Pensions, Health Care and Long-term Care in Italy : Asisp Annual National Report, 2013

Following the major reforms adopted in 2009-2011, since 2012 only minor amendments have been introduced in the pension sector, but changes in pension parameters have resulted from the implementation of the latest 2010 and 2011 reforms (Sacconi and Fornero reforms). These aimed at reducing expenditure in the short-medium term by means of both measures directed to shorten previously introduced transition periods and quick implementation of much stricter eligibility conditions (section 2.1.3). Combined with the introduction of the NDC systems in 1995, most recent reforms have put the Italian pension system on a sound path with regard to financial sustainability. Actually, the fast implementation of tighter eligibility conditions jointly with the presence of three “automatic stabilizers” of pension expenditure are expected to cushion the impact of demographic transformation in the next decades. Consequently, Italy is one of the few countries in Europe where public pension expenditure is projected to decrease in 2010-2060 (section 2.2.2). The recent pension debate has thus mostly focused on the social sustainability of recent reforms (sections 2.2.2 and 2.3), the challenges implied by the latter (section 2.2.2), as well as the adequacy and the fairness of the pension system both in the short and the long run (sections 2.2.1 and 2.3). Since the onset of the crisis the issue of the economic sustainability of the health care system has become central in Italy. Almost the whole debate about the NHS transformation has been monopolized by this issue. The necessity for cost-containment and the search for more efficiency does not come only from the need to improve the economic performance of the NHS, but also (and mainly) from the need to face the huge public debt. The reform targets in the most recent years have been mainly the following: increases in co-payments; more control on drugs and pharmaceutical expenditure; cuts in the expenditure for health care related goods and services; restructuring of the hospital care provision with the aim of reducing the number of hospital beds; a relatively strong freeze in terms of health care personnel salary increases and, also, in terms of new hiring. Cuts in health care public expenditure were clearly visible in 2009-2012: the annual growth rate of expenditure in public health care in real terms was on average -0.7% between 2009 and 2012. The financial sustainability of the NHS does not seem at risk from a strictly economic point of view, if expenditure remains under control as it has been in the last decade. However a series of problems might impoverish the quality and the performance of the system in the near future and some of them are already doing so. These problems are linked to: inequalities in the access, related to territorial as well as social class differences; long waiting lists and increasing co-payments; the aging of the workforce and the choices made in terms of its management (not particularly high salary levels, freezing of salaries, etc.). In terms of performance the Italian NHS has been able in the last decade to keep the pace of transformation in terms of performance as the other main Western European health care systems. In comparison with major reforms introduced in the last two decades in many EU countries (for example: Germany, France, Spain, the Czech Republic, etc.), there have been no major policy changes in the Italian Long Term Care system. Overall the Italian LTC seems a system that so far has been able to invest a consistent amount of resources, at least in line with many other EU countries, but obtaining partially sub-optimal results. The strong role of uncontrolled cash allowances, the relative limited diffusion and coverage of professional (residential and home) services, the diffusion of migrant care work (often irregular), the absence of any selective universalism in order to partially restrict access to cash allowances to those in need both in terms of dependency but also economic resources, are elements that make the whole system not cost-effective, with limited quality and partially unfair.