It’s January. A year ago today we were trying to acclimate to life in Italy (I was teaching at a school in Venice for the spring semester). A lot happened to us while we were there; one time, my daughter got a bug bite and her right eye puffed up painfully. It was bad enough that we took her to an emergency room.

We had purchased international insurance – because we’re Americans, we worry about insurance a lot – but the hospital we went to didn’t have a formal relationship to our insurance company. We’d have to reimbursed. The nurses there, whose English wasn’t great, was very concerned that we might be paying out of pocket. They explained to us that we’d be covered by Italy’s national health insurance because of our immigration status but, since we hadn’t signed up for it, we would have to be reimbursed. They were very nice, and very worried for us.

They were so apologetic that we’d have to pay out of pocket, I became really worried myself. Was the bill we were about to receive going to destroy our credit card balance? How hard was it going to be, and how long would it take, to be reimbursed by my insurance coverage? Should I apply for Italy’s insurance?

The doctor’s visit went well and my daughter was given an ointment and something to take. We felt reassured she’d be OK. When I went to pay, I had to go to a machine that read a form a nurse gave me and pay the machine directly. I don’t know why this was considered more efficient than my simply paying a cashier. In any case, the machine told me what I owed. The grand total: 20 euros. This is about $25 in US currency.

I should add here that my copay for going to the ER in the US is $50.

The amount was so little, I figured it wasn’t worth the hassle to to get reimbursed from my health insurance company – and certainly not worth the hassle to get signed up for Italy’s national insurance. It did make me think, however, that there must be a lot of subsidies that made even the out-of-pocket cost to an ER so affordable. The nurses’ concern that I’d have to pay anything, even if it was something I could eventually get reimbursed for, also struck me as so different from anything we can find in the US.

Here, in the US, health care is a commodity. If the ACA repeal passes through Congress and gets signed into law by the president, we will as a society move even further down the road of thinking of health care as something we need to purchase. Instead of strengthening institutions that make life easier for everyone, we will shift the burden more decisively to the individual. What eventually replaces the ACA might be branded “universal access,” but this is obviously just another way of saying to those who can’t afford health care, or don’t have employers willing to provide it, “you are on your own.” For many around the world, this must seem like a form of madness, or perhaps a form of organized and deliberate cruelty. They would not be wrong.