The new draft of the Calderoli Bill for the implementation of the differentiated autonomy of the ordinary statute Regions arrives today (2/2/23 editor's note) in the Council of Ministers. «A text – declares Nino Cartabellotta, President of the GIMBE Foundation – which at the moment “locks down” differentiated autonomy as a Affair between the Government and the Regions, eliminating Parliament's authority, does not provide resources to finance the essential levels of performance (LEP) and allows the transfer of autonomy to the Regions first without making up for the gaps between the various areas of the country". In detail, according to the draft submitted to the pre-Council of Ministers on 30 January 2023:
- Areas of autonomy. The text does not go into the merits of the reasons that lead the Regions to request greater autonomy on the 23 subjects.
- Role of Parliament. On the agreements defined between the Minister of Regional Affairs and the Regions, Parliament is only allowed to express a non-binding opinion and a ratification vote without the possibility of amendments. The Chambers will have no power to intervene on the provisions relating to the transfer of human and financial resources to the Regions, nor will they participate in the definition of the LEP. That is, the role of Parliament is absolutely marginal.
- Essential Performance Levels (LEP). They will be defined through Prime Ministerial Decree by a specific Technical Commission and, as administrative acts, they can only be challenged before the TAR, but not before the Constitutional Court. Formally they should be guaranteed to all citizens, but they remain orphaned of resources, which are fundamental for aligning the quality of services in the Central-Southern Regions with those in the North.
- Transfer of functions to the Regions. It can be carried out already after the definition of the LEP, without waiting for their implementation, i.e. autonomy precedes the recovery of the gaps between the various areas of the country.
The GIMBE Foundation developed the report Differentiated regionalism in healthcare, to spread political and social awareness that the implementation of greater autonomy in the matter of "health protection" «will give the final blow to the National Health Service (NHS) - specifies Cartabellotta - will increase regional inequalities and will normatively legitimize the gap between the North and South, violating the constitutional principle of equality of citizens in the right to health protection".
The GIMBE report retraces the "history" of differentiated regionalism, analyzes the critical issues of the draft bill, evaluates the potential impact on the NHS of the autonomies requested by Emilia-Romagna, Lombardy and Veneto, "photographs" the extent of regional inequalities on fulfillment of the Essential Levels of Assistance (LEA) and health mobility, formulates some conclusive considerations and precise progress requested from the Government.
«The report exclusively analyzes the greater autonomy requested by the Regions in matters of health protection – explains the President – even if, according to the principle Health in all policies and the recent approach One Health, numerous areas of greater autonomy have a potential impact on public health." In particular, protection of the environment and the ecosystem, protection and safety at work, nutrition, sports regulations; but also territorial government, large transport and navigation networks and complementary and supplementary social security.
From the analysis of requests for greater autonomy made by Emilia-Romagna, Lombardy and Veneto in the "health protection" area, some general considerations emerge, supported by almost 2.000 healthcare stakeholders during the survey promoted by the GIMBE Foundation:
- The abolition of spending ceilings for healthcare personnel and the establishment of training-work contracts to anticipate the entry into the world of work of specialists and family doctors today represent fundamental tools for tackling the serious shortage of healthcare personnel who should extended to all Regions.
- Some forms of autonomy risk subverting the governance tools of the NHS by increasing inequalities in the offering of services: tariff, reimbursement, remuneration and sharing system, governance system of companies and bodies of the Regional Health Service, determination of the number of scholarships for specialists and family doctors.
- Other instances are frankly "subversive". Greater autonomy regarding the establishment and management of supplementary health funds would give rise to regional mutual insurance systems detached from, albeit fragmented, national legislation. Furthermore, Veneto's request for regional supplementary bargaining for NHS employees, in addition to autonomy in matters of personnel management and regulation of freelance activity, risks creating competition between Regions with "migration" of personnel from South to North, placing a tombstone on national collective bargaining and the role of trade unions.
«The request for greater autonomy – continues Cartabellotta – comes precisely from the Regions which record the best national performances in healthcare». In fact, from the “photograph” on the obligations to maintain the LEAs relating to the decade 2010-2019 it emerges that the three Regions that have requested greater autonomy are placed in the top 5 places of the ranking, respectively Emilia Romagna (1st), Veneto (3rd) and Lombardy (5th), while in the first 10 positions there is no there is no Region in the South and only 2 in the Center (Umbria and Marche). Furthermore, the analysis of health mobility confirms the strong attractive capacity of the Northern Regions, which corresponds to the extremely limited one of the Central-Southern Regions, given that in the decade 2010-2019, thirteen Regions, almost all in the Central-South, accumulated a negative balance equal to €14 billion. And among the first four places for positive balance are always the three Regions that have requested the greatest autonomy: Lombardy (+€6,18 billion), Emilia-Romagna (+€3,35 billion), Tuscany (+€1,34, 1,14 billion), Veneto (+€1 billion). On the contrary, the five Regions with negative balances exceeding €2,94 billion are all in the Centre-South: Campania (-€2,71 billion), Calabria (-€2,19 billion), Lazio (-€2 billion) , Sicily (-€1,84 billion) and Puglia (-€XNUMX billion).
«These data – continues Cartabellotta – confirm that despite the definition of the LEAs since 2001, their annual monitoring and the use by the State of tools such as repayment plans and commissioners, unacceptable inequalities persist between the 21 regional health systems, in particular a North-South structural gap that compromises equity of access to services and fuels massive health mobility in the South-North direction." Consequently, the implementation of greater autonomy in healthcare, requested precisely by the Regions with the best healthcare performance and greater attractiveness, will only amplify the unacceptable inequalities recorded with simple competing regional competence in terms of health protection. «Differentiated regionalism in healthcare – explains the President – will end up normatively legitimizing the gap between North and South, violating the constitutional principle of equality of citizens in the right to health protection. Furthermore, in a historical moment in which the country has signed the PNRR with Europe, the transversal objective of which is precisely to reduce regional and territorial inequalities".
«Taking into account the serious sustainability crisis of the NHS and the impressive regional inequalities – concludes Cartabellotta – the GIMBE Foundation invites the Government to put aside hasty positions and proposes in the first instance to remove health protection from the matters on which the Regions can request greater autonomy. In the alternative, it requests that the possible implementation of differentiated regionalism in healthcare be managed with extreme balance, first of all bridging the structural gap between the North and South of the country, modifying the criteria for allocating the National Healthcare Requirement and increasing the ability to address and verify the State over the Regions. It is essential to safeguard the ability to redistribute income without compromising the exercise of fundamental constitutional rights, in particular the right to health protection: otherwise, healthcare risks becoming a public good for residents in the richest regions and a consumer good. for the poorest ones."
The GIMBE Observatory Report “Differentiated Regionalism in Healthcare” is available at: www.salviamo-ssn.it/report-regionalismo-differenziato
