A-Infos (en) Italy, FAS Sicilia Libertaria: GOING OFF THE ROAD TO DEFENSE PUBLIC HEALTH - Riccardo Ricceri (ca, de, it, pt, tr)[machine translation]

Healthcare represents a privileged point of view for analyzing the risks 
associated with differentiated autonomy. Without fear of appearing as 
catastrophists, we can affirm that with it we will give the definitive 
coup de grâce to a National Health System (NHS) already on the verge of 
collapse. ---- The NHS in fact coexists with deep structural fractures, 
distributed along the north/south faults, internal areas/metropolitan 
areas, rich classes/poor classes. Health is already transforming from a 
common good to a luxury good. Some indicators demonstrate this: the 
minimum levels of assistance (LEA) are far from being respected in the 
southern regions, or in areas, such as Lombardy, crushed by unfair 
competition from private individuals; the gap in average life is clear: 
those born in Sicily live on average 3-4 years less than those born in 
Lombardy; mobility from the South to the North (of patients and 
professionals) is constant, with stratospheric gains by the Northern 
Regions; the internal areas are increasingly impoverished, with 
peripheral EDs (throughout the country) often covered by only 
"pay-as-you-go" doctors and with home care reduced to a bare minimum due 
to the shortage of nurses.

Most of these inequalities follow the historical "two speeds" of the 
country (both geographical and income-based), but they also reflect the 
precise political choices made over the decades, aimed at maintaining 
(if not increasing) the gaps. Let's think, for example, about how the 
National Health Fund is distributed. Considering that the criterion used 
takes into account almost exclusively the age of the population, the 
northern regions come out at an advantage. Now, taking into account the 
fragility associated with aging is legitimate. But it is unacceptable 
that the fragility connected to poverty is not considered, and that the 
disease is not considered in its social dimension. The latent assumption 
of this approach lies in the moralism of the wealthy classes, who tend 
to consider poverty not as the product of historical and political 
conditions, but as the manifestation of a natural disparity. That is: if 
the poor is poor, it is his fault alone. Only such a preconception can 
explain why - already today - the State does not increase funding to 
Regions that struggle to comply with the LEAs.

It is on this structural crisis that the sword of Damocles of 
differentiated autonomy hangs. Although the contours of the reform are 
still unclear, it is not at all difficult to predict the risks. In fact, 
the three Regions ask to be able to manage almost the entire healthcare 
sector independently: spending constraints; specializations; tariff 
systems; corporate governance; the management of supplementary funds; 
personnel management.

Without going into detail, there is every reason to fear that the 
application of these rules will seriously compromise the redistributive 
principle underlying the NHS. A system which, although already in 
crisis, today still acts as a "corrective" for the imbalances within the 
country and as a minimum guarantee of equity and universality.

When the richest Regions keep most of the resources for themselves, to 
the inevitable detriment of the others (with a "mors tua vita mea" 
mechanism), it is easy to imagine that the Southern Regions will 
increasingly depend on those of the North; that internal and peripheral 
areas will depend on large urban centres; and that the less wealthy 
classes will remain increasingly at the mercy of private healthcare 
speculation.

To be honest, the reform provides "security" guarantees, such as 
compliance with the LEAs and budget constraints. But these are more 
threats than guarantees. If today the NHS is already struggling to 
comply with the LEAs in many Regions, what guarantees will we have in 
the future from a "balkanised" healthcare system without any 
redistributive equity anymore? Furthermore, how can the foreseeable 
territorial imbalances be remedied, once spending increases are excluded?

Differentiated autonomy is therefore a "multifunctional" maneuver which 
at the same time: completes the dismantling of welfare and the 
financialisation of healthcare; the gap between rich and poor is 
increasing, as is the gap between North and South; places a tombstone on 
the principles of equity and the right to health. At the same time, and 
a non-negligible detail, it serves as a convenient political bargaining 
chip between promoters of federalism and promoters of presidentialism.

This strategy, which to the cynical eye of realpolitik may seem 
enlightened, will soon show all its shortsightedness, with catastrophic 
effects not only on the southern regions, but on the stability of the 
entire country system.

Such a fragmented and asymmetric healthcare system will in fact lead to 
an overload of the Northern Regions, increasingly besieged by both 
patients and professionals, attracted by the mirage of higher salaries. 
It is easy to foresee that the "VIP" Regions will try to defend 
themselves from the assault on diligence, and not through the 
strengthening of public services (which is apparently not possible, 
given that the Calderoli DDL itself places budget constraints), but 
rather by resorting to private individual without an agreement, who will 
thank you. Those who will suffer first (across the country) will be 
above all citizens not belonging to the high or very high income 
brackets, who will have to give up treatment or the (increasingly 
higher) costs of policies.

But what is even more important to underline is the worsening of the 
territorial imbalance of the healthcare system as a whole. Health 
protection works (and we learned this the hard way with the pandemic) 
only under certain conditions: that the system that manages it is spread 
equally and widely across the territory; that all citizens have equal 
access to care; that prevention is preferred to cure; that we think in a 
coordinated way at an international level, sharing knowledge and care. 
How would we have addressed the pandemic in a "regionalized" healthcare 
system? Who would have prevented Lombardy from vaccinating "per GDP", as 
Moratti had unfortunately suggested?

In such a tragic situation, healthcare workers continue to focus on 
their small salary battles, unable to understand that the real game is 
being played on another field. The associations, civil society, sector 
operators are struggling to develop a clear and shared vision, so that 
the DDL proceeds quickly and the time available to us is running out. 
Recently, encouraging signs have arrived from the squares of Naples, 
which has united many acronyms and turned the spotlight on the topic. 
However, the debate in Italy continues to remain under the radar. If we 
don't want to give up "our greatest social achievement and a pillar of 
democracy", we need to trigger the debate and take to the streets. And 
we need to do it now.

Riccardo Ricceri

https://www.sicilialibertaria.it/
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