Chapter 2

and tariffs (of laboratories) for a further € 1,1 billion.
Depending on one’s degree of optimism regarding both the efficacy of the regional rationalization
plans and of price cuts, but also on the extent to which the final Budget Act
resembles the present proposal, the public expenditure in 2007 should lie between €
102,7 billion and € 105,0 billion, with a deficit from of € 2,0 to € 4,3 billion.
Summarizing, on the “worst” of the hypotheses, the gap between resources allocated
and expenditure of 0,4 percentage points of GDP is in line with the historical figure, whereas
on the “best” hypothesis the gap would fall to 0,15 points.
In the light of the international evidence assembled in the Volume (see chapters 2.1-2.6),
this seems to be neither an Italian anomaly, nor a particularly critical aspect. If we exclude
countries that avoid deficit “by definition”, that is by adjusting insurance premiums
(Netherlands) or adopting rationing policies (Australia), in the other cases (Argentina,
France, Spain, USA) the problems seem rather similar to our own. The fundamental difference
one finds is rather less conflict or at least less sensitivity to assignment of responsibility
for deficits. This results in quicker adjustment, avoiding the costs necessarily
incurred in accumulation of debt and/or delay in payment by the public sector.
International experience therefore indicates that one important aspect of the management
of the system relates to the manner of conducting deficit set off, avoiding new
shortcomings to the (hopefully partial) failure of cost containment policies.
Coming back to analysis of the Italian scenario, the final results depend greatly on the
ability of central and local health policies to act coherently and in coordination to achieve
the rationalization measures proposed in the Budget Act.
Reading of the measures proposed, however, seems to indicate a sort of “immature federalism”.
The positive logic of federalism would leave the local authority the task of pursuing
maximum efficiency while leaving the central level of government with the task of
setting general principles and checking on respect for rights. From a Budget Act, one
expects definition of the resources available centrally and, if appropriate to ensure financial
balance, an indication on levels of rationing of the services.
In the current Budget Act (a Government one even if, thanks to the current political situation,
it is the fruit of an agreement between State and Regions) practically all the actions
proposed fall within the competence of the Regions, with actions relating to general principles
being very limited. About 50% of the actions foreseen by the Act, relate to Regional
rationalization plans and the other 50% to measures for investing households with
responsibility for costs; the effects of these last are qualitatively certain, since they provide
for transfer of costs, but quantitatively uncertain, because they are linked to specific
regional situations (in the first place, the level of exemptions).
It seems legitimate to ask oneself whether such actions should or should not be regulated
centrally.
Going back to the question of co-payments, arguing on the point of principle, we could
(or should) conclude that, if they represent only a way for creation of a sense of responsibility
towards appropriate use of resources, then regional legislation would be the most
appropriate: that being the level were “fine tuning” is possible. On the other hand, if implicit
rationing is the true aim, then the central government level would be the correct one.
[21]
CEIS Health Report 2006