Differentiated autonomy it is already a de facto reality at a healthcare level. We are not talking about ‘desired’ autonomy, a devolution of competences negotiated between the Regions and the central State. More than anything, it is the result of the inequalities that already exist between North and South. The governors of Calabria and Basilicata know something about this, belonging to the same majority that is preparing the reform in Rome, and it is no coincidence that they have raised their voices in dissent to their own party and alliance comrades. Poor quality services in Southern Italy lead to thousands of patients and doctors fleeing to hospitals in Emilia-Romagna, Lombardy and Veneto. According to a report by the Gimbe Foundation, with the reform just approved by the Chamber of Deputies, this “structural difference” between regional healthcare systems will be increasingly accentuated: this will be seen in the differentiated salaries of healthcare personnel, in the differentiated quantity of scholarships up to arrive at differentiated tariffs for services, which could become a great opportunity for private individuals to obtain more patients (who therefore become customers).
During their last audition parliamentarian on the reform just approved in Montecitorio, the Gimbe Foundation, an authoritative research institute based in Bologna and specialized in health research, asked the majority to “eliminate health protection from the matters on which the Regions can request greater autonomy”. Gimbe has two fears in this regard, starting from the Lep, the essential levels of performance, i.e. the minimum levels of quality and quantity that the central State, beyond the degrees of autonomy of the Regions, must guarantee in the provision of a public service from North to South. The bill signed by Roberto Calderoli provides that matters where the possible financing or achievement of the Lep has not yet been achieved may also be subject to the transfer of competence from Rome to the Regions. The majority tried to patch things up, placing the definition of the essential levels as a sine qua non condition for proceeding with single devolution. But the substance does not change, as the report points out: “The assignment of greater autonomy precedes the recovery of the gaps between the various areas of the country”. What worries the researchers, and we come to the second fear, is also the procedure for assigning the level of autonomy to the individual Regions, in the hands of the Prime Minister, with a Parliament that is “effectively stripped of both the evaluation and approval of the major autonomies requests, both in the initial phase of defining the Lep”.
The problem is that, according to Gimbe, if the National Health Service risks being “fractured” between North and South in the case of differentiated autonomy, it is in reality already divided into “21 profoundly unequal regional health systems”, with the residents of most of the Southern Regions “to whom no minimum levels of assistance are guaranteed”. A ‘de facto’ differentiated autonomy which in itself already causes some major critical issues. Think about the quality of the service. From the analysis of essential services – those provided by the NHS free of charge or upon payment of a ticket – in the period 2010-2019, the foundation led by Nino Cartabellotta calculated the fulfillment percentages region by region. A sort of report card on the health of each of the 21 regional subjects (Trentino Alto Adige is made up of two autonomous provinces). At the top of the ranking are the three regions that, before the pandemic, had already advanced their intention to request greater skills: Emilia-Romagna (with a compliance rate of 93%), Veneto (89%) and Lombardy (87 %). And then gradually decreases, with percentages between 75 and 85% for some central regions, up to the rear, below the sufficiency: Calabria (59%), Campania (58%) and Sardinia (56% ).
Endless times waiting for a visit, need to resort to private spending for families, giving up treatment, crowded emergency rooms, inability to find a doctor or family pediatrician near home. All seasoned with an obvious consequence: a growing healthcare migration. In 2021, the services provided by Northern Regions to patients from the South reached 4.25 billion euros. Three Regions received 93.3% of this money: Emilia-Romagna, Lombardy and Veneto. We are talking about resources that are not disbursed directly by patients. How does it work? The Southern patient books in the North, carries out the visit or service (in 75% of cases these are hospital admissions), and then the Region of residence takes care of paying. In ten years the Gimbe Foundation calculates that Abruzzo, Basilicata, Calabria, Campania, Sicily, Sardinia and Puglia have paid something like 13.2 billion euros into the Po Valley. This dynamic, among other things, prevents the Southern Regions themselves from respecting the efficiency of their accounts. Translated: the health services of Molise and Calabria are under administration and those of the other four have been engaged in arduous debt repayment plans for at least ten years.
Health mobility it not only affects patients, but also staff. To give an example, in 2021 the number of nurses in Italy was 6.2 per 1,000 inhabitants, well below the OECD average of 9.9. Behind that already low number, however, lies a huge geographical inequality: in Friuli Venezia Giulia they are 6.72 per 1,000 patients while in Campania they do not go beyond 3.59 per 1,000, even less than half. The recovery plans and the commissionerships mentioned above, being instruments that only look at economic-financial recovery, make it much more complicated to proceed with the hiring of new staff. So a spiral reaction is triggered – one problem leads to another – whereby the North-South “structural fracture” brought about by the Calderoli reform will definitively compromise “the equality of citizens in the exercise of the constitutional right to health protection” .
The greatest autonomies already requested by Emilia-Romagna, Lombardy and Veneto, continues the Gimbe report, will exacerbate the already existing fracture: from the flight of health professionals towards the richer regions capable of offering more advantageous salaries and scholarships to the greater business opportunities for private healthcare, taking advantage of the opportunities guaranteed by 21 different tariff, reimbursement, remuneration and sharing systems. Without modifying the distribution criteria of the National Health Fund, without exceeding the Repayment Plans and without increasing the State’s ability to verify the Regions, with differentiated autonomy, healthcare “will become a public good in the richest Northern Regions and a consumption for the other Regions”. Last but not least: the reform can also become a problem for the North. The further weakening of quality in the South risks generating a paradoxical effect, a further increase in mobility towards the North which risks undermining its ability to respond to the demand for services: the “red light” has already come on in Lombardy, which in 2021 it is in first place for active mobility (+732 million euros) but also in second place for passive mobility (-461 million). Translated: more and more Lombard residents are going for treatment outside the Region. Why? Too many come from the South.
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