The flop of the Schillaci reform of territorial healthcare requires two types of considerations: one related to the specific issue of territorial healthcare and one, of a broader perspective, related to the spirit with which to approach the reforms our country needs.
The specifics of the aborted reform. To understand the meaning of the tensions that led to the abortion of the reform, one must start from the current status of general practitioners. In this regard, the idea has emerged that general practitioners oppose the Schillaci reform en masse because they would not want to give up their current status as freelancers. But are we sure that general practitioners can currently be considered freelancers? To practice as a general practitioner, it is not enough to be registered in the medical register, thus being licensed to practice! One must be accepted by the region of residence and sign a veritable straitjacket contract that strictly defines the gross compensation for each patient (regardless of the services provided), the maximum number of patients that can be followed, the working days (Monday to Friday), the hours of service delivery (from 08:00 to 20:00). It is forbidden to work at night and during holidays and pre-holidays (left to the monopoly of so-called medical guards), as well as the fixed remuneration per patient does not change if additional services beyond the basic one are performed (for example, if a basic electrocardiogram is performed, or allergy tests are done).
What remains of the characteristics of the freelance service is the unique and trusting relationship with the patient and, partly but only concerning urban areas, the freedom of choice of the doctor by the patient. The unique doctor-patient relationship is that strange thing whereby the professional, as soon as he sees his client, mentally frames him and all the case characteristics, diagnostic doubts, difficulties, and therapeutic complications come to mind. Well, the Schillaci reform eliminates this freelance characteristic with a devaluation of the service and consequent increase in costs. The patient should go to the so-called “health house” where they would be treated by the doctor on duty and not by their own doctor. At the level of specialist and hospital medicine, this bureaucratization of the profession has led to the dual regime of free service, on one hand, where one is treated by the specialist on duty with waiting lists of months, and on the other hand, the provision under the intra moenia regime where one can choose the professional and where waiting lines do not exist. With the corollary of both for profit and no profit organizations that provide various paid services, so-called “token doctors” (doctors who refuse the bureaucratic and unprofessional hospital relationship) and insurance coverages that certainly do not respond to the logic of mutual solidarity. It does not take much imagination to foresee that the Schillaci reform would create a dual regime (skewed free assistance and quality paid assistance) in primary healthcare similarly to what already happens for specialist and hospital care. In tourist areas, this is already happening since, as a resident of Florence, for example, I cannot access free territorial healthcare in Rimini or Taormina.
To save a healthcare service capable of assisting all those in need, one must not chase the demand for increased funding called for by the left. It is essential to reconsider the architecture of our NHS based on choices made in 1978 to bring the Communist party into the government area. In particular, the financing system must be redesigned. Today the various branches of the healthcare system are funded from above. There is a different mode of financing: that based on the remuneration of individual services, where the remuneration of the service is not made by the patient but by a so-called “third payer” entity. In the system based on top-down financing, the dignity and freedom of the citizen-patient is lost, who finds themselves at the mercy of a structure more bureaucratic than medical-professional, in which they have no possibility to choose the professional who convinces them most (and whose professionals are not motivated to give their best) nor can they choose where to be treated (allowing the survival of structures where there is no demand and letting structures languish that, either due to geographic location or quality of services, are overloaded). It should not be overlooked either that in the “freelance” regime the doctor takes on all the bureaucratic and management work (which today exceeds the work related to the purely professional service) while in the Schillaci system, once their hours are over, the doctor could quite simply not care.
The Schillaci reform (which more or less reprises the ideas of Minister Livia Turco’s proposal) is, beyond the analysis reported above, incapable of taking operational costs into account (the PNRR contribution indeed covers only structural investment). Various problems arise here for the post-PNRR period, where the operating expenses of non-self-sustaining structures will have to be faced. I cannot help but think of the case of nurseries. In Florence, since the time of the RENZI administration, there have been several hundred unused nursery places, for which the taxpayer still pays operating costs. Places unused not so much because of a lack of children but because the fees to be paid to municipal nurseries are significantly higher than those requested by private nurseries.
The impasse of the Schillaci reform should initiate a rethink ab imis of the structure of our NHS. It is a matter of acknowledging that Italian civil society rejects a bureaucratic and centralized system and, therefore, of configuring a system that combines solidarity (the sick must worry about their pathology and not how to cope with the expenses it entails) with responsibility (financing individual services through the third payer mechanism). It is a matter of designing a series of steps that bring into system the various facts that are escaping the bureaucratic-centralist logic: the token doctors, the coexistence of partly salaried and partly freelance doctors, the jungle of for profit and no profit structures, etc. In particular, the constraints preventing mutual insurance companies from other EU countries from operating in Italy should be overcome (where they could represent a good stepping stone to a generalized “third payer” regime). Currently, a Belgian, Dutch, or German citizen who needs treatment in Italy would have their expenses covered by their “third payer” entity while as an Italian in other EU countries I am entitled only to emergency services. As a resident in Tuscany, I do not have access to healthcare services even in another Italian region. The separation of the service from the payment of the cost of the individual service (according to the third payer principle) would highlight and restore balance to two further problems. First of all, the fact that healthcare costs due to accidents must be covered by an accident insurance system and not by the solidarity system towards illness. It would also allow a proper coverage of social costs, today the subject of institutional tug-of-war between municipalities and ASLs.
From all these considerations, we can draw a broader conclusion. The reforms Italy needs require the ability to redesign some institutional aspects of our country by reconnecting the rules governing the functioning of the system to the principles of individual freedom and responsibility. To be able to do this, it is necessary to have a perspective that goes beyond the situation that has crystallized in Italy since the 1970s. Our operators (like Minister Schillaci) know only this reality and do not know how to frame it in a broad comparative context. The reforms that can result resemble very much patches put to cover some holes here and there.
