(The original text is available here http://rivincitasociale.altervista.org/la-sanita-tra-tagli-e-corruzione-una-vittima-eccellente-del-federalismo-fiscale/ )
Contents:
Update of the essay in the light of the Covid-19 health crisis.
1) Introductory illustrations
2) Neoliberal monetarism and fiscal federalism
3) Monetarist public policy, economic stability laws and structural cuts
4) Monetarism and fiscal federalism applied at the provincial level (Calabria)
a) Regional restructuring plan and economic-financial restructuring (i.e., deficits)
b) Pharma-care and drug policy
c) Human resources and Staff Policy
5) Conclusions.
6 ) What would an ideal health-care system look like?
Update of the essay in the light of the Covid-19 health crisis.
It has been said that « austerity kills ». But austerity is only one consequence of the crassly inegalitarian Marginalist neoliberal and monetarist policies especially those that implement the theories of Ludwig Mises, Hayek, Friedman and Cie, all these over-paid and over-represented high and lower servi in camera of capital whose visibility flies against the natural democratic logic of Great Numbers, if not of positive action policies. Their a-republican, a-social and avowed eugenic character is rather clear. If one compares their inspiration with that of the Fathers of the American Constitution and with that expressed in Rights of Man of Thomas Paine, it clearly appears to be frontally un-American. It must be understood that their neoliberal monetarist theories are consciously constructed as un-scientific narratives for the use of « gentiles » peoples and of so-called un-awakened « nihilists militants».(1) The scientific proof of these allegations will be found for instance in the Note 11 of the essay below and in my Methodological introduction (available here : http://www.la-commune-paraclet.com/livresFrame1Source1.htm#livresbookmark For a brief summary of the Marginalist narrative see http://rivincitasociale.altervista.org/the-pseudo-economic-science-of-the-bourgeoisie-here-is-why-we-should-quickly-change-economic-paradigm/ )
I am not a doctor in medicine but as a former professor I have come to appreciate Prof. Testart’s warnings and his insistence on the need for citizens to participate in deontological discussions that pertain to scientific research especially in the health-care area. The genetic and biological revolutions have opened new fields of inquiry and allowed new and unprecedented know-how that do not always answer the demands of the most basic deontological codes. For instance, the Covid-19 crisis raises the question of the strengthening of arms control treaties, particularly for intermediate missiles, space weaponry and bio-weapons (2) The strengthening of these treaties now seem to be an immediate priority and should include intrusive and non announced verifications in loco, to foster mutual trust and World stability.
My personal opinion is that Western elites have – at best – underestimated the seriousness of the Covid-19 crisis. Contrary to WHO requirements no stocks of PPE – masks, gloves, blouses etc – were maintained; in many countries they were destroyed without replacement in the last few years and even months. They were not reconstituted as soon as the news were coming out of China indicating the seriousness of the new virus threat. Is it conceivable that a system that value free available hospital beds more than human patients can manage the profit line sacrificing such emergency stocks? And what is more, even in officially nuclear great powers? The systemic and a-social absurdity is plain.
The best strategy that emerges from what we know to date world-wide seems to consist in early selective confinement of infected zones, a measure that should be associated with very wide testing while all citizens, nation-wide, will be informed about the most evident symptoms to watch for – for instance dry cough, fever, diarrhea, fatigue etc – When the symptoms would appear, they should be able to contact the family doctor or the neighborhood clinic – when it exists – or the hospital. These should be able to rely on personnel sufficiently trained to go to the potential patient’s home who, by then, would have confined her/himself, in order to administer one of the available tests. The next day, the test would be redone to avoid false negatives. If positive, the patient would go immediately to the clinic or to the emergency ward to undergo the cardiogram and other exams needed to prescribe the chloroquine derivatives along with antibiotics. Chinese and prof. Raoult’s results indicate that this should be done without waiting from the early stages of detection. (3) After a week, a new test would be performed again and if the viral level has not diminished importantly, the patient would be assessed by the hospital.
In the end this strategy would cost much less and would avoid the total shutdown at least outside of the red zones. However, as long as the country has not been officially declared free from the virus, all citizens everywhere should take some precautions such as indicated by the Authorities. For instance wearing masks and gloves in public to avoid infecting others, practice social distancing, washing their hands often and other such precautions especially in common transportation systems and in the workplaces. Such a strategy would free high intensive care rooms which would then be able to treat other patients, including heavier Covid-19 cases, as long as their situation requires instead of practicing a cynical or forced triage on who to save according to some vague assessment of « chances to survive ».
This triage practice is not merely a dramatic consequence of the saturation of intensive health-care units. It is a direct result of the private management health-care whose blueprint is equally imposed on public health-care structures and on pharma-care. Patients as human disappear from the radar and are treated as cure-objects and as hospital beds to financially optimize in the shorter time possible by doctors who conceive themselves, despite their Hippocratic Oath, as small and medium businesses. Just like bourgeois lawyers who, according to Keynes’s apt phrase, quickly end-up transforming poetry into prose and prose into jargon, the humanity of their trades and arts being lost through the hegemony of what he knowingly called the « animal spirits of capitalism». While cuts where implemented and beds reduced, the eugenic narrative of « dying with dignity » through legalised euthanasia was invented. Hospital beds must be freed quickly especially if one cannot afford costly private care. The ignominy of these ideological choices did not clearly appear to the public in normal circumstances because, everyone of us want to preserve a control over one’s own existence. However there is not real control when the material conditions of informed choice are structurally absent.(4) In my eyes the current mass triage and euthanasia, which even doctors now find unbearable, is criminal through systemic neglect and should probably be addressed this way. There is plenty of liquidities and huge bailouts for banks and enterprises. Aside from QEs, for 2019 stocks buybacks were set to hit a record $1 trillion. (see: https://markets.businessinsider.com/news/stocks/stock-buybacks-outlook-estimated-record-amid-warren-sanders-political-criticism-2019-7-1028325693 ) Surely when a socially and ideologically sick society is ready to spend that kind of money on buybacks, and more billions on weapons of mass destruction, the underfunding of Medicare, Medicaid and health-care in general as well as the chronic underfunding of all other public services is unacceptable and loudly calls for a day of reckoning. The question always remains : « Who pays for the QE and bailouts? And against what kind of social counterparts? » (5)
Similarly this rigorous and targeted approach to confinement would largely mitigate the risk of the second wave of contamination which usually happens when total confinement is lifted.
Such an approach requires strategic planning which can best be achieved in non-profit public health-care structures relying on at least partial public pharma-care. To be effective, drastic though geographically considered measures must be taken from the very beginning. Just like prof. Raoult’s treatment must be dispensed in the very early stages. Using it in the last stages of the Covid-19 illness in some purported clinical trials simply amounts to either intellectual sloppiness or dishonesty; it will only prove what the Chinese doctors and prof. Raoult have said all along: used in the later stages of the illness, will not be effective.
The pragmatic question facing our societies is what to do now that our Western leaders have lost two to three weeks before reacting in the most amateurish and contradictory fashion while neglecting to stocks enough PPE equipment even for medical and hospital staffs ? And at time, ignoring the need to shelter seniors when they are confined in retirement homes. (6)
Given the time lost, the total national-wide confinement of the citizens is now necessary. But it is done ignoring the workers who are left to infect themselves in public transportation systems as well as on the working places, disregarding the most obvious security rules. In fact, it simply – cynically ? -seems to aim at achieving the earlier oft stated goal of « herd immunity » but at a lesser and more acceptable political and economic price. The hope it to slow down the death rate and the saturation of the poorly staffed and poorly available intensive care beds. As discussed in my essay, this sad state of affaire is the direct consequence of the privatization of the health-care system as well as of other similar public essential so-called « common goods ». It is also the consequences of the preference given to high technology rather than to down-to-earth preventive front-line medicine. The disaster unfolding under our eyes was, and in fact had been, announced by many, including courageous doctors and nurses who resorted to sectoral strikes to protest against the deterioration of health services as well as of their own working conditions.
Presently, economic essential services are not defined with the health of the public in mind, the obsession being to maintain profit. This despite the fact, that everyone knows that the current economic-financial and sanitary crisis is already more serious than the subprime crisis. And it will be so profound, whatever strategy one adopts to confront it, that a serious revision of how the economy and social services are run will become a priority after the Covid- crisis has passed.
Some rational measures should be quickly adopted. For instance, the division of the work force into three cohorts in industries where teleworking or so-called smart-working is not possible. Each cohort would then be part of three shifts starting and finishing at least half an hour apart so as to avoid contagion in packed public transportations systems. President Trump’s decision on chloroquine derivative and antibiotics must be praised but it should be applied rigorously in order to maximise the impact of the treatment. Wall-to-wall testing of patients presenting early symptoms and of their acquaintances according to needs should become routine; the approach should include early medication of patients who tested positive as well as new testing of the treated patients after one week of treatment.
The planning should be such as to slowly pass from the nation-wide confinement to selective confinement as described above. As we have already said, this will help control the second wave of contagion and, in the end, be less costly. However, it requires immediate mass availability of PPE and wide access to chloroquine derivatives plus antibiotics. As we said earlier, this does not interfere in the least with the hospitals’ role and the administration of other treatments, but hopefully, in acting in such a way, the hospitals will not be as saturated. And they will not have to resort – or impose – an inhuman triage.
Doctors and others experts will play their roles, including the search for a vaccine, but as we know patients are dying now, and contrary to Big Pharma or Bill Gates et al., they cannot wait for a high-profit vaccine or for the result of some fancy simulation in some university.
The point is that while urgent measures resting on facts – in the absence of better remedies – are taken, the search for better cures must undergo their course. Including preventive studies. For instance, I am quite intrigued by articles in Le Monde which point to the preventive effect of the tuberculosis vaccine. Knowing that, so far, some 80-90 Italian doctors have died and more than 13 000 health-care personnel have been infected, this should be examined quickly. Unfortunately, these dramatic numbers also show elsewhere. I suppose that a statistical verification could be done rapidly given the cohorts of health-care personnel involved world-wide. A good sample could try to correlated infection with the tuberculosis vaccine and perhaps the date at which the last vaccine was done. However, we should add our voice to those who have denounced the lack of most basic PPE for the health-care and retirement homes personnel.
Here is a brief note on the necessity and superiority of socio-economic planning.
Contrary to Ludwig Mises and such ilks, Humans beings are the most valued form of capital. Hence public preventive medicine, as well as public front-line clinics, should become the norm. They make the difference when epidemic or pandemic strike.
As for the strictly socio-economic aspect, it is clear that the current capitalist QE and stimulus plans do not solve any of the underlying contradictions of hegemonic speculative finance. They only make them worse. More, contrary to « efficient market » crapish theories, speculative fast-moving finance only makes the misallocations of capital already inherent in the working of the « invisible hand » worse. It is the opposite with socio-economic planning.
For instance, a planned economy coming out of the pandemic will only need to readjust its 5-Year Plan at the margin to account for the domestic and international disruptions. It can come to the rescue of other countries while carefully watching over to avoid any domestic strong second wave; it can increase internal demand if only by paying a small bonus to the disciplined workers who were locked down for weeks; it can temporarily slow down the production destined for export while using stocks as a cushion in order to be ready when things get better.
Above all it can readjust the 5-Year Plan at a very low cost using public credit within the framework of the proportionally symmetrical investment policy carried out in tune with the Equations of Enlarged Reproduction. This should be done taking good care to account for the insertion of the Social Formation within the World Economy and to manage the rate of change mainly according to the real value of the national money given by the macro-economic competitiveness of the Social Formation.
On that basis, given the difficulty facing many countries in the World today, it can offer swaps of credit lines bilaterally or multilaterally arranged between countries to relaunch economic growth and to lend flexibility to international trade. It can and should intervene to offer such lines of credit to countries that would otherwise need to go to the IMF and hence be subjected to its conditionalities. This could be done simply: for instance using useless US dollars to buy a good share of the public and private debts of a given country in order to restructure them in the national money at very low interest rates and on a longer term. This would be mutually beneficial. This strategy could go along with the credit lines swaps mentioned above. World trade and World cooperation would thus be maintained and strong foundations would be laid for the future when normalcy will return.
Paul De Marco, April 6, 2020
Notes:
1) On the militant and awakened nihilists see my Pour Marx, contre le nihilisme in http://www.la-commune-paraclet.com/livresFrame1Source1.htm#livresbookmark
1 ) See the article here Logistical and Technical Exploration into the Origins of the Wuhan Strain of Coronavirus (COVID-19), Posted on January 31, 2020March 21, 2020 by harvard2thebighouse https://harvardtothebighouse.com/2020/01/31/logistical-and-technical-analysis-of-the-origins-of-the-wuhan-coronavirus-2019-ncov/ (originally quoted in Zerohedge site) A disinterested reading is required to raise the good question rather than coming to a, by definition here, shaky conclusion. For instance, is it possible to proceed to a statistical analysis of pulmonary death in the US or among American citizens and employees around August and September 2019 and if a doubt is raised to proceed with few exhumation and post mortem exams? This will help dealing with possible other pandemic.
3 ) As we write it seems that prof. Raoult has treated more than 2000 patients with less than ten deaths. We are waiting for details however, this rate of success is without parallel in the EU including Germany that has some 20 intensive care beds for 1000 people compared to at most 3.8 hospital beds in Italy!!!
4 ) see here http://www.la-commune-paraclet.com/terri_schiavoFrame1Source1.htm
6 ) The unnecessary death of our seniors is very troublesome to say the least. And at time it might even raise penal questions. See : La strage di anziani nelle case di riposo? Chiedete a Fontana perché…di Redazione Contropiano https://contropiano.org/news/politica-news/2020/04/06/la-strage-di-anziani-nelle-case-di-riposo-chiedete-a-fontana-perche-0126375
XXX
We are dealing here with the devastating effect of fiscal federalism on Health-care. This text is the complete written version of my contribution for the Conference held in Reggio Calabria which is in part available at this link: https://www.facebook.com/FedericaDieniM5S/videos/vb.296261957143986/718701461566698/?type=2&theater .
We can already imagine what would happen with the further regressive drift embodied in so-called “competitive federalism”.
Contents:
1) Introductory illustrations
2) Neoliberal monetarism and fiscal federalism
3) Monetarist public policy, economic stability laws and structural cuts
4) Monetarism and fiscal federalism applied at the provincial level (Calabria)
a) Regional restructuring plan and economic-financial restructuring (i.e., deficits)
b) Pharma-care and drug policy
c) Human resources and Staff Policy
5) Conclusions.
6 ) What would an ideal health-care system look like?
1) INTRODUCTORY ILLUSTRATIONS
Paradoxically, while the Italian public health system is about to collapse, several high-quality medical analyzes are available. Among these, the Meridian Report is very useful to access medical data. The Calabrian neoliberal restructuring plan known as « Piano di rientro » (PdR) of 2001 still informs all current decisions and should therefore be read carefully. This analysis is conducted from the point of view of Political Economy. We can safely say that all the news items we read in various publications find their explanation in the socio-economic logic summarized in the financial laws of the country.
Traditionally, politics has been defined as the ability to allocate Community resources to the Community. The accumulation of inequalities reveals that it is a resource allocation that favors certain social groups at the expense of others, thus revealing the ruling class’s choice of a model of society.
a) First illustration according to the Auditor General.
In a monetarist context, that is to say within the Darwinian return to the law of the jungle, it is often difficult to distinguish between corruption and the market, particularly when some leaders would pretend that the « market » is more efficient when it is less regulated. Corruption quickly becomes systemic. Here is what the Italian Auditor General writes on the subject: «(In Health-care) real episodes of malfeasance are interwoven with surprising ease with aspects of mismanagement, sometimes favored by the lack of control systems … The health-care system presents unacceptable levels of organizational malfunctioning and mismanagement that feed the already negative consequences caused by frequent episodes of corruption to the detriment of the Community. »(Auditor General’s 2014 Report quoted in the Meridian Report 2015. My translation.)
The measured wording offered by the Auditor Court can be admired. Meanwhile, it estimates that the fight against corruption would make it possible to recover € 6 billion or 5.6% of health expenditure in 2014. Again according to the Meridian Report, Italy was ranked 145th with Greece in the International Corruption Perception Index, the corruption index of the public and private sector.
In general, in the framework of a system already marked by corruption, the dismantling of the public sector in favor of the private sector can only aggravate things, making universal access to essential services random for growing parts of the population. Even when it is not very efficient, the public sector operates as a counter-power to the criminal underworld and its savage patronage. Health-care spending is the major item of regional budgets, accounting for some 66% and more of the economically depressed Calabrian Region. Within the Welfare State, this role was strongly supported by the high rate of unionization in the Public Administration workers and employees. For our country this aspect deserves to be underlined especially in an era where the dysfunctions of the public sector are artificially aggravated to better legitimize privatizations in the eyes of citizens / beneficiaries that are increasingly disgusted by the resulting inefficiencies. To paraphrase the Gospel in a reverse mode, the ruling caste is criticized to better protect it.
In the particular context of our country and our region, there is no doubt that privatization and deregulation will still fuel this debilitating and dangerous connection underlined by the Auditor General. Unfortunately this calls into question the health and well-being of our towns and cities as well as of our democracy.
b) Second illustration relating to Healthcare as a social right.
Before the contribution to social criticism offered by Ken Loach, in 1972, to be precise, an English film entitled « Where does it hurt? » (Https://www.youtube.com/watch?v=r_PdlHZDKDk . It seems that the film is now unavailable on Youtube, which is a shame …) It was a hilarious though very serious and very effective comedy. One fine morning an American worker loses his job; to end the day usefully, he decides to follow current fad and go to the hospital to do a check-up exam. Being now unemployed, the hospital staff dissuades him. As we know, the American system is mainly private and therefore the patients are charged the full cost of services. Just like a fine charcuterie factory, a private hospital has to make profits in order to pay dividends on stocks. As the worker was about to leave the premises, the director, a role perfectly played by Peter Sellers, understands that this worker owns a house which can be foreclosed. He is therefore solvent and consequently the hospital director arranges his immediate admittance. The poor worker will then be immediately subjected to a whole battery of treatments as useless as expensive as can be.
At that time the British were very proud of their NHS. Today, in the UK, rampant privatization manages the beds in a Tayloristic fashion. A few years ago certain hospitals were built to maximize beds so that rooms which ended-up being too small to contain both patients, medical staff and equipment were built. With a well-established Burkean method it was all masked with abstruse analysis relating to the pros or cons of individual versus collective rooms and other analysis made their best to obfuscate the number and severity of patients’ and staff’s falls and injuries unfolding in these too narrow spaces …
In 1972, the British ruling class was still imbued with the thought of Lord Beveridge, the author of the 1942 White Paper which was at the origin of the post-war British health-care system. The Report established the difference between social insurance experienced as a citizen’s right and often private, confessional and stigmatizing social assistance. Already in the 1920s, in reaction to the victorious October Revolution, Beveridge defended a Charter of Social Rights seen as a method to legitimize the system and intended, at the same time, as a counter-cyclical stabilization mechanism. Therefore, with their coming to power in 1933 in the aftermath of the Great Depression of 1929, the American New Dealers invited him together with Keynes for a series of conferences in defense of the new socio-economic thought closely linked to the emergence of the so-called Welfare State, as well as of the European Social State born from the Resistance.
We cannot rationally discuss the health-care system without emphasizing its aspect closely linked to social rights. These are protected by the Constitution, born from the Resistance to Nazifascism, as well as by the Universal Declaration of Individual and Social Rights of 1948 with a similar origin in parallel with the fundamental United Nations Charter.
c) Third illustration relating to the economic multiplier of the public health-care system.
In 2013, an important book emblematically entitled The Body economic: Why austerity kills (HarperCollins Publishers) appeared. (For a review see: http://www.la-commune-paraclet.com/Book%20ReviewsFrame1Source1.htm .)The two young authors, David Stuckler and Sanjay Basù, were sensitive to the degradation of the epidemiological picture caused by the subprime crisis. The former works at the London School of Hygiene & Tropical Medecine, the latter is an epidemiologist, professor of medicine at the Stanford Prevention Research Center.
In the book they set out the socio-economic reasons for the decline in life expectancy especially among men in the Russian Federation; they illustrate the worsening of the situation with the introduction of neoliberal reforms (privatizations having, for example, a deadly impact with the closure of the Soviet monotowns).
Similarly, they show the rapid and indecent health degradation in Greece due to austerity, the tip of the iceberg being the rapid spread of AID and a high suicide rate. For the United States, the authors show how the collapse of the housing market with the subprime crisis was linked to the West Nile virus epidemic: in fact, the abandoned pools around Bakersville had become mosquito incubators, one of the vectors of virus propagation. According to them, between 2007 and 2013, the crisis was responsible for over 10,000 deaths. Their study is now confirmed by many other studies related to suicides and health degradation, not to mention the increases in certain cancers related to the crisis. (1)
More important was their discussion of the role of the economic multiplier. For years, I have insisted on the extroversion of the Multiplier due to the free trade and monetarist public policy. The two authors addressed the problem directly by comparing the recipes offered by well-known mainstream economists such as Reinhart and Rogoff or as Olivier Blanchard – when he was at the IMF – in favor of austerity programs and, on the other hand, the destructive path of so-called fiscal consolidation. While Blanchard and others pointed to a simple “miscalculation” to explain the already glaring failure of austerity policies at the time, the two authors stressed that, unlike their assumptions with respect to national income, the Multiplier for the healthcare was around 3% instead of being around 0.5%. If the generally high multiplier of State public services is reduced with privatization, then it is no wonder that the generic multiplier is slim. For these public sectors, health, education, transport, public infrastructures etc., the Multiplier is always higher, and this will remain the case until these public services are subjected to global free-trade – TTIP etc. Thus the authors were able to illustrate the fact that the countries that curbed the dismantling of public services and adopted policies of accompaniment and re-insertion for the unemployed were doing better than the others. This conclusion must be underlined in our country.
This topic is very important. And confirmed by all available scientific studies. For example, I have shown that the very modest economic recovery, although short-lived, was not due to the inept political policies of the Federal Reserve (Tarp, QE etc.) but rather to the federal government’s economic stimulus plan. The objective analysis of the program shows a strong Multiplier for the stimuli that occurred in the sectors that were at least partially public – roads, sewers, bridges, schools, health-care etc. (2)
In summary, the main error of all versions of Marginalist theories in this matter consists in confusing the generic multiplier with the sectoral multiplier while ignoring the public vs private framework. This mistake aggravated the problems of the so-called path of fiscal consolidation in Europe, a policy that has failed everywhere, as is now obvious to any impartial observer .
d) The teachings of the failure and rescue of GM and Chrysler in 2008-2010.
The underlying problem arose because productivity growth in the automotive sector in the form of automation and robotization “freed” a large part of the workforce. These restructuring accelerated by the financialisation of the economy – Roe, etc. – made GM and Chrysler unable to finance their in-house social plans, especially pension plans.
We all know that public pension systems cost much less than private systems. This is because they respond to a non-profit mutualistic logic. Theirs is a contributory actuarial logic. Therefore, they favor both microeconomic productivity and macroeconomic competitiveness.
Despite this evidence, American private systems are emulated in the neoliberal Western World. For example, we know that Healthcare in the US cost 16.4% of GDP in 2013 leaving 47 million citizens without coverage. According to various forecasts, Obamacare will cost more, always leaving around 30 million without coverage, and this within the framework of a degraded epidemiological environment. In the same year, the OECD average was 8.9% for a more or less universal coverage.(3)
Life expectancy in 2015 was 78.8 years in the US and 80.5 years in the OECD. In 1970, life expectancy in the US was one year higher than the OECD average. Obesity, asthma, diabetes and other chronic diseases are most prevalent in the United States.
In conclusion we note two paradoxes:
a) The private system for public goods is hugely wasteful, but waste appears as GDP growth thus ruining the real economy. (Added comment: On the contrary, though universally accessible public sectors do cost far less in GDP terms, they are counted as budget costs hence, often, as additions to the public debt, simply because having no « market price » they do not appear to contribute to the Wealth of the nation as measured by the Marginalist GDP, despite their huge contribution to the well-being of the citizens and to the macro-economic competitiveness and micro-economic productivity. This is most absurd but central to neoliberal and monetarist public policy.) It is a dangerous Marginalist accounting artifact, if only because these bogus Marginalist statistics inform the mainstream equations, first and foremost that of Blanchard et al. With the pretext to further economic “growth” a negative socio-economic spiral is ignited instead.
I have said elsewhere, for example in my Synopsis of Marxist Political Economy (see Livres-Books Section, www.la-commune-paraclet.com ) that Marginalism is ontologically unable to distinguish between speculative economy and real economy, simply because it cannot distinguish between interest and profit and even less between classic interest – linked, through the prudential ratio, to the performance of the economic system – and speculative interest. With the latter’s hegemony, banking and financial intermediation becomes autonomous, so that its speculative interest plays the role of sectoral profit. In this way, through the intra-sector equalization of the rate of profit caused by the capitalist mobility of capital, speculative interest cannibalizes the real economy. In reality, interest is always a part of profit, while the most productive sector determines the relative prices of the whole system. Thus banking-financial intermediation, acting as an autonomous economic sector, and enjoying an unbeatable organic composition of capital, appears to be the most productive and consequently dictates its logic to the entire system, notably its relative prices.
b) Paradoxically, the most wasteful system becomes the model to be copied in Italy and in the EU. This now includes the way of thinking – the “mind set” – as illustrated by the keywords imported from the Anglo-Saxon ideologically dominant pheres, for example public policy, spending review, output gap, monitoring and management software, etc.
2) NEOLIBERAL MONETARISM AND FISCAL FEDERALISM.
a ) The neoliberal monetarist counter-reform unleashed by Volcker, Reagan and Thatcher in 1979-82 was implemented in Italy.
(« The socio-economic consequences of MM Volcker, Reagan and Cie » could be foreseen from the very beginning as illustrated by the homonym essay available here: http://rivincitasociale.altervista.org/another-america-possible-feb-1-2017/ )
Here is the summary of the main stages. The first major change in this direction in Italy was marked by the privatization of Bankitalia in the early 1980s. Though the situation was initially contained, it ended with the internal sabotage of the PCI at the Bolognina meeting in 1991. It was followed immediately by the infamous 1992 Social Pact. In 2001, fiscal federalism arrived without any preliminary impact study. On April 20, 2012, Article 81 of the Constitution was changed to enshrine budget parity in the Constitution. That was done to prevent any change of course in the event of a real political alternance that could be caused by the austerity policies that inevitably unfolded from it. It should be stressed that this Article 81 is much more harmful than the so-called European Fiscal Compact – Two and Six Pack – if only because the latter is only a treaty therefore likely to be renegotiated, while it cannot be interpreted to contradict the articles of the Lisbon Treaty, including those which define exclusive national competences, in particular Social affairs.
b) The joint logic of the 1992 Social Pact and of the Maastricht Treaty (1991-1992).
In those years, the restructuring of the European common market began to adapt it to the opening to free trade and international competition under the hegemony of “private global governance”, that is, of transnational companies.
The great classical Walrasian economist, Maurice Allais, had asked for the creation of Community Preferences in order to discipline the logic of international competition within the framework of consolidated regional commercial blocs. Within these blocs, national enterprises – including public ones – could grow to reach a size sufficient to defend their interests at the international level, while strengthening the industrial-economic power of the European Community. The proposal was not retained, but the French Socialist Presidency and government demanded that some protection clauses for public enterprises (Article F, 3, 3b) and for social affairs be included in the Maastricht Treaty, in addition to the subsidiarity principle. To win the referendum, François Mitterrand and Jacques Delors were forced to promise a second round of negotiation to bring forth a Social Europe.
All of this was later forgotten in favor of monetarist harmonization policies. In fact, while the Maastricht Treaty was being ratified, the Uruguay Round formally launched in Punta del Est in 1986 was about to end – in effect, the treaty was signed at the Marrakesh summit on April 15, 1994. This transformed the GATT into a World Trade Organization. In the framework of the WTO, the residual tariff barriers for all international trade were dismantled, with the exception of services.
Behind the Social Pact of 1992 and the Maastricht Treaty was the underlying logic of global free-trade. Its two key elements are the following:
First, give preference to individual capitalist wages by gradually dismantling the two other components of “global net revenue ” of the households, that is, the “deferred salary ” (social security and pensions, UI etc) and the other transfers to the households in the form of guaranteed universal access to social services and infrastructure. public. (Note the difference between this concept and the reductive Marginalist concept of « disposable income ».) It was moving towards a globally flexible labor market, causing the end of the inflation or Cola clause and leading to the Biagi law, soon followed by the so-called Trentatreu, etc. to end-up with the « esodati » – litterally washed away – pushed aside by Fornero’s pension reform as well as the disastrous Jobs Act of Gutgeld-Renzi-Poletti.
Second, this downward international competition was framed by the definition of anti-dumping at the WTO. It discards all references to the rights of the workers, including the minimum rights enshrined by the International Labor Organization. As a result, the cost of labor reduced to individual wages irrespective of the households’ needs was substituted to the cost of production worldwide to assess faire competition. Similarly, the current definition of anti-dumping excludes any reference to environmental criteria. Nor is the precautionary principle considered.
It is obvious that this choice creates a strong unemployment rate which is poorly masked with the growth of precarious workers. (Note that official labour statistics which follow the ILO definition excludes form the ranks of the unemployed anyone that has worked even one hour during the last statistical evaluation …The real unemployment rate in the US as elsewhere in the West, is more than double the official rate, and even worse when counting the under-employed and the working poor (to use Julius Wilson’s terminology.) As a result, downward competition on the global labor market destroys social contributions, in turn forcing the dismantling and privatization of many services. Inevitably it also destroys the fiscal policy of the State, hence fiscal revenues. This is because an increasingly large part of the work is paid with wages so poor that they are actually exempted from Income tax – this is the case for around 50% of workers and employees in France. The monetarist public policy has however provided that the Nation State must clear the field to make room for stateless private initiatives included the provision of essential services … with the exception of the bailouts of banks and industries such as GM, Chrysler etc., which remain on the public purse.
c) A legitimate question is to ask what would happen with TTIP.
In fact, we can already predict that things will get much worse. This is because the tariffs are already almost entirely dismantled under the WTO. TTIP concerns services and in particular what remains of public social services and financial services.
The rules currently in force in the EU would be changed without any respect for the precautionary principle. It’s not just about bleach-treated chicken or about protecting brands and names of cheese or wine. The rules also concern protocols for the introduction of new drugs. The subject is serious enough. Just remember the American position on GMOs or on the introduction of new materials, for example those that include nanotechnologies. A few years ago Professor Séralini warned about the harmful action of GMOs on endocrine disruptors based on a study that lasted around 2 years, while the other studies, often financed by private individuals andfirms, last around a few weeks!
To this danger is added that of the conflict resolution tribunal designed to protect the prerogatives of transnational private companies against the regalian prerogative of the States. This court already operates within the framework of the NAFTA treaty. Its verified defects are far worse than those of the, sometimes ultra vires, interventions by the Court of Luxembourg in favor of the private sector.
d ) Fiscal federalism or institutionalization of monetarist tendencies.
With the affirmation of monetarist free-trade, the project of building a Social Europe founded on the Europe of Nations was discarded. We returned to the Spinellian idea of an Atlantic Europe in which the Nations-States must give way to regionalization. In this context, federalist harmonization must be based on the monetarist Public Policy, that is, on the dismantling of the European Welfare State, including the economic regulation and collective bargaining and negotiations among social and economic players enshrined in the Constitution. Free global competition enhanced by the new definition of anti-dumping at the WTO must reign supreme, including with the sometimes out-of-mandate help of the Court of Luxembourg.
The Constitution of our “one and indivisible” Republic, its cardinal principles (right to work, national solidarity, health-care protection, public education, mixed economy, institutionalized social negotiation and collective bargaining in the CNEL, etc.) was reformed to impose fiscal federalism without any preliminary study of the inevitable impact. To be sure, this reform was stricto sensu a-constitutional but it was illegitimately pushed trough referring to the alleged need to comply with international treaties according to Article 11. This is a complete logical reversal. In reality, according to this very important article of the Constitution, the Italian State could not sign international treaties that go beyond the rules established by the Constitution itself and by the Charter of the United Nations, written precisely as an international complement to the democratic constitutions born like it from the anti-Nazi-fascist WW II alliance.
It is not surprising that this Italian fiscal federalism was and continues to be a sensational failure.
– Articles 117 and 119 are contradictory.
– in fact, given that the logic of regionalization increases regional disparities, it is difficult to respect the LEAs (the minimum national health-care national norms.) The same is true for the LEP namely the other minimal norms for all other essential services.
– the financial autonomy conferred on the regions (additional IRPEF, IRAP, VAT) is disastrously subject to regional disparity!
e ) Failure is there for all to see
The problem of standard costs versus historical costs was never solved. The problem of the impossible application was not only methodological, it referred to the unresolved problem of equalization in the context of growing regional disparities.
Here are the essential facts about the regional LEA / GDP correlation for 2007:
Lombardia Calabria
GDP per capita: 31 600.00 euro 15 800.00 (obviously it is an average …)
Poverty incidence: 3.7% 23.3%
Employment rate: 65.5% 44.6% (today it is 42.3% according to the POR)
The failure of regional health-care systems occurs easily with the multiplication of the Restructuring Plans (PdR) which have become permanent, with the single exception that of Liguria.
f ) Reopening of Chapter V of the Constitution: to make mistakes is human, to persevere is diabolical!
The logic of this constitutional revision is summarized with the terms “differentiated federalism” or, as I personally prefer, with the expression “competitive federalism”, precisely the drift that was recently rejected by the German State, even if it already is a federal state. The goal was well described by Gutgled – the guy of Israeli origin who wrote the program for the unelected Renzi, see the Books review section of the website www.la-commune-paraclet.com – It was already implemented by the minister Madia (added : although the courts overturned parts of her law ). It consists in temporarily repatriating certain regional powers so as to be able to systematically privatize at the local level, including common goods and services to citizens usually already devolved to the private sector by the Public Administration (outsourcing etc.), without having to incur the rebellion of citizens as was the case for example in Naples (failed privatisation of water system). At the local level there are over 8000 public or participated companies, among which a few hundred valued at over 2 billion euros. They are tempting for stateless speculative finance especially in a Western world where real investment opportunities have become scarce. Large companies spend mountains of cash in the so-called “buybacks” in order to favor equities by supporting dividends rather than risking new investments in a context characterized by a downward internal demand due to the generalization of precariousness.
The end of the Internal Stability Pact – copied from Reagan – is also expected, but only for regions that are able to exploit their access to credit and derivatives to make present an apparently sustainable budget. Now we all know how Draghi used these tools when he worked for the Goldman Sachs to massage Greece’s national accounts and get her into the Eurozone. This in a context in which the Italian regions are already mostly on the verge of bankruptcy. The most serious problem lies in the fact that this modification of the Internal Stability Pact was written to later allow the devolution of powers, temporarily centralized, in order to favor privatization together with almost all the other competences belonging to the national State in favor of the Regions that can present a budget under « control ». To obtain more powers it will then suffice to ask for them! Trento and Bolzano are the model to be generalized… at least for some Northern Regions. (See Article 116 of the counter-reform.) This amounts to destroying the Italian national State, our “Republic, one and indivisible”. If fiscal federalism has already proven to be a disaster, especially for the South, we can easily imagine what will happen with competitive federalism! And not only for the LEA!
Finally, to be brief, we mention the end of social negotiation and social bargaining with the proposed abolition of the CNEL. This regressive coup would come after the adoption of the catastrophic and expensive Jobs Act and the abolition of the Statute 18, namely the Italian Labor Code. Here it is a question of changing the whole system of industrial and economic relations to favor of the monetarist Public policy. The result has already led to general precariousness – part-time, vouchers, apprenticeships, etc. – especially in the South. The latest numbers on the active population in Calabria are 38.6% !!! Now, without or with few contributions and direct taxes levied on the paycheck, public systems – pensions, social safety nets, education, transport and health – cannot stand. Given that even general taxation does not hold, regional financial autonomy will only produce Third-World globalization. Oscar Lange, summarized by Lippincott, pointed out years ago: « At the present time the very place where tyranny exists in democratic states is in privately owned industry; here power is exercised autocratically and often ruthlessly. To be sure, private ownership of the means of production prevents government from tyrannizing over industry; at the same time, it enables industry to dominate over government and to tyrannize over workers. In view of this condition of things, government ownership of basic industry carried out by a democratic government offers a means of taking autocracy out of industry. » (p 32-33) (See Oskar Lange, Fred M. Taylor, On the Economic Theory of Socialism, edited by Benjamin Lippincott, First McGraw-Hill Paperbacks, 1964, pp. 32-33.) )For my critique of Marginbalist socialism see : http://www.la-commune-paraclet.com/EPI%20TWOFrame1Source1.htm#marginalistsocialism )
The basic problem can be summarized with this alternative: Atlantic monetarist federalism (that is, a Europe of the regions dominate by “private global governance”) or a return to classical intergovernmental European integration, that is, a return to the necessary construction of a Social Europe based on the Europe of Nations. ( On this topic as well as the centrality of the opting out clause see the pertinent articles in the section International Political Economy of www.la-commune-paraclet.com )
III ) MONETARIST PUBLIC POLICY, ECONOMIC STABILITY LAWS AND STRUCTURAL CUTS.
A ) The current Public Policy was conceived largely in Chicago University (the various von Mises’s emulators such as von Hayek, Milton Friedman etc.).
The pretext for this real socio-economic and cultural counter-reform was the finding that the so-called pump-priming stimulus plans as known as « Keynesians » plans, no longer worked – apart from the disastrous so-called “military Keynesianism” which resulted in the expensive Reaganian rearmament program known as Star Wars.
In fact, this was partly true, but it was a consequence of Keynes’ defeat against the American H. White at the Savannah Conference on March 9, 1946 when the Bretton Woods system and its twins, the IMF and the World Bank, were born . In short, the opening of National Social Formations with the dismantling of tariffs – Gatt, Kennedy Round – led to the extroversion of the economic multiplier. This trend had been aggravated in the 1970s – early 1980s for Italy – with the privatization of central banks which would subsequently be increasingly subject to the speculative global markets dominated by Federal Reserve (FED) policies, at least until the 2007-2008 crisis. With this crisis, the Fed has merely become reactive, signaling a fundamental change in the world economic order.
Instead of re-internalizing the Multiplier thanks to the creation of a new socio-economic coherence of the national or supranational Social Formation compatible with a global fair trade – for example with recourse to a good definition of anti-dumping, or with the logic of the commercial blocks contained in the Community preferences recommended by Maurice Allais – it was preferred to reduce the role of the State. This was done in the name of irrational theories which today are ridiculed by facts, for example Laffer’s theory of crowding out, or that of the “efficient market”. Although Laffer confessed to having drawn his curve on a napkin in a restaurant, it was false to claim that State intervention through business and public services was detrimental to investment; in fact, today, despite the various liquidity injections to facilitate primary and other markets and banks, only a credit crunch is obtained.
As far as the “efficient market” is concerned, it is sufficient to observe that the opening of the globe to capital, including electronic capital – Big Bang of stocks exchanges etc. – did not lead to any stabilization but, on the contrary, it made the global market more erratic and with more dangerous crises due to the new interdependence of so-called “systemic” institutions. After the dramatic rise in interest rates with Volcker-Reagan, there was the crisis in Mexico (82), then the Plazza Accord (86), the Savings & Loan crisis (86-95) and so on until the baht crisis ( 97), the ruble crisis (98), the New Techs or dot-com bubble (2001) and finally the subprime (2007-2008) followed by the current chaotic world … (Added see « Credit without collateral » and « The Treasury and the Fed » in the International Political Economy of www.la-commune-paraclet.com )
If nothing else, the stock market capitalization and the cross power of the major primary banks increase the gregarious – moutonnier – character of global capital making everything more chaotic and more dangerous. In addition, as demonstrated by the subprime crisis, not even the Bank for International Settlements – the central bank of central banks – knew the exact magnitude of derivatives and of their montages. In fact, the conclusion drawn from the experience of 2007-2008 is all contained in the simple precaution recommended by Stephen G. Cecchetti, a BIS employee. He pragmatically proposed an emergency pause of at least 2 weeks in case of serious problems within the systemic banks to give time to analyze the data and to react so as to prevent the bursting of the CDS chain. Despite the new Basel III rules – and the 2010 Dodd-Frank Act – this agreed timing remains the only operative control rules … ex post, to be clear.
The recipes of the monetarist Public Policy led to the dismantling of the Welfare State and its public services, including the health-care system. The recipes were and remain: deregulate and privatize; dismantle the labor code (as well as the cardinal principles of the Constitution) and therefore, according to the original recipe of the Chicago Boys implemented in Chile by Pinochet, sacrifice the internal demand of the households as well as internal trade, in order to lower the public debt . Without even paying attention to the fact that this recipe could not rationally be applied by all States at the same time. In fact, all the States of the Eurozone have sacrificed wages and social contributions causing an economic downward spiral while their relative trade positions have changed little, but above all when this happened it was mostly in favor of the richer States, including Germany.
B) Here is a summary of the results of this domestic wall-to-wall austerity policy.
i) GDP has been negative since 2011. The pseudo coma-recovery does not take into account the recent change in national accounts. This was done in October 2014 by adding a very small part of tax evasion, drugs, prostitution and certain expenditure on armaments as well as some evaluation of some new intellectual property rights in order to cause an automatic accounting increase of around 3% and more of GDP! Without adding any job hence any social contribution and tax revenues … this change happened a year earlier in the USA.
ii) The industrial fabric is destroyed on average by 22% at the national level but much more in the South. Given the escape of FIAT and the rampant privatization of our last large conglomerates such as Finmeccanica and Fincantieri, the share of the so-called North-East Model, founded on small businesses is growing, but it is forced to survive with German or Austrian subcontracting.
iii) At the level of the trade balance, the small surplus is due to a more drastic drop in imports – a trend also favored by the current low oil price.
iv) The Primary surplus, the aspect boasted as an advantage by our leaders chosen with imperial profiling, appears positive. Unfortunately, in an economy that is stagnating or almost stagnant, it is clear that it was mainly due to linear cuts and privatizations. When the Fiscal Compact was launched at the European level, there were still about 600 billion euros to be privatized in Italy but in reality no more than half that amount counting local businesses. (http://www.sinistrainrete.info/europa/2293-giorgio-gattei-la-germania-contro-tutti.html , 20 settembre 2012). It is true that the Israeli-Italian Gutgeld, the chief-ideologue of the PD of the unelected Renzi, had already begun to evaluate the proceeds of privatization not only those coming from the private management of museums and other cultural sites but also those coming from privatisation of the sites themselves! So that the primary Italian surpluses of 3% or 4% of GDP become more and more difficult to achieve, even with the violation of the European Maastricht and Fiscal compact criteria parameters that could have already been worth a penalty of 0.2% of GDP to our country during the last two years. A little more flexibility was grated to obedient Italian leaders – just enough to gain time to to allow them to proceed with the residual privatizations and to impose reforms without causing popular rebellions.
v) The balance of accounts thanks to the spending review and the various linear cuts is summarized in this way by the 2016 DEF (p 21) A spending review of € 25 billion is estimated; a reduction of purchases by centralised agencies of € 35 with a Consip which distinguishes between 19 categories of goods. Furthermore, the privatizations scheduled for 2016/2017/2018, will have to amount to at least 0.5% of GDP !.
C) Impact on Healthcare? Expenditure blocked around € 111 billion.
The GDP forecast for 2016-2019 is counting on a growth of 2.8%. But healthcare spending will not grow beyond 1.5%. So that the planned cuts are 1.783 billion for 2016; 3.5 billion for 2017 and 5 billion for 2018.
In this context, private healthcare spending can only grow. From 2010 to 2014 while public spending decreased from – 0.6% , private spending increased by + 2.1% and amounted for 23% of the total (Ticket etc.)
No one will then be surprised by the degradation of the epidemiological framework, for example the increase in the incidence of chronic diseases such as obesity, diabetes etc. We also note the very high number of Caesarians birth compared to the European average, which in the South is a real shame.
The general data speak for itself. So from 2005 to 2013, life expectancy has increased for more than 2 years. But healthy life expectancy has decreased 5.8 years, while unhealthy life expectancy has gone from 13.6 years to 21.4 years, that is, an increase of 7.8 years.
The renunciation of treatment affects on average 9.5% of the Italian citizens, 3% in South Tyrol and 15% in Calabria. This in a general context in which workers die on average 6 to 11 years before their managers depending on the activities considered!
Waiting times for 11 typologies of exams plus the use of the lab is a few weeks to 2 months on average! Despite this unacceptable situation the Minister Lorenzin instituted 203 visits and paid examinations in May 2016, including the recourse to laboratory and to specialists, sometimes subjected to the ticket but only under under certain conditions.
This logic leads the minister to adopt ad hoc emergency interventions in contradiction with the planned linear cuts but, in fact, over-determined by them. For example, there is talk of additional 850 million euros to cover the new LEAs; 650 million for the vaccination plan; 500 million for the introduction of new drugs and to combat Hepatitis C; 500 million for the renewal of employees’ contracts.
It seems to me that the oft-praised and vital « preventive medicine » is giving way for what the minister and her councillors called – American style ? – « defensive medicine » – to be added to the biological testament to free hospital beds? – designed to protect doctors and surgeons from possible lawsuits, given that the health-care system is being degraded in such a tragic way.
D ) Budget laws and Fiscal compact = a public communication exercise to mask the organized waste of public wealth in favor of the richest 1% and 20%
According to various reports, in particular Oxfam 2016, 10 people in Italy are richer than 3 million less wealthy; the richest 20% holds 67.7% of national wealth ..And it is getting worse year after year …
This waste must be read in the context of the violation of the of European Criteria that led the EU to give our country an exceptional margin of 0.85% of the GDP, one which was typically immediately wasted. Here are some more eye-catching details:
The Jobs Act did cost € 18 billion in 2015.
Tthe infamous 80 euros in paychecks given manly to dependent employees for vulgar electoral reasons – while their public contracts have been blocked for over 7 years – do cost 10 billion yealry.
The IMU was canceled for the more affluent 2/3 who was still paid it without problems (while local taxation increased by 22%) IRAP and IRES. It represents al loss of revenues around 5 billion for already money-strapped local government.
Voluntary disclosure – that is, the whitening of the huge fiscal evasion which amount to 200-300 billion a year in Italy – reported 3 billion.
The reform of the betting games etc : 1 billion.
According to the Court of Auditors, tax expenditures went from 254 billion euros in 2015 to 330 billion in 2015. The tax evasion which is difficult to evaluate is at least equal to or greater than the tax expenditures. (Added; Tax expenditures is the jewel of neoliberal monetarist policy, one granted it disappears from the budget radars. Hence in more recent reports the General Auditor has chosen to follow the Senate in assessing the yearly amount to just 70 billion euros, counting the exonerations for invalidity and such which, of course, are legitimate if notoriously avaricious, but amount to no more than peanuts …)
All this in a favorable but mutable international context: low euro / low spread / low oil prices and with an Italian rating still valued at BBB …
The question of alternatives therefore arises. Some TINA propagandists – there is no alternative – claim that there are no alternatives. Others, fortunately less mainstream, underline the disastrous impact of the current definition of anti-dumping which imposes a race to the bottom on the basis of individual wages alone – thus destroying both social contributions and general taxation, see above. These insist on the emblematic experience of RTT, that is the general reduction of working week in France with the Jospin government. The RTT did only cost € 23 billion to generalize 35 weekly daylight hours with a framework agreement. More than 350,000 permanent jobs were created by restoring social programs with contributions and general taxation.(The direct and indirect amount for the « gauche plurielle » was around 1.2 million jobs.)
In fact, thanks to RTT, the deficit of the Social Security had almost disappeared in just two years – there was a residual deficit of 4 billion euros, a matter of months no more; the unemployment rate fell from almost 11% dropped to just under 8%. This consolidated general fiscal revenues so that after two years of government under the « gauche plurielle » the French public debt had fallen to 59% of GDP, that is to say, under the 3% Criterion of the Maastricht Treaty. The effective working hours, including the on average 4 additional over-time hours, meant higher paycheques. Thus a new sociology of entertainment developed spontaneously. In comparison, with a 60-hour legal week, the hours actually worked on average in the United States with increasingly precarious jobs were 33.8 hours. It should be added that the French industrial fabric was strengthened not only with the revitalization of public enterprises but also with the arrival of foreign direct investments, France being then one of the first destinations for direct foreign investment despite all the ideological clichés circulated. Productivity and competitiveness had increased thanks to the RTT.
Thus we can judge of the waste and irrationality of the current Italian transversal policy. With these wastes, at least 2 French RTTs could be implemented!
4 ) MONETARISM AND FISCAL FEDERALISM APPLIED AT THE PROVINCIAL LEVEL.
Without much surprise, the conjunction between neoliberal monetarism and fiscal federalism led to the collapse of the provincial health-care system.
This prompted the Region to ask the national government for a health Restructuring Plan or Piano di Rientro (PdR). (4) The Ministry of Economy and Finance (MEF) appointed an Advisor. The process quickly led to the appointment of a commissioner and the drafting of a PdR entirely impregnated by an economic-financial logic solely aimed at the elimination of the deficit.
The 2007 PdR must be taken seriously because it still remains the basis of the current reorganization. Here is what the Regional Health Service Rationalization and Redevelopment Plan (2010) wrote: « “The plan, therefore, from a mere technical-administrative ” restructuring ” economic-financial instrument », becomes a lever and an opportunity for an overall rethinking of the regional health-care system. » (5)
There is no doubt about the spirit that informs the restructuring of the Calabrian health-care system. This logic is strongly assisted and framed by the multitude of national and regional monitoring and control agencies (LEA, AGENA, ANAC, SUA, etc …)
As could have been foreseen, this economic-financial logic accentuated all the problems and inappropriate features already present in our regional system.
Formally speaking, the PdR almost made the deficits disappear. For example, in 2014, the regional deficit was 68 million euro, then reduced to 28 million euro after “coverage and adjustments”. It is enough to know some of the tricks masked by this euphemistic phrase to remain lucidly pessimistic. However, privatization increased although it was already grotesquely out of norm. The norm was 30% maximum for the private sector. In 2007, out of 73 regional offices, 37 were public and 36 private. The situation worsened rapidly, including for the so-called sharing of cost by citizens, that is, the ticket and the various expenses of one’s own pocket for drugs and for a growing list of tests and exams. In Cosenza, the private sector outstrips the public sector. In Crotone, only one of 6 nursing homes is public. Of course, many services offered by the private sector are reimbursed with public money while the heavier and therefore more expensive services tend to remain the prerogative of the public sector. To paraphrase Malbranche, healthcare profitability has its reasons which reason ignores. Perhaps some will remember what we mentioned at the beginning when with referred to Peter Sellers’s film « Where does it hurt? ».
Despite this diagnosis, the PdR’s recommendation was to identify about twenty public facilities to be converted into long-term care, in sanitary residences and in health homes. It is noted that these functions reserved for the public sector are the most expensive, therefore usually ignored by the private sector, except when patients are above a comfortable income threshold. If the PdR mentioned the hospitals in mountainous areas, this consideration, which was made necessary by Article 44 of the Constitution, was then totally ignored as evidenced by the almost definitive closure of the Acri hospital and of the San Giovanni in Fiore hospital (my City and that of Joachim of Fiore). It suffices to look around to understand that the closure of certain hospitals, including in mountainous regions, aims above all to make the beds available to private hospitals located in the larger nearby towns.
The current reorganization into Hubs, Spokes, General Hospitals and accredited private nursing homes stems from this recommendation. It is a very troubled process: apart from the issue of hospitals in mountainous regions, the pathological disorganization and the uncontrollable indebtedness of Reggio Calabria and Catazarao revealed all the rottenness of a drifting sector despite the presence of a Commissioner. For example, the 2014 debt of the hospital Renato Dulbecco of Catanzaro is estimated at € 85 million; that of Reggio, often given as the worst case, is not even known!
The collapse of the Calabrian health-care system does not stop there. Despite the Framework Program Agreement signed with the MEF, out of 608 million euros available for investments in technology and for the construction of new hospitals, 258 million are not yet used. A little while ago there was talk of the construction of a new hospital in Cosenza probably in an electoral vein, but without saying a word about our hospitals located in mountainous areas with very respectable potential basin of their own for instance in the Sila Plateau…
Worse still, this is how the Restructuring Plan provided for the reorganization of our system, in particular the use of beds. A three-year cut of 65,000 fewer hospitalizations in the public sector and only 7,000 fewer in the private sector was planned cold. The enormity of passive mobility is not surprising: that is, in 2014, more than 60,000 Calabrians were treated outsideof the Region for an exorbitant cost of 214 256 688 euros.
The results are clear. With such corporate management and increasing privatization, the citizen beneficiary becomes a mere customer worthy of attention only if s/he is solvent.
In terms of the LEA threshold, Calabria is in last place of the classification. Given an Italian average at 160, Piedmont shows a score of 200 and Calabria of 137.
In terms of beds, the 2014 standard was 3.7 / 000. Before the PdR the regional score was 3.9 / 000 while today it is only 2.77 / 000. The PdR set a target of 3.8 / 000.
As far as passive mobility is concerned, we have already given the main numbers above. We should add that this passive mobility mainly concerns oncological, orthopedic, thyroid interventions, etc. Orthopedics together with prostheses account for 50% of total passive mobility. The hospitalization rate outside of the Region is 31/000. If the Restructuring Plan logic is clearly debunked by these numbers, we must emphasize that this logic does not change, so that there the best one gets is vacuous talk of recovering only 30% of this passive mobility in the future. (6)
The percentages of Caesarean birth are the emblem of all the drifting of an archaic society, still endogamous and chained in neoliberal monetarist poverty. It seems that, in this case, male doctors are usually even more hasty than the ordinary. If these percentages remain outside the norm in Italy compared to other countries, the norm is even more violated in Calabria. The PdR itself mentions a 70% rate in certain structures. (7)
In terms of sharing of cost, or ticket, the cost of private health-care increases everywhere in the country and even more in the South, causing a serious deterioration of the epidemiological framework. The immediate result can be read in the growing number of townspeople who simply and dramatically renounce treatment. (8) Already in 2014, the Meridian Report noted that if life expectancy had increased by 2 years from 2005-2013, at the same time the years in good health had gone down 5.8 years while the unhealthy years had grown 7.8 years from 13.6 to 21.4 years. Suffice it to add that workers, according to their profession, die 6 or 11 years on average before their managers.
With all of this, perhaps not surprisingly given the increasingly unequal structure of incomes, private coverage does not take off in Italy – health funds, insurance, etc. This trend can be easily analyzed because these coverage are mostly related to dependent work, more or less stable. (Added: Our main unions, once on the Left, have mostly agreed to this social regression at the expense of our public health-care system) Having included the protection of private insurance together with the promotion of competition in the constitutional counter-reform therefore seems out of place. In effect, the constitutional destruction of social programs based on the principles of distribution and national solidarity would be sanctioned in frontal violation with the cardinal principles of our Constitution. It should be emphasized that these are not modifiable and therefore not directly object of the counter-reform. (Added: to understand the regressive constitutional reform trenched in the December 4, 2026 referendum, see the Categoria « Constituzione » in this same site.)
The commissioner mission has no end in sight obviously simply because the powers of the Commissioner ad acta are limited to the content indicated by the judge who defines his role as commissioner. In so doing, the function of the Commissioner cannot lead to any real recovery nor to any real reduction and cancellation of the deficits, because they cannot purging the system. (9) Furthermore, the role of the Commissioner is constrained by the division of competences between government levels. Sometimes, the commissioner is used by politicians to save their clientelistic and mafia or corrupted system because the public function, often infiltrated by the underworld, is not in the least affected. They remain in place. As we all know, bureaucracy is conceived as the true “permanent government” especially in regimes subject to electoral deadlines. The same problem is encountered with the commissariat of the municipalities, the role of the Commissioner limiting himself most often to establishing a list of subjects to be paid in priority, often without in the least questioning the legitimacy of the expenses and of the contracts signed by those municipalities that fell into bankruptcy and insolvency … Therefore, with a Restructuring Plan that dates back to 2007, it is not surprising that the restructuring, even if it is malicious for the non-standard part entrusted to the private sector, has no end in sight, and that the amount of inappropriateness and waste does not decrease. Quite the contrary. (Added: health-care budget accounts for 66 % or so of regional budget; imagine what this means for mafia and ‘ndrangheta gangrened southern Italian societies …On the contrary the only way to fight corruption would be to return to a solid public sector over-watched by solid unions and citizens’ pressure groups.)
As we will see below, the health-care personnel was and continues to be sacrificed to this peculiar restructuring. Its is often subjected to improper working conditions. If this refers to a general condition in the regional public administration – in Calabria we are talking of about 1000 non-stabilized precarious workers – in this specific case it does not only jeopardize the services offered to citizens as beneficiaries and as taxpayers, but also their own health.
The general epidemiological picture, already heavily compromised by our health-care tradition and the financial-economic crisis, is still getting worse. This observation is valid for all of Italy but obviously with much more important drifts in the South and in Calabria. Thus, obesity and diabetes are taking epidemic forms, in addition to cardiovascular diseases, to those related to the digestive and respiratory systems, etc.
4b ) PHARMA-CARE AND DRUG POLICY.
We have already mentioned the recent growth in the sharing in of health-care spending by citizens, in addition to their tax contribution. Let’s examine the situation in more detail. In fact, one of the interesting peculiarities of spending on drugs in Italy was its containment achieved without compromising patient’s health. Two factors contributed mainly to this: first, the fact that doctors often enjoyed a public statute not being constrained by the commoditization logic of the big drug companies; second, the public system rightly privileged generic drugs.
Unfortunately things are changing.
As a percentage of total expenditure, pharmaceutical expenditure was: 1985 (17.8%); 1995 (10.7%); 2007 (11.4%); 2008 (10.25%); 2009 (9.8%); 2014 (7.6%); 2015 (according to the Court of Auditors 7.6%).
However, the 2016 Court of Auditors notes that pharmaceutical spending increased by + 2% gross of paybacks, i.e. the reimbursement mechanism envisaged for drug companies when a certain threshold is exceeded. It is then learned that the repayments due in 2013-2015 were used in the 2015 budget, thus masking the real impacts of the cuts and privatizations. 20% of the increase is due to hepatitis C treatment. The new hepatitis C drug heals in more than 90% of cases; its production cost is 100 euros; its selling price is 41 000 euros, which is strictly intolerable. (10) This reveals another structural problem of our current drug policy, namely keeping costs down with restricted access to innovations in an era now witnessing a theoretical and technical revolution in biology, pharmacy and genetics.
In general, therefore, pharmaceutical expenditure tends to explode for technical and privatization reasons but is still maintained at the expense of patients with the use of the ticket. This is falsely seen as a moderating factor of consumption with respect to the rates of renunciation of care and the degradation of life expectancy in good health or tout court.
The remedies conceived within the framework of monetarist logic are worse than evil (we have already denounced above the regressive thought on the matter formulated by the Austrian Jewish-fascist von Mises, the father of all current monetarist neoliberal regressions.( 11) This von Mises, despite having fled in America after Anschluss, never changed the ideas he held when he was a councillor to the Austrian Fascist Chancellor. In Italy, things seemd very good for Margherita Sarfatti et al., at least up until 1938 … indeed, Mussolini’s pro-Semitic Fascism was the model preferred by this rabble, a model in fact now pursued again but in a so-called “softer”, that is, more insidious, fashion.)
For example, direct sales of drugs are accelerated in almost all regions while the deregulation of pharmacies is under way. We use purely Anglo-Saxon methods and software, therefore more suitable for privatized systems – I refer again to the film with Peter Sellers mentioned in the introduction. In fact, the operational vocabulary is almost all English – payback, monitoring etc. Here, the benchmarking in question is strongly supported by the monitoring and control agencies already mentioned, including AGENA, ANAC, SUA etc. It is not surprising that Minister Lorenzin, instead of emphasizing preventive medicine, favors cuts and defensive medicine aimed at protecting doctors against the foreseeable increase in lawsuits for the inappropriate nature of the services afforded to the masses by the privatization of the system. (12)
In this context, we already see a very serious problem emerging which is linked to the poor introduction of new innovative drugs. In 2014, their consumption was 91.2% lower than in other large European countries such as Germany, France, GB. We will soon have to hope for the repatriation of Emergency!
Typically, it takes 5 years before these consumption rates improve. For example, the consumption for new drugs introduced in 2013 was less than 81.6%; for 2012 it was at 66.7%; and for 2010 (i.e. 5 years) at 16.5%.
The OSCE underlines an Italian paradox: the generic part was multiplied by 4 since 2000. In 2013, they accounted for 19% of volumes and 11% of the value of total pharmaceutical expenditure. The OSCE average was 48%.
Pharmaceutical spending has always been an important part of total healthcare spending. This share is always destined to growth at least until the path of socialization of pharma-care is chosen as it was done a short while ago with hospital spending. Therefore, these monetarist drifts, already clearly perceptible for pharmaceutical expenditure, as well as for equipment and machinery, software etc., demonstrate a total absence of industrial and economic strategy, despite the fact that the country spends around 7% of the GDP for the health sector.
The pharmaceutical sector however remains important in Italy. One could therefore think, in addition to privileging generics, to introduce a chosen list of innovative drugs at prices equivalent to generics, negotiating the volumes and duration of the purchases, and partially compensating the companies with subsidies for R&D. Indeed, this strategy would be beneficial for patients, public finances and pharmaceutical agencies as R&D is a matter of survival for them, while heavily affecting costs. If we add to this the savings in terms of marketing for the drugs chosen in Italy, then there should be no hesitation. The same argument can and should be proposed especially for the most sophisticated equipment. They imply a highly skilled workforce, therefore outlets for our universities and colleges, both upstream and downstream of the economic value chains.
In this not very bright picture, the situation in Calabria still shows a worse trend than the national average. Once again – see the division of hospital facilities -, if we consider public and private expenditure per capita, Calabria shows the urgency of a real rehabilitation that would unfold according to a completely different logic, that is, a public logic respectful of legality and of the Constitution . Our regional health-care system is pathologically ill with bad business and corruption at all levels. The reason is very simple given that the health-care system represents the largest item of regional expenditure, and therefore in a source of parasitic malfeasance that destroys everything is puts its hands on without minimally knowing how to create new wealth. With such a perverted and pathological forma mentis, the only way to get rich consists in the transfer of public money directly into the pockets of private individuals. This parasitic logic is similarly extended to access to the European funds something done in the usual corrupt fashion and without the least strategic planning. (Added: Because of the lack of planning and the ability to come up with the necessary co-financing Italy, the same country now abandoned into the hands of lousy and disgraceful and incompetent pitres at all levels, who now ask for covidbonds, while chronically unable to respect due process, is about to louse some 45 billion euros in unused 2014-2020 European funds!) In such a context, the breakdown will soon be irreversible.
The same wicked drift is being prepared with waste management … Here are the numbers:
Public and private expenditure per capita:
For Italy: total (2263 euros); private (435 euros, that is 19, 22% of the total); public (1829 euro)
For the Val d’Aosta: (2648 euros); private (648 euros, that is 24, 4% of the total); public (2000 euro)
Calabria: total (1945 euros); private (€ 274, ie 14% of the total); public (1671 euro)
Calabria ranks in the last three. The total expenditure for Sicily is 1912 euros; in Campania it is 1900 euros.
We draw our conclusion from the excellent Meridian Report 2014:
« In the Group of Regions (8) which spend less than the national average are the Southern Regions, with the exception of Molise and the Regions subject to Restructuring Plans with the exception of Molise, Piedmont, Lazio. »
We know that the only Region that came out of its Restructuring Plan was Liguria, but that was for accounting reasons. What was said above explains the reasons for this failure, especially for patients who are victims of this way of cleaning up the accounts by placing the priority on the logic of privatization and that of cancelling deficits. We explained above that this drift is also the result of fiscal federalism which was imposed in Italy without any preliminary impact study, and without even having developed a methodology for calculating the “standard cost”, ergo without a real equalization fund apart from the linear cuts imposed by the Laws of stability, and therefore with fake LEAs strongly correlated with regional GDP. Yet the equalization process is enshrined in the Constitution. Imagine then the effect on the health-care system of the “competitive federalism” contained in the infamous constitutional counter-reform of Renzi-Gutgeld!
4c) PERSONNEL AND STAFF POLICIES.
In Italy, in 2016, a year before the drafting of the PdR, the cost for personnel was 33.1% of the total healthcare expenditure. In Calabria, it was 39.2% of the total. With the PdR, personnel policies are re-framed by the logic of regional austerity.
i ) Restructuring: We have seen above how the PdR envisaged the conversion of about twenty small hospital structures. Restructuring always has a major impact on the workforce and their social representation. For a person not still accustomed to certain Calabrian practices, that is to say routinely intolerable and totally illegal, it is still shocking to realize that it is impossible to obtain an idea, even a rough one, of the workforce employed in the sector and therefore to evaluate the full effects of the reorganization. There seems to be a more or less hidden if not occult management of human resources. We know, more or less, that there are around 1000 precarious male and female workers awaiting stabilization at the regional PA level. When I checked on the Internet pages of the regional sections of the unions I found absolutely nothing available on the subject, and very often not even on health-care in general. There is something like a systematic connivance and / or discouragement. The Commissioner ad acta does not even seem to be disturbed by the fact, nor by the knowledge that – as I was told – it would be easy to establish exact numbers from the wages paid out… In these conditions, talking about the Restructuring Plan is very risky and it is even riskier to hope for good results from the prescribed reorganization.
We also know the euphemism used by the PdR to summarize its personnel policies. It made it clear that the « targeted blocking of the turn over » should be carried out, but within the the percentages allowed by category. That is: Administrators (5%). Professional (5%). Healthcare staff (50%). technical staff (10%).
In its peculiar accounting logic, the PdR specified the savings under IRAP – a ridiculously low Italian business tax – that this blockage promises to reach, that is 7.5% of the total personnel costs! We have seen that the decrease in hospitalisation (65,000 plus 7,000 in three years) exacerbated the cost of passive mobility. This reduction in staff effectively translates into unbearably hard shifts for that personnel in the known context of the increase in inappropriate situations already present in our region, if not the increase in medical malpractice as such. The practical consequences of these choices cannot be masked with the use of VAT numbers, even in the case of nurses …
The story doesn’t end here. We have to add the general suspension of the renewal of contracts for more than 7 years now. The forced alignment of personnel costs with the rise in the cost of national standards is notoriously difficult to establish.
But the most serious thing in our Calabrian context seems to me to be the calculated non-compulsory nature of the normal procedures that “govern” procurement. In plain language, recourse to the Single Regional Contracting Authority or the SUA agency according to the law of December 7, 2007 is not mandatory. The non-mandatory thresholds are calculated artfully, just multiplying the contracts below these thresholds is enough to transfer millions and millions into private pockets without nobody checking. (Added: This happens under the nose of the anti-mafia parliament committee. It is sad but not surprising to note that one of the first measure taken by the government led by the Lega-M5S movement was to raise these thresholds further …)
Thus, the non-mandatory threshold is € 150,000 for work contracts. And 20,000 euros and less for service and supply contracts. And 20,000 euros and less for mixed contracts (services and supplies). Finally it is 75,000 euros and less for mixed contracts (works-services-supplies.)
This system considerably aggravates all the consequences of outsourcing practices in the public and private sectors. In the Calabrian context, here lies one of the major sources of the pervasive corruption reported by the Court of Auditors as we mentioned at the beginning of this analysis. This state of (bad) business is still worsened by two incomprehensible Italian practices except in the context of the consolidated habit of circumventing the laws from within the system. The first concerns not only the transparency of the awarding of contracts but also the lack of an authentic hence verifiable « cahier des charges », that is the list of criteria to be met to win the tender, and on the basis of which the checks or audits can lawfully proceed subsequently. Without this « cahier des charges », there can be no legal fair competition between the contracting companies and above all there can be no control over the quality of the services subject to the contracts. Second, the winners of the contracts can get away with it because there is no obligation to publish the cahier des charges as well as the costs of the winners of the contracts. The Italian Freedom of Information Act does not allow any verification and the Italian class action procedure has no teeth. To top it all, to my knowledge, there is no Ombudsperson in the healthcare system. These are very serious shortcomings with disastrous effects for the whole country and particularly for Calabria. They should be corrected urgently with rigorous laws.
ii) Demography (age) of personnel and staff.
The aging of personnel, already too pronounced, is still aggravated by the absurd increase in the retirement age in Italy. In fact, already with the Prodi government, Italy, by anticipating the other European countries, had absorbed a large part of the pension cost due to demographic trends. If it is true that at that time, the system absorbed around 14% of GDP, it is also true that the State benefited greatly from it also because around 20 billion euros were already used to finance the assistance system (13). Years ago I protested against unnecessary, regressive and harmful retirement age policies. The reason was clear: artificially keeping around 4 million seniors at work meant aggravating the unemployment of young people by at least half or 2/3 of this figure, preventing the necessary renewal of qualifications, especially in public bureaucracies at the time the introduction of new TIC technology. For the more arduous jobs the consequences are much more dramatic. And we all know that the jobs in the hospital milieu are not among the most restful!
The result is disastrous at least from what can be understood from the available data. In 2014, 50% of Italian hospital staff were over 55 years old. The OECD average was 16% !!! Just look at 2007 in Calabria. 50% were over 50 and 10% over 60.
iii) The percentage of managers compared to the total staff tells another aspect of this risky but targeted management story of the system and of its resources. If, in Italy, the managers made up 20% of the total staff, the corresponding percentage in Calabria was 24%. And, with some exception, they are notoriously not among the most qualified … Recall the so-called passive mobility percentage … (added: and accountability is null with the active complicity of the Medical college and of the magistrates, for instance, those of Cosenza.)
iv) Systemic precarization. We have already mentioned the more or less 1000 un-stabilized temporary workers in the regional PA. In the context of privatizations that equally concerns the local public agencies and enterprises – Madia law, Renzi-Gutgeld constitutional reform, perhaps also TTIP etc., see the analysis on the constitutional counter-reform available on this same site – outsourced workers will be subject to the same general Jobs Act logic, at least if they are “lucky” to be able to fall under it, that is to say, to enjoy a permanent precariousness statute renewed from 36 months to 36 months as long as the fiscal exonerations are judged sufficient by the entrepreneurs and bosses. As these exonerations will end after a few years, which is already starting, open-ended contracts also drop. And to top it off, the Jobs Act allows for layoffs without due economic cause. (14). As was quickly demonstrated, the entry into force of the Jobs Act caused a very strong surge in vouchers, which from a few tens of thousands amounted to more than 1.4 million « workers » a little while ago !!! If all this was not enough, the constitutional counter-reform imagined by Renzi-Gutgeld will aggravate the latest villainous laws on the representation of workers and their unions and provide for the end of institutionalized social negotiation and collective bargaining with the abolition of the constitutionalised CNEL (15).
It should be remembered that the EU has adopted a directive that allows the passage of 40 hours per week to 48, 60, 65, and even to 72 hours per week, according to the needs of entreprises. In the past, when the 48-hour weekly law was adopted in France, this law was presented and defended in the National Assembly by Jules Guesde; the latter was based on a dossier established by the great Marxist Paul Lafargue, Karl Marx’s son-in-law and a professional doctor of medicine. Lafargue established how, after an average of 48 hours of work, the workforce was so worn out that its productivity decreased. In the framework of the new filo-Semite Nietzschean regression – a regression that has been dirtying our country for the second time since 1922 – these arguments firmly based on science no longer mean anything. The labor force, embodied in a citizen is worth less than a robot. Rosa Luxemburg clearly stated the alternative before us: socialism or barbarism. In other words, either we continue with the current trends and share the poverty between the workers , while the richest 10% of the population still gets richer, or all citizens apt to work do their fair share. In the latter alternative, we would all work less thanks to the reduction of the working week but initially for the same individual wages but with increased collectively paid and universally accessible social services. This alternative would automatically correct for the lower wages given that the norm would return to be full-time employment and it would be based on a new definition of anti-dumping at the WTO in order to protect the three component of the « global net revenue » of the households. (on this topic see the Appeal here : http://rivincitasociale.altervista.org/test/ )
In its 2016 report, Oxfam noted that 62 people were wealthier than half the inhabitants of the planet, while 1% were richer than the remaining 99%. These inequalities are also observable in Italy where 10% already possess 63% of national wealth. (16) In the South these inequalities are even more exaggerated. According to the 2016 Operational Plan of Calabria, the employment rate in our province was 42.3% while the poor or at risk people were 45.8. (17) When I wrote this head the employment rate had fallen to 38.6%.
5) CONCLUSIONS
It would perhaps be appropriate to draw some conclusions from this analysis. We attempt to do it this in a way that will not be formally normative but that will strive to be operational.
a) Synthesize, update and disseminate information. Today even the victims of the Restructuring Plan think that it is necessary to continue implementing it without even knowing what this monetarist PdR recommends in terms of restructuring and privatization. We are all convinced that the system must be restructured but this must be done putting the health and well-being of the citizens at the center of the process. Today we all have under our yes the results of the catastrophic choice to convert twenty hospital facilities and to reduce hospitalizations by 65,000 in public facilities and only by 7,000 in private facilities. The enormity of passive mobility – or out of the region health migration – requires no further comment. Perhaps the most emblematic element of the pervasive ignorance of the issues maintained by the System concerns the impossibilityof determining the number of employees in the Calabrian healthcare structures and therefore their working conditions etc. This does not even happen in Third World countries.
b) Transparency and obligation to follow a public and transparent process for all contracts. We have seen how the thresholds for procurement contracts exempt from all obligations are artfully determined causing an immense transfer of public money into private pockets without any control possibility. Therefore, all purchases, regardless of the sums considered, must imperatively be subject to public contracts with verifiable and published « cahiers des charges ». SUA’s competence must be extended to all contracts with ANAC verification. Disclosure must be automatic even if, in general, the Italian Freedom of Information Act must be extended.
c) Create a regional Ombudsperson dedicated to the Health sector and strengthen class action. All reports, including the PdR itself, insist on what is euphemistically called systemic “inappropriateness”. This state of affairs results only from the lack of responsibility in the sector, at least as regards the services received by patients. It is true that Standard Operating Procedures (SOP) are very important for the proper functioning of bureaucracies and complex social systems. These are now introduced alongside with new technologies with a view to privatizing or to monitor expenditures. The essential is forgotten, that is, the relationship with patients. Only by creating institutional channels of empowerment of citizens and patients can we hope to get out of the current dramatically dysfunctional framework.
d) Change the mandate and powers of the Commissioner ad acta. Today the Commissioner ad acta is linked to the legal decisions made prior to his appointment. In addition, he remains a prisoner of the division of competences between national and regional levels. This remains true in the case of the commissariat of the municipalities placed under legal trusteeship. Indeed, the Commissioner ad acta sees his function limited to the reduction and cancellation of deficits. Most often he confines himself to prepare a list of debtors to be repaid in priority. This is done without any auditing that would be de rigueur for all contracts given their typical opacity, in order to put an end to the bad deals that too often characterize them. Some are reimbursed in priority instead of ending up in jail. Indeed, the de facto function of the Commissioner ad acta, especially in the South, is to save the system, especially the most rotten one, without ever cleaning the Augean stables. Our politicians immediately understood how to exploit this inappropriate institution, they understood that if the elected officials are sometimes suspended, all the bureaucracy remains intact, obviously with all its clientele and other connections. To be effective, the Commissioner ad acta must base himself on a complete and rigorous auditing and have the power to sanction all those who have not respected the public interest and the laws, without exception. Otherwise, it fatally becomes the guarantor of the malpractice system and its best legitimacy even if in spite of himself.
e) Change the economic paradigm of reference. We have shown above the link between cause and effect between neoliberal monetarism and fiscal federalism, and between these and the collapse of the Italian health-care system as well as of the entire country. One can no longer think in terms of exceptions, for example for Article 107 of the Treaty on the Functioning of the European Union. This article allows for different but theoretically transitional measures in the event of a strong structural disadvantage in terms of unemployment, regional disparity, etc. Or, with regards to Article 44 of the Constitution and its provision for the hospitals in mountainous regions. Today, global free trade and hegemonic speculation have drastically reduced the effectiveness of these exceptions. On top of this Marginalism, particularly speculative monetarist Marginalism, is just a cynical a-scientific narrative. Its purpose is to impose the “forced return to a society of new domesticity and new slavery”. For the demonstration the reader is send back to 1) « Hi-Ha. The donkish visual hallucinations of bourgeois economists » (2009); 2) Synopsis of Marxist Political Economy , (2013). Both are freely accessible in www.la-commune-paraclet.com , the first in Download Now in the Livres-Books Section and the second in the same Section.
f) Finally, it may be useful to indicate what the ideal health-care model would be. The percentages of the sector in term of GDP show that the system is more rational, more effective and much less expensive when it is public.
(Public regimes are less costly but powerfully contribute to macro-economic competitiveness which in turn supports micro-economic productivity. In the EU member States, public health-care in the 1970s, when it was working at its best, amounted to 9 % of GDP and all were covered; but it did cost 15 % of GDP for the wasteful American private system which left 47 million citizens without any coverage. I must add that Obamacare is even more wasteful and still leaves more that 30 million out. This is because the reform was implemented to please Big Pharma and was thus carefully framed under freedom of commerce clause; of course, the courts used it to quickly dismantle most parts of it. The Federal government could had used its « power of the purse » to create less expensive, collectively paid and universally accessible system thus depriving the Courts of the power to meddle with the general interest of the nation on behalf of the rich. Does anyone remember FDR and his willingness to « send the court packing » if it uselessly opposed his New Deal Social Security reforms? )
In the current context, the public system is often insidiously manipulated and managed to become dysfunctional in order to legitimize its privatization. The national and regional examples are manifold. It suffices to mention the recent disappearance of around 50 million euros in Calabria Verde without anyone noticing (!), in order to understand the trick. In other words, when a public system does not work, just send all the managers home and reorganize it to make the system operational and efficient again without privatizing it. In this way, you avoid having to face the huge waste induced by the private system and the tragic transformation of users into customers.
That said, the public health-care system should follow the following strategic lines:
First and Second levels.
The first level is the one on the front line: it includes medical offices and laboratories. It is well understood that the first line clinics should not be confused with the emergency wards. With socialized medicine, doctors can easily be grouped together by making available to them first-line laboratories and classical x-rays for their front-line neighbourhood clinics. This would favor preventive medicine. In addition, we know that the medical profession is among the first to most likely use new technologies, including for epidemiological and prescriptions monitoring. The centralization of this information with due respect for privacy would allow better national and regional planning. Furthermore, it would favor research: in fact, the databases thus constituted would be of great use for general practitioners which would also specialize in epidemiological research, turning them into experts on the ground. This implies that working hours, those reserved for patients and those for research should be taken into account. Everything could then be coordinated at university level, not only nationally but internationally.
The second level would include what the PdR calls Hub, Spoke and general hospitals without forgetting the hospitals in mountainous regions or those located in less accessible islands. It is not necessary to close the hospital of San Giovanni in Fiore with its important Sila basin only to increase the profitability of certain private hospitals located in the nearest large cities, but difficult to access in less than 60 minutes by ambulance. Especially in winter time, our Sila region being aptly describe as the Norway of the Mediterranean Sea … We specify that the helicopter rescue is necessary but cannot justify the closure of mountain hospitals because the helicopter cannot always take off. In the mountain regions or at sea, turbulence is often important, not to mention the winter conditions. The problem experienced by crowded emergency wards cannot be solved with the artificial and dissuasive long waiting periods, contrary to the spirit of the system, not to mention the Hippocratic Oath. Just provide a good emergency triage in hospitals and provide a first-line clinic such as describe above alongside and equipped with a first-line labs and x-rays facilities. In this way, it would take care of the patients and their illness and discomfort while favoring the establishment of a database relating to this type of visits. Preventive medicine should also be concerned by these symptoms and the social tensions they manifest. To solve real or presumed problems one must first study their genesis.
Develop research and gerontology, geriatrics and home maintenance services. The population ages. Home maintenance, in addition to preserving the autonomy of seniors, costs much less. Therefore, the distribution of hospitals on the territory cannot disregard specific basins to be served very quickly, particularly in mountainous areas and islands. It should be stressed that tourism is an important investment: in fact, depending on the available infrastructures, the sector multiplier is around 4 or 7 euros for one euro invested. Seniors make up a large portion of the tourist clientele. Furthermore, given general aging, geriatric treatments will represent over 4% of world GDP, a source to be exploited.
The lack of socialization of pharma-care and drugs, with payment of doctors for each medical acts instead of a montly fee, remains one of the most expensive items in the health-care system. The choice of private health and insurance funds are much more expensive because it does not respond to the pure social mutualising logic; instead, it opposes to this the optimization of dividends for shareholders in medical clinical and hospital businesses. Furthermore, it is antithetical to today’s logic of the generalization of precariousness. Precariousness decreases social contributions and general tax revenues. This also applies to the ticket eupheministically called moderating tickets. We repeat that the Obamacare’s predictable and already noticeable bankruptcy was precisely due to the choice made to favor Big Pharma and the big insurance companies.
As a transition, before reaching the total socialization of the drug policy, one can think of extending the use of generics and of favoring the introduction of new latest generation drugs when these are considered efficient hence necessary, but do so at an almost generic price. We addressed that topic above. This can be done by negotiating volumes of purchases for a fixed period – thus insuring guaranteed revenues for pharmaceutical companies, in addition to huge savings on marketing etc. To this would be added adequate compensation for the financing of their R&D activities, the nerve of the “war” in this domain. It should be emphasized that sovereign States have the right, enshrined in the World Health Organization, to suspend patents in the event of a social emergency. In short, if the State decides to protect the health of its citizens, pharmaceutical companies have an interest in negotiating in good faith. (Note added on June 15, 2016: see the important article by Médecins du monde and their petition to be emulated in Italy: Prix des médicaments : la campagne que les labos ne veulent pas voir Entretien réalisé par Alexandre Fache Lundi, 13 Juin, 2016, L’Humanité http://www.humanite.fr/prix-des-medicaments-la-campagne-que-les-labos-ne-veulent-pas-voir-609422 )
The same thing can be said for the socialization of medical and hospital equipment given the important percentage of public money spent in the sector. In other words, defending a leading industrial sector, and moreover a sector that needs a workforce that is often highly qualified and therefore inclined to give young people outlets worthy of their interest and of their scientific and technological curiosity.
Paul De Marco, former professor of International Relations – International Political Economy
NOTE:
1 ) HealthTumori così la crisi economica ha fatto aumentare la mortalità, According to the research the economic crisis has increased the cases of cancer.Between 2008 and 2010 there were over 260 thousand more deaths from cancer in OECD countries and around 160 thousand in the European Union. But it is a phenomenon not limited to that two-year period: as unemployment grows, the victims increase. Unless healthcare is universal. The research published in The Lancet, by TINA SIMONIELLO 26 May 2016, http://www.repubblica.it/salute/medicina/2016/05/26/news/mortalita_per_cancro_e_crisi_economica_una_relazione_pericolosa-140584166/?ref=HREC1-4
2) Vedi in http://www.washingtonpost.com/blogs/wonkblog/post/did-the-stimulus-work-a-review-of-the-nine-best-studies-on-the-subject/2011/08/16/gIQAThbibJ_blog.html ; See also http://www.letemps.ch/Page/Uuid/49105d0e-c67f-11e4-959d-74804f4bcbe7/La_bonne_et_la_mauvaise_austérité (These links were provided by Jean-Charles in the site of G. Ugeux on March 11, 2013). See also: « La commission européenne de plus en plus keynésienne ! » Crédits : Reuters) Ivan Best | 05/03/2015, 10:02 – 1396 mots http://www.latribune.fr/actualites/economie/union-europeenne/20150304tribcdbd1e118/la-commission-europeenne-de-plus-en-plus-keynesienne.html. e http://www.la-commune-paraclet.com/EPI%20TWOFrame1Source1.htm#feddilemma .The extroversion of the Multiplier is one of the elements that I have been emphasizing for some time, for example in my “Tous ensemble” (1998) and in my “Keynesianism, Marxism, Economic Stability and Growth” (2005); previously Livre I and Livre III in Download Now, Livres-Books Section of the website www.la-commune-paraclet.com
3) USA vs OECD http://www.oecd.org/unitedstates/Health-at-a-Glance-2015-Key-Findings-UNITED-STATES.pdf
4 ) http://regione.calabria.it/sanita/allegati/piano_di_rientro.pdf and http://www.salute.gov.it/portale/temi/p2_6.jsp?id=1993&area=pianiRientro&menu=calabria
5 ) http://www.salute.gov.it/imgs/C_17_pubblicazioni_1224_alached.pdf (2013)
6 ) http://regione.calabria.it/sanita/allegati/piano_di_rientro.pdf , p 15
7 ) Idem, p 17.
8 ) Health 2016 06 08 Censis 11 milioni di italiani hanno rinunciato alle cure. Pesano le liste d’attesa. They are two million more than in 2012. Almost a quarter of the elderly skip or postpone exams and therapies. Private spending increases by 3%. 08 June 2016 http://www.repubblica.it/salute/2016/06/08/news/censis_11_milioni_di_italiani_hanno_rinunciato_alle_cure_nel_2016-141551883/?ref=HREA-1
9 ) Commissario Ausiliare del giudice che ne dispone l’investitura (ecco il blocco sugli aspetti penali) (see http://www.gazzettaamministrativa.it/opencms/opencms/_gazzetta_amministrativa/_permalink_news.html?resId=4fe7423c-a9fa-11e2-8ddc-5b005dcc639c ) e https://it.wikipedia.org/wiki/Commissario_ad_acta e http://www.spiaaldiritto.it/articolo.php?id=236
11 ) See von Mises Socialism https://mises.org/library/socialism-economic-and-sociological-analysis. The fascist Jewish-Austrian von Mises says that the public health system creates illnesses which otherwise is just a matter of psychological and Willpower. (p 475-476 etc.) In fact, with a life expectancy of around 40 years, half a billion Dalits comrades in India do not have the luxury of being able to get sick … Today in the West, von Mises’ rabbinic-Nietzschean disciples do their best to abolish illnesses by abolishing public health-care !!! For von Mises, any kind of State interventionism was considered a form of socialism, including the efficient German war planning during the First World War, in addition to Keynesianism and economic regulation-regulation theories.
13) http://formiche.net/2015/02/22/inps-pensioni-previdenza-assistenza/ e http://rivincitasociale.altervista.org/la-500-scassata-di-boeri-ed-il-miracolo-pensionistico-della-precarieta/
14) Vedi le critiche al Jobs Act in questo medesimo sito. Vedi pure la « Guida al Jobs Act. CGIL » http://www.fisac-cgil.it/wp-content/uploads/2015/04/Guida-Jobs-Act.pdf
15) L’Articlo 99 della Costituzione che sanciva il CNEL viene cancellato dalla contro-riforma renzi-gutgeldiana. Vedi gli articoli sulla controriforma in questo medesimo sito.
16) « Una economia per l’1% », Oxfam 2016, http://www.oxfamitalia.org/wp-content/uploads/2016/01/Rapporto-Oxfam-Gennaio-2016_-Un-Economia-per-lunopercento.pdf e Poletti: “Reddito minimo di 320 euro al mese per un milione di poveri con minori”(ansa) http://www.repubblica.it/economia/2016/02/01/news/giuliano_poletti_il_ministro_del_lavoro_spiega_il_piano_per_gli_indigenti_e_conferma_l_impegno_del_governo_a_dare_fles-132453506/?ref=HREC1-1
17) POR Tasso di occupazione (2007-2013, p 2/150 = 44,5 % http://regione.calabria.it/calabriaeuropa/allegati/prog_2007_2013/por_fse/por_calabria_fse_2007_2013.pdf ; POR Tasso di occupazione (2014-2020, p 13 = 2013 39,0%. http://www.regione.calabria.it/calabriaeuropa/calabriaeuropa/images/archivio/Programme_2014IT16M2OP006_1_3_it.pdf