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The challenge to welfare is longevity

Caring for elderly people who are dependent and frail is a sector of healthcare that was deeply impacted in 2020 and 2021. When the pandemic struck a severe crisis was already underway, stemming from the inner characteristics of this sector. The long-term care (LTC) sector was fragmented and under-financed. What’s more, in many regions norms and regulatory frameworks were out of date, and had not yet been adapted to respond to demographic, social and epidemiological changes. But the demographic issue is what many experts point to as the future time bomb that will explode Italy’s welfare system, affecting pensions, long-term care and healthcare in general. 


The question of aging is not just about pensions and monetary benefits: in-kind services, case management and more broadly caregiving are all critical, especially in light of estimates telling us that already today, 28% of over-65s are not capable of living autonomously and need daily care. For the time being, families are helping out using their own means, but state welfare with universal ambitions like in Italy cannot fail to address this social issue.  


Covid-19 played a part in revealing the criticalities of the LTC sector and can also be credited with igniting a general debate on services for the elderly, nursing homes in particular, and on the changes and investments that are needed. After sweeping collective awareness raising stemming from the Covid-19 deaths in nursing homes (known as RSAs in Italy), we expected – and prepared for – a major sector overhaul to start. 


Given the sector’s characteristics, the areas where change and investments were – and still are – needed (in terms of innovation and financial resources) can be summed up as follows: creating or reinforcing a network bringing together various community-based services for older adults (integrating healthcare, social services and housing); innovating service models by diversifying them to meet current heterogeneous needs; revising levels of national, regional and local financing and relative governance; implementing initiatives and policies to take on more care personnel, to revise roles and responsibilities, and to focus on structured industrial policies; and leveraging technology, to include prevention and active aging initiatives. 


But how many of these priorities have received a response from policy makers and been incorporated into current reform initiatives? 


In Italy’s investment package in the National Recovery and Resilience Plan (PNRR), the word “elderly” appears 23 times, mainly in reference to social challenges and the need to ensure support for people who are dependent. The plan outlines the rights of older adults with disabilities within the context of caregiving.  


But these are statements of intent. The most concrete points have to do with the role of care homes as outlined in Mission 6 (where the elderly are one of the potential user targets), and long-term care reform, which is one of the binding requirements for the disbursement of funds by the EU.  


The PNRR does address the social challenges that older adults are facing today, but this is confused with the question of disabilities. The elderly are also briefly mentioned in relation to caregivers and support for families, but as before within the sphere of statements of intent and principles. No specific actions ensue, except for those that serve to achieve other objectives. For example, Mission 5 talks about financing for urban development and renewal as this pertains to remodeling houses or building living facilities for the elderly; Mission 6 touches on the needs of the elderly concerning community care homes.   


The issue of long-term care was also included among the structural reforms envisaged by the PNRR and is one of the binding reforms concerning the disbursement of funds. This implies that by 2023 the government in office will have to ratify a law reforming the sector.  


In September, the National Long-Term Care Plan was updated, setting out the policy lines for three years (from 2022 to 2024), specifying the areas of innovation, and presenting the allocations of the National Long-Term Care Fund for the period. The value of the plan centers on programming, not decision-making, so there is no guarantee that the content will actually materialize (to include the forecasted resources earmarked for the Fund itself), but it does lay down policy guidelines. In this sense, the most interesting provisions of the plan are: the introduction of levels of assistance in social care, the intention to promote a national information system, and the idea to renovate institutional governance and service access for citizens. 


In October, a draft law for the LTC reform was presented and approved. This document does not yet constitute an actual reform act, but it is the first version (which is binding in terms of objectives). This draft law will have to be completed and then passed by the government that will be in power in 2023. The main provisions are: a proposal to reallocate (at national, regional and local levels) the powers of policy-making, regulation, financing and control of the sector under what is called the National LTC System; a focus on a new type of in-home care; and cash allowances (from restructuring the current social security companion benefits). 


After about two years, actual (and potential) results still have a long way to go to meet initial expectations. Concerning the interventions envisaged by Mission 6 - integrating dependent people into the local health service value chain - the public and private companies that deal with the elderly have not been included in planning and opening community homes or community hospitals (except in specific areas of the country). In many regions, the process is still ongoing, but the decisions taken up to now have left no room for this sector. The “investment game” was played exclusively on the issue of building infrastructure to replace the RSA model (Mission 5) – at least in theory. But in concrete terms, twelve months have passed since the PNRR was issued, and this type of intervention has been very limited. Moreover, what has been done has only benefitted RSAs owned by companies or public bodies. The investments earmarked for innovation and expanding service availability for the elderly have been called inadequate by many, who say that interventions do not respond to the actual needs of the population. 


As for the national reform, introduced as a cornerstone of the PNRR, we are still very far from coming up with implementation methods. The reform itself is strongly oriented toward establishing principles that can be embraced by all, as they are general – but equally generic. 


So where are we at right now? At a standstill? After the declarations and enthusiasm of 2021, marked by high expectations about the innovative potential of the PNRR as far as the elderly were concerned, 2022 was the year of disappointment when we realized that public and private companies in the sector have not actually been affected by the PNRR lines activated up to this point.  

Expectations remain for the future, but there is no doubt that as of today the PNRR has not helped increase or enhance the LTC sector (and truth be told, as we explained above, this was never one of the plan’s objectives). For the coming year, however, we can hope that efforts will be made, in line with the objectives of the reform, to: provide clear indications with respect to which innovative services should be promoted and integrated into the network of healthcare offerings; draw up a framework (lacking up to now) to serve as a national standard to guarantee fair access to services; open a round table on the future of companies in the sector and in particular on their economic sustainability and the crisis of healthcare professionals.