Interview
Pierino di Silverio: ‘The frailest citizens in poorer regions will pay the price’
Health care will become even more unequal under differentiated autonomy. ‘Without a redistribution of resources at the national level, these regions will be forced to either raise taxes or reduce benefits.’
We spoke with Pierino di Silverio, secretary-general of Italian doctors and healthcare managers union Anaao-Assomed, about the effect of regional autonomy on health care.
Secretary Di Silverio, a number of analyses have shown that healthcare is already unequal. Is there anything still left to devolve to the regions?
Article 116 allows further devolutions of functions to the regions. For example, in the healthcare system today, the organization of the service, the essential levels of care and collective contracts are not yet regionalized. With the new law on differentiated autonomy, it will be possible for all these functions to be taken over at the regional level.
What will be the consequences for citizens?
With differentiated autonomy, Lombardy could decide that ultrasound scans during pregnancy are not one of the essential services that must be guaranteed free of charge; Veneto could decide the same for another service, and so on. Italy could become fragmented into 21 small states, even more than it already is today. Inequalities will grow further. The southern regions are starting off at a disadvantage, not so much because of the lower quality of political and administrative work, but, most importantly, because of a significantly lower income level that translates into lower tax revenues. Without a redistribution of resources at the national level, these regions will be forced to either raise taxes or reduce benefits.
But the inequalities between regions are already very large.
Thousands of care recipients have to go from one region to another to get treatment, and this results in resource transfers in favor of the regions that treat more people from other regions. Soon, this mechanism could be taken to the next level. A region could decide that citizens from other regions need to pay a different co-pay, or put a cap on the number of services made available to out-of-region patients. The cost of regional mobility would be passed down from the institutions to individual patients, and the frailest citizens in poorer regions would pay the price. But it’s not just the patients receiving care who will migrate.
What do you mean?
Professional mobility will be added to the mix. Now-autonomous regions will be able to offer a collective contract that is different from the national contract, offering better wage conditions than others. Southern regions would be doubly disadvantaged, because more doctors and nurses will choose to move elsewhere, since poorer areas will not have the means to offer competitive conditions.
Won’t the Essential Levels of Care (LEAs) be enough to keep healthcare services equitable at the national level?
LEAs will be incorporated within the Essential Levels of Social Benefits (LEPS). But achieving the LEPS would require that more resources be sent to the most backward regions to compensate for the inequalities that will be created. Instead, the bill that was passed only refers to standard requirements established on the basis of historical spending: in short, the resources available will be the same as before, so inequalities will increase.
This is what we are already witnessing with the current LEAs, which don’t guarantee the reduction of inequalities.
They don’t work, for the same reason: guaranteeing the LEAs requires more resources, which are not being allocated. We have been calling for years for the implementation of the equalization fund that has been planned since 2013 to rebalance the distribution of the National Health Fund (the set of resources that the government allocates to the regions for health services each year – n. ed.) so as to take into account the regions’ social deprivation index. But this mechanism has only been applied since 2022, and only for 0.75 percent of the total. It must be made clear that in healthcare, equitability is a prerequisite for effectiveness, and not the other way around, as many believe. At this point, the citizens have not yet realized that the welfare state is being blown up. When they realize it, there will be a social uprising.
Will you try to obstruct this reform?
We are considering the possibility of a repeal referendum, and an appeal to the European Court for the violation of Article 32 of the Constitution, which guarantees the protection of “health as a fundamental right of the individual and collective interest, and guarantees free medical care to patients.” But I hope the regions will also make their voices heard.
Originally published at https://ilmanifesto.it/di-silverio-con-lautonomia-sara-penalizzato-il-sud-aumenteranno-le-tasse-o-si-ridurranno-le-prestazioni-sanitarie on 2024-06-21