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oggi è il: 20|12|2014


No alla trasformazione degli ospedali in fondazioni
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Negli ultimi mesi con crescente insistenza le decisioni sugli attuali assetti istituzionali nel settore della sanità hanno evidenziato un orientamento legislativo promosso dall’attuale governo di centro destra teso al superamento degli enti o aziende pubbliche per la gestione delle funzioni pubbliche individuate dalla legge, in vista di una progressiva e generalizzata affermazione della fondazione.

La prima esperienza in Lombardia si è avuta con la depubblicizzazione delle ex II.PP.AA.BB, ipotesi prevista dai decreti attuativi della legge 328/2000 ma che in Lombardia, specialmente per responsabilità della legge regionale di attuazione che scoraggiava la trasformazione in aziende pubbliche di servizi alla persona, ha finito con vedere la trasformazione di oltre il 90% dei vecchi enti in fondazioni. Sul fronte della sanità la regione Lombardia ha previsto nel PSSR (Piano del Servizio Sanitario Regionale) la possibilità di sperimentare la trasformazione in fondazione di alcuni ospedali; a questa previsione si è aggiunto il decreto di Sirchia che prevede la possibilità di trasformare in fondazioni gli attuali istituti di ricerca e cura a carattere scientifico (IRCCS) e per questa via si è già dato corso alla fondazione Policlinico. Per quanto riguarda invece la sperimentazione prevista dal piano sanitario regionale, è in corso un’esperienza di fondazione ospedaliera a Mantova, ma numerose altre ipotesi fanno capolino sui giornali e nei confronti politici e sindacali a livello locale in diversi territori della Lombardia. Premesso quanto sopra, dal mio punto di vista la scelta di trasformare gli ospedali in fondazione, non solo è sbagliata ma è pericolosa per l’universalismo che, ad esempio, tutto il centro sinistra dichiara di voler difendere; universalismo che per continuare ad esistere in Italia, dato che il nostro sistema si fonda sulla fiscalità generale, deve basarsi sulla responsabilità diretta delle istituzioni pubbliche, cosa che verrebbe meno con le fondazioni essendo soggetti di diritto privato. Vediamo perché. La fondazione è, come accennato, un soggetto di diritto privato che ha come fine l’utilizzo di un patrimonio, che deve peraltro autoalimentarsi, in vista del raggiungimento di uno scopo. Questo vincolo, tra mezzi e fini, garantisce che le risorse messe a disposizione della fondazione siano impiegate esclusivamente per realizzare gli scopi prefissati nello statuto, ma lo statuto non potrà mai prevedere - non essendo connotata alla sua natura privatistica - il perseguimento di uno scopo generale ed astratto come il diritto alla salute posto in capo alla generalità dei cittadini direttamente dalla Costituzione.

A bene osservare, con le fondazioni verrebbe nei fatti a determinarsi una situazione quo ante alla riforma del 1978, che ha originato il Servizio sanitario nazionale proprio per realizzare la promessa costituzionale di un diritto sociale universale alla salute, cosi come posto dall’art. 32 Cost. Nella situazione precedente alla riforma le cure nella generalità dei casi erano garantite da diversi istituti nazionali con un’assicurazione obbligatoria per le diverse categorie di lavoratori pubblici e privati (INAM, INADEL, ENPAS, ecc...), una situazione ereditata in parte dal precedente regime fascista, che sarà definitivamente superata solo con l’istituzione del Servizio sanitario nazionale, perché è in quel contesto che si opererà la saldatura tra le previsioni del legislatore costituzionale del 1947 e il legislatore ordinario del 1978, quando il diritto alla salute è affermato come diritto sociale universale gratuito per l’insieme dei cittadini a prescindere dalle condizioni personali di ciscuno. Le fondazioni romperebbero in buona sostanza proprio il filo di continuità che lega il dettato costituzionale alla L. 833/78: il diritto alla salute previsto dall’articolo 32 della Cost., visto in combinazione con l’art. 3 che afferma il principio generale di uguaglianza dei cittadini. Un diritto alla salute che si definisce in astratto, non vincolato dalle risorse disponibili, come inevitabilmente avverrebbe invece se si procedesse alla trasformaszione delle attuali aziende pubbliche (enti pubblici a tutti gli effetti, in quanto ad esse si applica il regime giuridico e fiscale di diritto pubblico) in fondazione. Ciò produrrebbe come accennato una definitiva separazione tra il fine generale posto dalla Costituzione, che in quanto tale non è in alcun modo limitabile e per questo perseguibile solamente con un sistema universalistico, ma che in quanto fondato per il reperimento delle risorse sulla fiscalità generale, riconduce esplicitamente anche all’art. 53 della Cost. ove stabilisce che il finanziamento delle funzioni pubbliche debba essere posto in capo ai cittadini secondo il principio di proporzionalità e progressività, realizzando in questo modo una saldatura tra mezzi e fini che si concretizza nella inscindibilità tra Servizio sanitario nazionale e responsabilità istituzionale pubblica diretta a tutti i livelli istituzionali che sono chiamati ad assicurare la promozione della salute. Non a caso con la definizione dei livelli essenziali di assistenza (LEA) non si opera una limitazione del diritto, ma si stabilisce per tutti i cittadini la misura uniforme massima per tutto il territorio nazionale - misura massima e non minima come pretende la regione Lombardia -. E non a caso i LEA restano competenza esclusiva dello stato, in una accezione peraltro da intendere, a mio parere, vicina al principio dell’art. 3 Cost. più sopra richiamato, che affida alla Repubblica e non semplicemente agli apparati dello stato le garanzie di uguaglianza, di sviluppo e di tutela della persona umana. A proposito di tutto quanto ho provato ad evidenziare, trovo sorprendentemente deboli talune posizioni che anche nel centro sinistra individuano nella fondazione un’occasione per sopperire ai limiti dell’attuale legislazione (per ultima lo stesso D.lgs 229/98) in materia di partecipazione democratica e precipuamente degli enti locali territoriali. Il problema esiste ma la scelta della Fondazione, con la quale in taluni casi si pensa di poterlo risolvere, non dà assolutamente garanzie sul piano istituzionale, corrisponde forse ad uno slancio pragmatico, che tuttavia rischia di allontanarci pericolosamente dal costituzionalismo democratico, cui i principi della legge 833/78 sono ispirati chiaramente. Salvo che l’inversione operata dal centro destra a proposito di sussidiarietà, con il progetto di legge regionale in Lombardia e con il nuovo art. 118 della Costituzione con la revi-sione costituzionale in corso, non diventino definitivamente operanti, poiché in quest’ultima ipotesi le fondazioni alla pari di numerosi altri soggetti assumerebbero il potere di esercitare funzioni pubbliche, addirittura in via prioritaria rispetto alle istituzioni pubbliche, ma il "pubblico non statale" di Formigoni non è un mezzo per integrare la gestione dei servizi bensì una diversa concezione dello Stato. In realtà la principale attenzione di tutti coloro che considerano una priorità la difesa del servizio sanitario nei suoi fondamenti costitutivi, dovrebbe essere orientata a prevenire i rischi che investono tutti i sistemi di protezione di tipo universalistico. Innanzittutto individuando la natura delle varie insidie in atto contro il Servizio sanitario nazionale, e indicando contestualmente i modi di difenderlo da tali insidie e la fondazione, a ragion veduta, rientra tra queste.

Giuseppe VANACORE**Segretario regionale CGIL Lombardia.


Articolo pubblicato sul volume 157-158 della rivista Medicina Democratica
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