In recent years, the Italian healthcare sector has had to face a crucial challenge: how to guarantee the economic sustainability of the system without compromising the Essential Levels of Assistance (LEA). Spending caps, imposed at regional and national level, are a tool for controlling public spending aimed at containing costs, but their impact on access to care has raised critical questions, both from a health and legal perspective. This article explores the implications of such spending limits and the influence that recent court cases have had on the defense of Local Health Authorities (ASL) and in the protection of the right to health.
The introduction of spending caps: a double-edged sword? Health spending ceilings they were introduced as an austerity measure in response to the need to limit the growing Italian public debt, with regulation that has progressively taken on a complex and rigid structure. The logic behind this measure lies in the desire to avoid waste and improve the efficiency of public resources, but its application has demonstrated significant side effects. According to data from the Ministry of Health, in 2022 alone, in over 70% of Italian regions, healthcare costs exceeded the established limits, leading to cuts in the services offered and reductions in staff. In Lombardyfor example, the Region had to reduce the funds allocated to preventive diagnostics, an intervention that triggered critical reactions and reports from patient associations. Similar situations have occurred in other regions, including Lazio and Campania, where the reduction in funding has affected assistance services for chronic patients.
Il pathological moment: a direct impact on LEAs and patients The adoption of spending caps has led to a scenario that can be defined as a “pathological moment” in the healthcare system, in which the impossibility of guaranteeing LEAs directly affects patients. This term was recently used in an investigation by the Court of Auditors which highlighted the reduction of resources in some ASL is the basis of serious shortcomings in the care provided. The minimum performance guaranteed by the LEAs include, for example, specialist care, diagnostic and rehabilitation services. However, according to a report by the National Agency for Regional Health Services (AGENAS), in 2023 there was a 15% drop in the provision of services provided by the LEAs compared to the previous year, with serious repercussions especially for cancer patients and chronic. This delay in accessing essential treatments has resulted in a worsening of the quality of life for many patients and, in some cases, in an increase in mortality from preventable causes.
Judicial activities in defense of local health authorities: a fundamental role in ensuring sustainability. Local health authorities often find themselves in a delicate position: they must respect the spending limits imposed, while still guaranteeing adequate care for citizens. However, the impossibility of fulfilling both requirements brings local health authorities to court, often to defend themselves from lawsuits brought by patients and associations claiming the right to healthcare services. Judicial activities have, therefore, become one necessary defense for the ASLwho thus seek to protect their operations and respect budget constraints.
In a recent case, the Court of Naples ruled in favor of the local ASL, establishing that the right to health cannot be used to circumvent the spending limits imposed by law. However, others sentences have followed a different approach, requiring local health authorities to guarantee performance, even when this involves budget overruns. In 2023, a ruling from the Court of Cassation confirmed the requirement for an ASL of one Southern Region to provide life-saving drugs to a patient, despite the health budget had already been overcome, underlining how the right health must prevail over spending containment. These court cases have set a significant precedent, raising questions about how to balance the need to economic protection with the obligation to guarantee adequate care. Furthermore, i Italian courts have demonstrated a growing sensitivity towards the constitutional implications linked to the right to health, recognizing that spending caps cannot be a valid justification for denying essential treatments.
Towards a reform: the need for one review of spending ceilings. To resolve this impasse, a structural rethink of the rules that govern spending ceilings is necessary. Many experts propose a more flexible approach, based on the periodic review of spending limits based on real health needs and not on fixed economic parameters. One of the proposals put forward by AGENAS consists in the introduction of a dynamic monitoring system that allows spending limits to be updated based on efficiency data and clinical results, thus guaranteeing both economic sustainability and the quality of care.
In this context, also the involvement of judicial sector it can play a proactive role, supporting the activities of the local health authorities with clear and predictable jurisprudential guidelines. There Court of Auditorsfor example, proposed greater collaboration between the Ministry of Health and the Regions to identify critical spending areas and intervene in a targeted manner.
Conclusion: the balance between savings and the right to health. Spending ceilings represent a valid control tool, but their rigid application risks violating the fundamental principle enshrined in thearticle 32 of the Italian Constitutionaccording to which “the Republic protects health as a fundamental right of the individual and interest of the community.” Overcoming the pathological moment of the healthcare system requires a balanced vision and a regulatory reform that allows us to respond adequately to financial control needs and the protection of the right to health.
Mariagiusy Guarente*
Marcello Abbondolo*
* (Lawyer managers, ASL Avellino)
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