What Texas can learn from Italy’s big bet on primary care

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In early 2020, the world watched as a terrifying new virus arrived in Italy and brought the country to its knees. Images of vacant streets, doctors in head-to-toe protective gear and stacked body bags flooded the nightly news, serving as a warning of what awaited the rest of us.

By the time COVID-19 hit the United States in full force, the lessons from Italy were becoming painfully clear, pushing states, including Texas, to more quickly institute lockdowns, start testing and surveillance and try to equip health care providers as best as possible.

But there was no time for either country to build the robust, resilient health care system it would need to adequately respond to a crisis of this magnitude. Both Italy and the United States had long focused health care dollars on flashy hospitals and top-flight speciality care, allowing primary care to languish. Both countries paid the price for this policy choice during the pandemic.

Italy has taken this painful lesson to heart, rebuilding its health care system with a new focus: Helping people avoid the hospital by getting their basic health needs met close to home.

The country is pouring the equivalent of $17 billion in COVID-19 relief funds from the European Union into its health system, mostly in primary care. This unprecedented influx of cash is intended as a sharp shock to help reorient Italy’s health care system away from hospitals and into people-centered care.

A similar effort is long overdue in the United States, and especially in Texas. Here, in the land of massive hospitals, and extraordinary experiments in cutting-edge care, we have fewer primary care providers per capita than almost any other state.

Less than 6% of health care dollars in Texas go to primary care, lower than the national average, even as the need continues to grow.

“COVID just about killed primary care in Texas,” said Sue Bornstein, co-director of the Texas Primary Care Consortium, which advocates for more access to primary care. “There were so many practices that went under and people retired early. It really shone a bright, very unfavorable light on just how fragile this was.”

After decades of neglect, the growing crisis in primary care in Texas is forcing legislators, local leaders, health advocates and medical providers to take a hard look at what it would take to revive the foundation of the medical system.

Texas learned from Italy’s mistakes in the early days of the pandemic. Can they learn from the country’s effort to right the ship after the crisis has passed?

Re-centering primary care

At first glance, the American health care system seems to have little in common with its Italian counterpart.

Italy’s national health system pays for most medical care for residents. The country spends less per capita on health than most other European Union countries, but Italians still tend to live long, healthy lives.

Compare that to the United States, where a mostly privatized system costs the government and consumers more than in any other high-income country. Here, life expectancy is declining, and the U.S. ranks lowest for access to care, administrative efficiency, equity and health outcomes.

But despite these different starting places, both countries have ended up in similar predicaments, with health care systems that reward expensive, acute hospital care over comprehensive, accessible primary care.

Primary care is the easiest, cheapest way to keep a whole community healthy, according to an overwhelming body of evidence. Ensuring people have an ongoing relationship with a primary care provider close to home allows them to identify health issues early, manage them proactively, and avoid unnecessary hospital visits.

The pandemic revealed how far most health care systems have strayed from that premise. Nowhere was that more apparent than Lombardy, Italy. Each of Italy’s 20 regions decides how to deliver health care, resulting in a wide discrepancies from place to place. The wealthy, northern Italian region of Lombardy has taken an approach that feels distinctly Texan.

Anchored by Milan, the country’s economic capital, Lombardy is where Italy’s free-for-all medical system is becoming ever more market-driven and privatized. In some ways, it has paid off — The region is home to five of the 10 best Italian hospitals, according to a 2024 ranking. Italians from other regions come to Lombardy for cutting-edge specialty care they can’t get at home.

But when COVID-19 arrived, Lombardy’s hospitals were quickly overwhelmed and there was no primary care system to help people stay healthy at home. As many as 35,000 people died in Lombardy in the first months of the pandemic, a much higher mortality rate than any other region for that period, generating international attention on the region’s health care system.

If Lombardy is the face of Italy’s failure to invest in primary care, Texas is the poster child for the United States. Despite our world-renowned hospitals, nearly 40% of Texans say they do not have a usual source of health care, compared to 29% nationwide. Texas has just 86 primary care providers per 100,000 people, the second-lowest in the nation, meaning even people who have a doctor often wait months for appointments or are only seen for the most urgent situations.

“In Texas, we’re always chasing sexy, we’re chasing big, and we’re letting the infrastructure, the foundation of the health care system deteriorate,” said Tom Banning, CEO of the Texas Academy of Family Physicians.

Primary care is supposed to be the front door to the rest of the health care system. Without that relationship, people are left on their own to try to stumble into the care they need. Some take the accessible but extraordinarily expensive route through the emergency room, or an urgent care clinic. Others forgo health care entirely until it’s too late.

By emphasizing hospitals over human-centered care, Lombardy and Texas leave people feeling medically homeless. But there’s another way.

A home for health care needs

The daisy yellow building, with chipping paint and high, arched windows, had been a lifeblood of the northern Italian town of San Secondo Parmense as long as anyone could remember. Originally part of the Catholic Church, this building served as the area’s hospital since the late 1700s.

When the hospital closed more than 15 years ago, the aging, increasingly sick residents of this small village, 70 miles minutes west of Bologna, were forced to travel to nearby cities for medical care.

It’s a familiar tale in Texas, where 26 rural hospitals have closed in the last 15 years, leaving vast swaths of the state without nearby access to medical care.

But that wasn’t the end of the story for San Secondo. In 2012, the space was reborn, not as an acute care hospital, but as a casa della comunitá, a community health home. The regional government helped convene all the remaining fragments of the health care system — primary care doctors and nurses, pediatricians, mental health services, family planning — and put them under one roof, alongside social workers and community groups.

“We’re putting back into this community, basic medicine, [social] services, all in a different form than people are used to,” said clinic director Dr. Severino Aimi. “It’s been a gradual process to convince [people] they don’t have to go to the hospital for this care.”

Emilia-Romagna, the region just south of Lombardy where San Secondo sits, has spent the last 15 years consolidating hospitals and opening hyperlocal comprehensive primary care clinics in their place.

“We tell the patient, we’re going to give you something instead [of a hospital] where you can have all your services,” said Andrea Donatini, the regional director for the project. “People start to appreciate it quickly.”

Emilia-Romagna originally called these clinics casa della salute, health homes. Italy has recently rebranded them as casa della comunitá, community homes, to emphasize the social services they offer alongside medical care.

In Emilia-Romagna, patients who are registered to a primary care physician at one of these clinics, rather than a solo practitioner, report fewer emergency room visits and overall hospital admissions, research shows, especially the longer the clinic is open.

“Any health care services that we can take off of the acute care hospitals, we do,” Aimi said. “It’s more sustainable from a financial point of view, more convenient for the population, and the proximity [is a benefit for] elderly people, especially.”

In San Secondo, this means proactively working with elderly residents struggling with chronic conditions. Rather than having them travel to the clinic, let alone a nearby city, for frequent appointments, the casa della comunitá built out a team where nurses and social workers stay in touch with patients through weekly phone calls, answering questions, helping them decide when to come in-person and offering in-home care when needed.

“A fragile patient, who is elderly, with many diseases and many medications to take, and maybe he lives with his wife, who is managing all this with difficulty, that is someone who is at risk of frequent hospitalization,” said Dr. Silvia Castagnetti, a general practitioner at the clinic. “But with the right support, they can be better managed with us and stay at home.”

The fragmented U.S. health system

What Italy refers to as a casa della comunitá, the research refers to as a “patient-centered medical home,” an idea that’s been around in different forms since the 1960s. Having a medical home means rather than the patient going from office to office to find the care they need, it comes to them, coordinated through their primary care provider.

“​​Our system is complex and unless you have somebody quarterbacking it, consults can get lost and recommendations may not be understood or received properly,” said Bornstein, with the Texas Primary Care Consortium.

While the fragmented U.S. health care system doesn’t lend itself to wholesale reforms the way the Italian system does, some states have used the levers available to them to encourage the patient-centered medical home model to take hold.

In 2010, around the time the Affordable Care Act was introduced, the Minnesota legislature passed a series of health care reform measures to strengthen primary care. Doctors who teamed up and got certified as patient-centered medical homes were eligible for increased reimbursement for patients with government-subsidized health insurance like Medicaid, and the state encouraged private insurers to follow suit.

Today, more than half of Minnesota’s primary care clinics are enrolled in the program, serving 80% of counties. Patients enrolled in one of these clinics showed better health outcomes with far fewer hospital visits; data from the first five years of the program also showed racial disparities in health outcomes were significantly improved for health home patients.

It has also proven to be a good investment on the state’s part. Widespread adoption of the patient-centered medical home model saved Medicaid and Medicare more than $1 billion in Minnesota in the first five years, due in large part to dramatically lower rates of hospitalization.

Texas tried a small-scale version of this — in 2008, Bornstein and others launched the Texas Medical Home Initiative, which helped transform a handful of community clinics into patient-centered medical homes. The pilot program was successful, she said, but “a drop in the bucket” for a state this size.

There are primary care practices in Texas today that are certified as patient-centered medical homes. But it’s not widespread enough to have the transformative effect Bornstein had once hoped for.

“We ran into challenges scaling this in a state that is not only large but as diverse as Texas,” she said. “And the funding just wasn’t there.”

Emilia-Romagna’s medical makeover

Around the same time states started dipping a toe in the patient-centered medical home model, Emilia-Romagna was going all in on the idea. The region, which is slightly smaller than the Dallas-Fort Worth area, has built almost 130 casa della comunitá in the last 15 years. Some are tiny “spoke” clinics, with just a doctor, a nurse and a rotation of other services, while others are larger, more resourced “hubs.”

Each clinic caters to the unique needs of the area it serves. While many of the rural casa della comunitá are in refurbished hospitals or government buildings that the community already associated with health care, the clinic in Navile, a neighborhood in Bologna, stands out for its newness.

The four-story building has a lime green facade and cheery signage in multiple languages to entice people to come inside. As the regional capital and home to the oldest continuously operating university in the world, Bologna is a mix of students, artists and professionals, as well as working-class Italians and a growing foreign-born population from Africa and the Middle East.

It’s those last two groups that the casa della comunitá has done the most work to attract. Neither is quick to proactively seek out medical care, said clinic director Dr. Giampaolo Marino, who took a new role with the regional health authority earlier this year.

“We want to make it as easy as we can,” Marino said. “We want people to use all of our services rather than having improper use of the emergency room in the hospital or waiting to see a specialist.”

In addition to robust comprehensive primary care, the casa della comunitá hosts walking groups, vaccine clinics, and support groups; and offers a mental health clinic, eye exams and on-site lab tests. They’ve even built out an Italian version of a 24-hour urgent care clinic to help people avoid going to the hospital for more minor conditions.

Many of the immigrant families in the area readily used the casa della comunitá for their children’s health care. But the parents resisted getting checked out themselves, and the doctors struggled to overcome the language barrier to explain the wide range of services available to them.

So they started hosting Italian classes.

“Some of the women didn’t trust other Italian schools, or their husbands didn’t want them to go to the schools,” said Dr. Giuseppe Drago, a pediatrician at the clinic. “But because they trust the doctors, when we ask them to sign up [for classes], they do.”

So many moms started coming to the classes, Drago said, they recently had to rent a bigger room in a municipal building down the street.

Taking community health homes nationwide

Inspired by the success of the casa della comunitá in Emilia-Romagna, Italy is taking the idea nationwide, using European Union funding to build more than a thousand new clinics across the country in just the next few years.

But decades of underinvestment in primary care won’t be solved just with new buildings. If Italy doesn’t address underlying issues like workforce shortages, the new casa della comunitá will be like “cathedrals in the desert,” Dr. Alessandro Dabbene, vice-secretary of Italy’s general practitioner’s union said.

Primary care has long been seen as a less attractive, less prestigious career path than specialization, in Italy as in the U.S.

“Primary care is quite invisible,” said Dr. Alessandro Mereu, a general practitioner in Sesto Fiorentino, a suburb of Florence. “We do quite a bit of work to keep the system going, but no one ever talks about primary care the way they talk about a new hospital.”

In Italy, a majority of physicians are over the age of 55 and a quarter plan to retire before 2027, setting up a looming crisis, particularly in rural and already under-resourced areas. The United States isn’t faring much better, with 47% of doctors over the age of 55, according to 2021 data from the Association of American Medical Colleges. Family medicine and other primary care specialties tend to skew even older.

In Texas, just a third of primary care physicians are over the age of 55, according to 2020 state data. But that doesn’t diminish the fact that the state has a significant shortage of primary care providers of all ages.

In an effort to grow the primary care workforce, Texas has invested in medical schools and residency programs that focus on rural and community health, and repays medical school loans for doctors that work in primary care.

These efforts will hopefully help reverse the decades-long decline in doctors choosing primary care. But it’ll take years to see the payoff — and even then, is likely only one part of the solution.

“At the end of this, we’re still going to be in a hole,” Banning, with the Texas Academy of Family Physicians, said. “But when you find yourself in a hole, you at least need to stop digging, which is what these programs help with.”

Italy is offering a salary bump to doctors who work in a casa della comunitá. But they’re also hoping that building more support around primary care itself will make the job more appealing to the doctors already working, and those they hope to recruit in the future. In Emilia-Romagna, older doctors were more resistant to teaming up, but younger physicians tend to be eager to work in group settings for the better work-life balance, professional development and institutional support, Donatini said.

Primary care providers love what they do, Bornstein said. They just want the system they support to love them back.

“The gratifying part of being a doctor is sitting there, talking to a patient, learning about them and helping them navigate through a very complicated, and let me say, hostile, health care system,” she said. “We help them feel at home. That’s why we’re there, every day.”

Revitalizing the anemic Texas primary care system

Earlier this summer, Banning got a call from a longtime primary care doctor and past president of the Texas Academy of Family Physicians.

“His family doctor had recently retired, and he couldn’t get in to see one of his colleagues for a physical until November,” Banning said. “He was asking me if I knew anyone accepting new patients.”

COVID-19 strained Texas’ already beleaguered primary care system, and people are starting to get frustrated with long wait times and delayed care, Banning said. But it hasn’t yet moved the needle in Texas the way it has in Italy.

“I don’t think that constituents have felt the effects to the point where they’re calling their legislators,” Banning said. But if the state waits until a crisis point to more forcefully intervene, he said, the problem will only be more entrenched than it already is.

If given a magic wand — or access to $17 billion, as Italy has — Banning would make medical school entirely free for primary care physicians. He’d also more quickly transition how doctors get paid, emphasizing quality over quantity of care, and incentivizing doctors to treat underserved populations.

And he’d build a federally qualified health center in every county in Texas.

These safety net clinics that serve poor and uninsured people are the closest thing Texas has to casa della comunitá. They are federally funded and required to provide comprehensive primary, dental and behavioral health care at low or no cost, and are run by a patient-led board of directors. Many of these clinics in Texas are expanding social services to more directly help their vulnerable clients with transportation, food access and job training. As a result of the wide range of primary care services they provide, most are certified as patient-centered medical homes.

Jana Eubank, the CEO of the Texas Association of Community Health Centers, the advocacy group that represents the clinics, said their mandate is to make sure the patient is the most important part of the care team.

“We don’t just say, ‘this is what you need to do.’ We ask them, ‘what do you need?’ and we meet them where they are,” she said. “It’s really the patient driving their care… We’re really very focused on improving the overall health status of not only that person, but that whole community.”

Texas has 75 federally qualified health centers with 650 clinic sites between them. But it’s far from enough for a state of this size and medical need, Eubank said.

Unlike most other states, Texas typically hasn’t chipped in state dollars to supplement the federal funds these clinics receive. In some ways, the state has worked against them. Since Texas hasn’t expanded Medicaid, these clinics have to foot the full bill for people who, in other states, would have been covered by the program.

But in 2021, the Legislature put $20 million of federal COVID-19 relief dollars into an incubator program that helped 35 clinics expand operations, including building a women’s health clinic in the Rio Grande Valley, adding an on-site pharmacy in the Panhandle and purchasing a mobile mammography clinic in central Texas. In 2023, the Legislature kicked in an additional $40 million.

This money was essential to keeping clinics afloat, and expanding, during tight budget years, Eubank said. But it’s far from enough. Under the program’s strict rules, it can often take years for a clinic to qualify to begin receiving federal funds, during which they must be providing the full spectrum of services to prove their eligibility.

As a result, these clinics are still reaching just a small portion of the vulnerable Texans they’re supposed to be serving. As a first step to revitalizing primary care in Texas, the state should consider more aggressively shoring up what’s already working, Eubank said.

“We provide some of the best comprehensive primary care in Texas in our clinics,” Eubank said. “People think of us as the ‘poor people’s clinic,’ but really, this is the standard of care everyone should expect from their health care system.”

Without some attention from state leaders, accessible, comprehensive primary health care will be increasingly out of reach for most Texans, whether they’re seeking it at a safety net clinic or a high-end private practice. There simply won’t be enough doctors to see everyone.

“I applaud the Italians for having the foresight to look at COVID and the warts that it showed before it got to that point,” Banning said. As for Texas, he said, “we’ll just keep beating that drum.”

Disclosure: The Texas Association of Community Health Centers have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune’s journalism. Find a complete list of them here.

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