had never come this close to the legendary ‘bureaucracy’ before, so from an academic standpoint it is certainly most interesting. In practical terms a pain in the proverbial.”
Another reader who asked not to be named, also in Le Marche, had a similar experience that ended in even more frustration.
“Appointments for Covid jabs in my age group were being accepted on March 29th. I applied for a tessera sanitaria card on April 1st when it became apparent that – contrary to previous assurances – that a tessera sanitaria number would be required after all,” he told The Local.
“My tessera sanitaria card with the necessary number has never arrived. The Regione Marche health service apparently realized that some residents like myself did not have a tessera sanitaria number and set up a SMS system requiring only a codice fiscale [tax code]” in mid-April, he said.
“Having sent my CF by SMS I am today advised (by return SMS) that it is not my turn so they will not issue me a booking. Indeed, it is ‘not my turn’ – I am 73 and with all the delays they are now accepting bookings for those in their 60s, so I have apparently missed my turn…
“You could not make this up.”
People reported similar lags in Lazio, Puglia and Sicily. And with regions all over Italy forced to pause vaccinations for over-60s this week because they’ve run out of doses, delays risk multiplying for those who aren’t already in line.
Yet even people who are still waiting for their health card are further ahead than some foreign residents in other parts of Italy, who have been unable to sign up for Italian healthcare at all due to a highly devolved system that allows each region’s health service to set its own rules about who can enrol and how.
“I live in Umbria and it is the only region in Italy that does not allow EU citizens to opt in to the health system by paying an annual fee, as non-EU residents do,” says Pam, a British-Australian who moved to Italy before the UK left the EU.
“I can’t see any progress there until the Umbrian health authorities change their rules, which they are said to be considering but who knows for how long they will be doing that.”
Fellow Brit Chris is in the same situation: “We pay Italian taxes, we live here, we have a bank account, we have private health insurance and yet we can’t get a tessera sanitaria. It’s a joke.”
The Local has heard from several people in Umbria who have attempted to take up the issue with their local health authority, or ASL/USL. “The initial response was ‘there’s nothing we can do for you’,” says another Chris, a retiree who has lived in the region since 2017. “After a while the lady behind the counter admitted it was a strange situation, took a copy of all our docs and said she would look into it.” To date he has not had any success.
Local officials are often sympathetic, but in the absence of clear instructions from higher authorities, they’re unable to do much.
“I have contacted the local ASL and vaccination centres, local doctors, the British Embassy, Sanità Puglia, and even the mayor!” says Roberta Mitchell, a Brit who has lived in Italy for 40 years and recently moved from Rome to Locorotondo. “The health services (when they responded) were not equipped to deal with the problem.”
With private health insurance via her international employer, she has not joined the public system. And though Puglia’s health service advised on its website that people who were not enrolled would be able to book vaccinations in pharmacies from mid-April, this turned out not to be the case.
“We are in an administrative limbo,” says Roberta, who is in the process of trying to transfer of her residency to a temporary address in Puglia – while waiting to complete purchase of a house – in order to register with the health service there.
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The national government is becoming aware of the need to make exceptions. In the past week Italy’s Covid-19 emergency commissioner issued the first official guidance on allowing people not enrolled in the national health service to book a jab – though so far, the special allowance only applies to Italians who usually live abroad, diplomats, and staff of international institutions such as the EU or UN.
That won’t help most of the people The Local has heard from. But there are a few signs of encouragement.
Sicily recently offered AstraZeneca vaccinations without appointments to everyone over 60 for a three-day period, allowing even foreign visitors to get a jab. Meanwhile people in Lazio, Piedmont and Tuscany reported that they were able to register for an appointment without a health card, via phone or email rather than online.
In Piedmont, Chris Matten managed to reach his ASL’s public health department, who asked him for a declaration of residence, a copy of his ID and proof that he was in a priority category. “Yes, it took two visits in person and two emails until I found the right avenue, but other readers in Piemonte who wish to register can just email the SISP Novara office, and it should work,” says Chris, who is now waiting to be contacted with details of his first appointment.
Without clear, definite instructions to all regional and local authorities, however, there is no guarantee that what works in one part of Italy will work in another. Our reader Donald observed: “My protestation that ‘everybody is entitled to vaccination according to the government’ is always responded to with ‘well that’s Italy, this is Le Marche’.”
“It is of vital importance that the government makes ALL the regional health services aware of their decisions,” says Roberta in Puglia.
“All health authorities should have Covid-19 vaccine registration websites changed to eliminate the requirement for a tessera sanitaria for all legal residents. All health workers should be advised they cannot verbally tell Italian residents they must have a tessera sanitaria. The process to reserve a Covid-19 vaccination should be uniform throughout Italy,” argues Christina in Sicily.
Others suggested allowing people to book an appointment using only their codice fiscale or ID, or creating an option to join the health service temporarily.
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Until the authorities make the process more flexible, Roberta says she and others in her situation face “a waiting game”. They will be vaccinated eventually, since Italy plans to offer vaccination on a walk-in basis once those in high-risk groups – and the public system – have had their jabs.
But for the older people we spoke to, the prospect of remaining unvaccinated as Italy invites tourists back over the summer, then lining up for a jab alongside 20-year-olds, was understandably frightening. “For people like me this is a life and death issue,” says Robin Stirling, a British resident in Umbria who is over 70 with health problems.
In fact the stakes are high for everyone, as many people pointed out. Pam says she wants to tell the Italian authorities: “Residents without health cards are just as vulnerable to the virus, and as capable of spreading it to others, as those with cards, so a vaccination programme that excludes them will always be less effective.”
Thank you to everyone who shared their experiences with The Local, even if they’re not included here.
The Local is continuing to follow this issue and will post any new updates on how to get vaccinated without a health card as they appear. Find more coverage of Italy’s vaccination campaign here.