If the “waiting list” belonged to a corporation, it would certainly be shorter. But here we are dealing with a list without representation, made up of millions of citizens where everyone suffers his own discomfort in solitude or gets by as he can. Who can. Nevertheless no government has ever declared its intention to cut health care spending, on the contrary, billions of investments have always been pitted. To understand if the state gets enough out of it, experts use an indicator: the ratio between public funding for the national health service and GDP. If the percentage incidence with respect to the value of all goods and services produced in our country is low, it means that the State does not invest enough in the health of its citizens. With 114.4 billion put up in 2019, Italy comes to the pandemic with a level of financing to GDP ratio of 6.4%, versus 9.8% in Germany, 9.3% in France and 7.8% in the UK (OECD data). 2020 is the year of record spending: 120.5 billion, equal to 7.3% of GDP. The great lesson of Covid is that of a solemn commitment: no more savings and cuts in health care. What happened after?
Covid costs left uncovered
In 2021 the Regions are spending 8.3 billion more to cover the extra costs: hospitalizations of those who have contracted the virus, swabs, recruitment of doctors, nurses, and mass vaccinations. To date, the State has repaid them only 4.45: it means that the Regions have accumulated a hole of 3.86 billion. Lombardy was reimbursed a billion less than what it spent; to Lazio 442.8 million; to Emilia-Romagna 436; to Piedmont 288; to Veneto 277; to Tuscany of 239; to Puglia 205.5; to Campania 216; to Abruzzo 61.6; to Umbria 59.4; to Sardinia 50; in Basilicata 13.
Expensive energy not refunded
In 2022 the Regions will continue to incur extra expenses related to Covid: hospitalizations, mandatory sanitization of hospital environments, exits for additional staff, as well as visits and exams to be recovered. However, with the end of the state of emergency on 31 March, the de facto state no longer recognizes the additional funding. In addition, 1.4 billion in costs are added due to the soaring electricity and gas bills. With the decree of 10 January 2023, the Meloni government puts 1.6 billion under the item “higher costs of energy sources and for the persistence of the pandemic”. The funds are distributed as a percentage of the population of the individual regions. Result: Emilia-Romagna spends 188.2 million on bills alone and takes 120.9 million; Tuscany 153 and takes 101; Umbria 31 and takes 23.8; Basilicata 21, and they give him 14.7. And then: Abruzzo goes down by 19.3 million; Puglia by 2.6; Sardinia by 3.6; Liguria and Friuli by 2.
Regional budgets
Healthcare weighs approximately 80% on the budgets of the Regions, and the last two years are all felt. The comparison between 2022 and 2019 demonstrates this: the Regions that had accounts in order are now in debt. Emilia-Romagna is in the red by 84.9 million; the Piedmont of 21; Lazio of 125.5; Basilicata of 20.9 million; Umbria of 69.5 million, Sardinia of 41.7. While already negative regions such as Tuscany, Abruzzo and Puglia have worsened their financial situation. Balanced but very tight budget for Lombardy which closes with 296 thousand euros against 6.3 million in 2019, and Veneto with 7 million against 29.4 in 2029. Now the 20 Regions will receive 1 billion and 85 million for the so-called payback: those who have purchased medical devices in excess of the fixed spending limit in past years will recover 50%. In essence, a little money is distributed to all the Regions that have gone over another expenditure chapter, hoping that it will plug the hole opened up by the Covid costs and bills. Difficult.
Underfinancing of the NHS
After all, funding for the health service grows only on paper: 123.4 billion in 2021; 125.98 in 2022; 136 in 2023; 132.7 in 2024 and 135 billion in 2025. But since money weighs compared to GDP, we went from 6.4% in 2019 to 6.9% in 2021, and then the curve reverses: 6.6% in 2022, 6.7% in 2023, to 6.3% in 2024 and 6.2% in 2025. In practice we are even going back compared to the pre-pandemic. To reach the levels of Germany and France it would take approximately 40 billion more a year, and 20 to at least reach the United Kingdom.
Risk no. 1
When resources are scarce, we are forced to save, just when it is necessary to invest in the challenges that await us. Starting with waiting lists. A few million of healthcare services lost due to the blockage/slowdown of healthcare activity during the key months of the pandemic remain to be recovered. In addition to examinations and specialist visits (see the Dataroom of 6 February 2023), the data released by the Ministry of Health and Agenas confirm the persistence of critical issues also regarding hospitalizations: in the case of cardiovascular interventions which must take precedence for reasons of urgency ( class A) and which should be performed within 30 days, as many as 14 Regions have worse results than those of 2019. The same goes for malignant tumours: 12 Regions have worsened their performance. It means that the percentage of interventions carried out within the times defined by law is reduced.
Risk no. 2
The reform of assistance in the area designed by Ministerial Decree 77 of May 2022 and envisaged by the Pnrr has been launched, which provides for the creation of at least 1,350 community homes, 400 community hospitals, 600 territorial operations centers and the development of telemedicine capable of assist at least 800,000 people over 65 at home. The 7 billion for the construction of the buildings come from the Pnrr. But the reform requires adequate staffing. The total need for doctors in 2027 is estimated at 42,331 in hospital. In a Dataroom from October 2022 we saw that the specialists who will be churned out by then by the Specialty Schools will be a total of 62,350. Taking into account that 10% do not finish their studies and 25% do not stay to work in the NHS, this means that 42,086 specialists will be ready for public hospitals, again by 2027. The income and expenditure are therefore in balance. But once again the accounts add up only on paper, because in reality once the places in the Schools have been banned, the specialties that are most needed are not chosen. In Emergency and Urgent Medicine 57% of places are not covered; in Anesthesia and resuscitation 17%; in Radiotherapy 74%. One of the problems that remain on the table is related to salaries: a German doctor earns 93.6% more than an Italian one.
The first 9 months of 2022 recorded a reduction in investment spending of over 13%. That means less money to buy new equipment and maintain departments
Risk no. 3
The first 9 months of 2022 recorded a reduction in investment spending of over 13%. Which means less money for the purchase of new equipment and for the maintenance of departments “in order to guarantee each citizen an adequate response to the demand for health, both in terms of prevention and treatment of various pathologies”. He points it out the Court of Auditors That writes: «The extraordinary program of public investments in health constitutes a substantial contribution to the pursuit of the public purpose of health protection (pursuant to article 32 of the Constitution) since the modernization of the structural and technological assets of the national health service allows it to better respond with increasingly appropriate, modern and safe structures and technologies to the health needs of the community and the expectations of operators and users of the National Health Service”. In conclusion: reeling off a few billion more always makes a certain impression, but compared to the needs they are only peanuts.