Commentary
What about the rights of citizens, not just those of the regions?
Health care is already terribly unequal between the rich and poor regions, and, at the same time, there is so much inequality within each of the richest and most developed regions that this too seems utterly unacceptable.
Many have been warning about the risks to the unity of the country, its development perspectives and the equality among citizens that will arise as a result of differentiated autonomy, a bill that has just been passed by Parliament. However, in the realm of healthcare, differentiated regionalism is an existing reality which has already resulted in major differences.
For one, there are differences in the share of the state health fund paid to each of the 19 regions and two autonomous provinces, which are managing the National Health Service according to the 2001 reform of Title V of the Constitution. But even more significant are the regional differences in private spending on healthcare. And there are also major differences in the net transfer of economic resources between regions for the healthcare mobility of their residents.
Taken together, these differences amount to an imbalance that severely penalizes the regions with the greatest economic and social difficulties.
Looking at the distribution of the state health fund among regions, the three regions with the highest funds per resident are Liguria, Umbria and Tuscany, and those with the lowest are Calabria, Campania and Basilicata, with a difference between the last and the first in the ranking (Calabria and Liguria respectively) approaching 10 percent.
When we look at the share of private spending on healthcare, the ranking changes at the top but remains essentially the same at the bottom. The three regions with the highest per capita spending are Lombardy, Emilia-Romagna and Liguria, and those with the lowest are Calabria, Basilicata and Campania. However, the net difference is even greater: in the region in last place – once again Calabria – private spending is more than 20 percent lower than in the top province, i.e. Lombardy.
Finally, when spending for health mobility is also taken into account, yet another transfer of resources from the poorest to the richest regions is plainly visible. The net health mobility balance is the difference between the value of the services a region buys from others that provide healthcare to its residents and the income it earns from healthcare it provides at its own facilities to residents of other regions.
In this particular ranking, the three regions with the highest negative mobility balance are Calabria, Campania and Sicily, with a cumulative negative balance of about 650 million euros, and those with the highest positive mobility balance are Veneto, Lombardy and Emilia-Romagna, which together benefit from a positive cash flow of about one billion euros. From a financial perspective, one can hardly imagine a more “differentiated” regionalism, and, if anything, it would seem more logical to take measures towards rebalancing it. Especially if one takes into account the overwhelming share of regional budgets that goes into public health spending, in all cases close to 75 percent, and even more so if one notes the steady growth of private healthcare spending, which privileges the richest regions and has already exceeded 25 percent of total healthcare spending, a number that is most likely underestimated as some spending is not captured in the statistics.
In a healthcare system that has long adopted the values of the market and economic efficiency, these blatant inequalities are often explained, and even justified, by touting the higher quality and quantity of the services provided, to the point of suggesting that it would be cheaper to keep investing more into regional systems, which supposedly work better than the national one. There are different ways of testing how well a healthcare system is functioning in relation to the expenses incurred in its operation, but perhaps the simplest and most straightforward approach is to measure the standardized mortality of the adult population and assess whether greater expenditures are matched by an equivalent reduction in mortality, and, on the other hand, whether a greater availability of resources and thus – at least theoretically – a greater availability of services is able to reach the entire population equally.
In other words, we can compare the health systems of different regions according to two criteria: their effectiveness, i.e., what level of standardized mortality they produce, and their equitability, i.e., how independent mortality is of the socioeconomic status of the population.
The levels of mortality in the adult population of Italian regions, standardized by age and sex, and their distribution according to the level of education was the subject of a thorough study conducted in 2019, with great methodological rigor and based on large datasets (A. Petrelli, L. Frova). The findings appeared to show a reduction in standardized mortality as health spending increases; however, at the same time, a greater difference in mortality between people of different socioeconomic status was observed in most regions with high per capita healthcare spending, as if the benefits of higher spending were not being distributed evenly among citizens. On the one hand, the higher levels of regional spending are matched by a reduction in mortality; on the other hand, 7 of the 10 regions with the highest spending also feature a wider gap in mortality between citizens with the highest level of education and those with the lowest. For example, Lombardy has a 10% lower mortality than Calabria, but in Calabria the difference in mortality between those with the highest and lowest levels of education is 20%, while in Lombardy it reaches 40%.
Thus, as we are facing the specter of differentiated regionalism, health care is already terribly unequal between the rich and poor regions, and, at the same time, there is so much inequality within each of the richest and most developed regions that this too seems utterly unacceptable. Perhaps it would be worthwhile to change the focus of the discussion from the rights of regions to the rights of actual citizens.
Originally published at https://ilmanifesto.it/i-diritti-dei-cittadini-non-sono-quelli-delle-regioni on 2024-06-21