JUDGMENT NO. 153

YEAR 2024

ITALIAN REPUBLIC

IN THE NAME OF THE ITALIAN PEOPLE

THE CONSTITUTIONAL COURT

composed of:

President: Augusto Antonio BARBERA;

Justices: Franco MODUGNO, Giulio PROSPERETTI, Giovanni AMOROSO, Francesco VIGANÒ, Luca ANTONINI, Stefano PETITTI, Angelo BUSCEMA, Emanuela NAVARRETTA, Maria Rosaria SAN GIORGIO, Filippo PATRONI GRIFFI, Marco D’ALBERTI, Giovanni PITRUZZELLA, Antonella SCIARRONE ALIBRANDI,

has delivered the following

JUDGMENT

in the constitutional legitimacy proceedings of Article 47 of the Law of the Liguria Region, 28 December 2023, no. 20, containing "Provisions connected to the stability law of the Liguria Region for the financial year 2024 (Provisions for the formation of the 2024-2026 budget)", initiated by the President of the Council of Ministers with an appeal notified on 27 February 2024, filed in the registry on 4 March 2024, registered under no. 10 of the 2024 appeals register, and published in the Official Gazette of the Republic no. 15, first special series, of the year 2024.

Having seen the act of constitution of the Liguria Region;

Having heard in the public hearing of 3 July 2024, the reporting Judge Antonella Sciarrone Alibrandi;

Having heard the State Attorney Fabrizio Fedeli for the President of the Council of Ministers and the attorney Francesco Saverio Marini for the Liguria Region;

Having deliberated in the deliberation chamber of 3 July 2024.

Considered in fact

1.‒ With an appeal filed on 4 March 2024 (reg. app. no. 10 of 2024), the President of the Council of Ministers, represented and defended by the State Attorney General, challenged Article 47 of the Law of the Liguria Region, 28 December 2023, no. 20, containing "Provisions connected to the stability law of the Liguria Region for the financial year 2024 (Provisions for the formation of the 2024-2026 budget)”, with reference to Articles 3, 117, second paragraph, letter l), and third paragraph, of the Constitution.

1.1.‒ The appellant challenges, first and foremost, paragraph 1 of the aforementioned Article 47, which provides that, on a transitional basis and until 2025, healthcare managers employed by the Regional Health Service (SSR), who have opted for the exercise of intramural private professional activity (ALPI), may operate in private accredited healthcare facilities, even partially, with the same SSR.

The regional provision would be in contrast with the fundamental state principles regarding the protection of health, which can be inferred, in particular, from Article 1, paragraph 4, of Law no. 120 of 3 August 2007 (Provisions on intramural private professional activity and other regulations on health matters), according to which the ALPI must be exercised in internal or external outpatient facilities of the healthcare company, public or private non-accredited, with which the company stipulates a specific agreement.

The appellant states that, according to the constant case law of the Constitutional Court, the provisions relating to the performance of intramural private professional activity, although suitable to simultaneously affect a plurality of matters, must still be attributed, primarily, to the matter of health protection. The close connection with the organization of the Regional Health Service and with healthcare services ‒ which are in turn conditioned, in many respects, by the capacity, professionalism, and commitment of all health professionals assigned to the services and, in particular, those holding an apical position ‒ would be a relevant element for the purposes of attributing the regulation of the ALPI to the matter of health protection. Such regulation, aimed at ensuring that the option made by the health professional in favor of the exclusive employment relationship with the SSR does not remain without consequences, would constitute the expression of a fundamental principle, with the specific purpose of ensuring a tendency towards uniformity between the different legislations and the healthcare systems of the regions and autonomous provinces with regard to a qualifying aspect of the relationship between health and users (the judgments of this Court no. 371 and no. 86 of 2008 and no. 50 of 2007 are cited). Even the regulation of the subjective profile of intramural activity would have the nature of a fundamental principle of the matter, being aimed at defining one of the most qualifying aspects of the healthcare organization, namely the identification of the subjects entitled to carry out the private profession within the healthcare facility, an aspect that requires uniform regulation throughout the national territory (the judgment no. 54 of 2015 of this Court is cited).

The appellant further states that, at the state level, the intramural private professional activity of doctors and healthcare managers is the subject of a detailed regulation, dictated "[in] order to guarantee the correct balance between institutional activity and intramural private professional activity" (Article 22-bis, paragraph 4, of Decree-Law no. 223 of 4 July 2006, containing "Urgent provisions for economic and social recovery, for the containment and rationalization of public spending, as well as interventions in tax revenue and the fight against tax evasion", converted, with amendments, into Law no. 248 of 4 August 2006).

The same need would also inspire the regulation concerning the "extended intramural" activity (i.e., the ALPI carried out in external substitute spaces of the company). The State Attorney General observes that all the provisions that have allowed it have underlined the exceptional and temporary nature of the use of substitute spaces outside the healthcare company, including professional offices (Article 3, paragraph 1, of Legislative Decree no. 254 of 28 July 2000, containing "Corrective and integrative provisions of Legislative Decree no. 229 of 19 June 1999, for the strengthening of the facilities for the private professional activity of healthcare managers", as subsequently amended). In particular, the appellant recalls that Article 22-bis, paragraph 3, of the aforementioned Decree-Law no. 223 of 2006, as converted, has reiterated the authorization for the use, on an extraordinary basis and subject to company authorization, of professional offices for the exercise of ALPI, the use of which is permitted by the legislator, on an extraordinary basis, within time limits that have been extended several times.

In the same perspective, Decree-Law no. 158 of 13 September 2012 (Urgent provisions to promote the country's development through a higher level of health protection), converted, with amendments, into Law no. 189 of 8 November 2012, by replacing the first and second periods of paragraph 4 of Article 1 of Law no. 120 of 2007, had also provided (in Article 2, paragraph 1, letter b) ‒ the appellant further recalls ‒ that the extraordinary survey of spaces to be dedicated to the ALPI was to be completed by 31 December 2012, and that outpatient spaces were also to be acquired through the purchase or lease at authorized, albeit still non-accredited, healthcare facilities, as well as through the stipulation of agreements with other public entities.

The prohibition of carrying out intramural private professional activity at accredited private facilities, as referred to in Article 1, paragraph 4, of Law no. 120 of 2007, would, on the other hand ‒ as emphasized by the appellant in the memorandum filed in the immediacy of the public hearing ‒ be a corollary to the principle of the uniqueness of the employment relationship of doctors employed by the National Health Service, sanctioned by Article 4, paragraph 7, of Law no. 412 of 30 December 1991 (Provisions on public finance), and aimed at preventing the emergence of a conflict of interest between the National Health Service and the accredited healthcare facilities, and at guaranteeing maximum efficiency and operational functionality to the public healthcare service.

Therefore, Article 47, paragraph 1, of the Liguria Regional Law no. 20 of 2023 would determine an unlawful extension of the scope of operation of the ALPI, allowing it to be carried out also in private accredited healthcare facilities, albeit partially, with the SSR.

1.2.‒ Paragraph 2 of the same Article 47 of the aforementioned regional law would also be in contrast with the fundamental principles established by the state legislator in the matter of health protection.

This provision, in fact, establishing, on a temporary basis and to reduce waiting lists, that the healthcare companies, bodies, and institutions of the SSR are authorized, until 2025, to acquire from their healthcare management employees in an exclusive employment relationship, individually or as a team, healthcare services under the intramural private profession regime pursuant to Law no. 120 of 2007 "also in the manner referred to in paragraph 1", would be in contrast with Article 15-quinquies, paragraph 2, of Legislative Decree no. 502 of 30 December 1992 (Reorganization of the regulation in health matters, pursuant to Article 1 of Law no. 421 of 23 October 1992) and with the provisions of Law no. 120 of 2007, which would not provide for the possibility for the SSN companies to purchase services provided under the ALPI regime by their healthcare managers.

Not only would the principle established by the state legislator be violated, according to which the intramural private profession must be characterized by the direct choice, by the user, of the individual professional to whom the service is requested, with costs borne by the assisted person, but the provision of the possibility for public healthcare companies to purchase healthcare services from their healthcare managers, under the intramural private profession regime, even at private accredited healthcare facilities, would reiterate the violation of the fundamental principle deriving from the interposed state legislation (Article 1, paragraph 4, of Law no. 120 of 2007), according to which the ALPI can only be exercised in internal or external outpatient facilities of the healthcare company, public or private non-accredited, with which the company stipulates a specific agreement.

1.3.‒ Consequently, paragraph 3 of the same Article 47 of the Liguria Regional Law no. 20 of 2023 would also be constitutionally illegitimate, which attributes to the Regional Council the task of establishing, with its own resolution, the criteria and procedures for carrying out the private professional activity "referred to in paragraph 2", as well as "the economic valorization of the private professional activity to be paid, per service, to professionals". This provision, in fact, according to the President of the Council of Ministers, would be destined to lapse as a result of the declaration of the constitutional illegitimacy of paragraph 2, to which it refers.

1.4.‒ With specific reference to paragraph 1 of the challenged Article 47 of the aforementioned regional law, the appellant also identifies a violation of the exclusive state legislative competence in the matter of civil law (ex Article 117, second paragraph, letter l, of the Constitution). The aforementioned paragraph, impacting on already existing employment relationships and determining, in detail and with immediate effects, essential and qualifying aspects, would realize an undue substitution of the source of regulation of the employment relationship, identified by state law in collective bargaining, conflicting with the rules of the national collective labor agreement signed on 23 January 2024, relating to healthcare management, which, in particular in Article 89, paragraph 1, letter c), establishes that the exercise of private professional activity must take place outside of the service commitment and only in facilities of another SSN company or of another non-accredited healthcare facility, subject to an agreement with the same.

1.5.‒ The entire Article 47 of the Liguria Regional Law no. 20 of 2023 is, finally, challenged for violation of Article 3 of the Constitution, since, by expanding the scope of operation of the ALPI for healthcare managers employed by the Ligurian SSR, it would frustrate the needs for uniformity underlying the state regulation of the intramural private profession, giving rise to an unreasonable disparity of treatment compared to the medical healthcare personnel who work in other regions.

2.‒ The Liguria Region was constituted in the proceedings and requested that the appeal be declared inadmissible and in any case unfounded.

2.1.‒ Firstly, the respondent considers the alleged violation of Article 117, third paragraph, of the Constitution, with regard to the matter of health protection, by Article 47, paragraph 1, of the Liguria Regional Law no. 20 of 2023, to be without foundation, since no fundamental principle would be inferred from the current state legislation that prohibits the finding of spaces for carrying out intramural activity at private facilities accredited with the SSN.

This principle would not be derived, in fact, either from Article 22-bis of Decree-Law no. 223 of 2006, as converted, which would merely extend the possibility of the extraordinary exercise of intramural private professional activity in professional offices on a transitional basis, or from Article 15-quinquies of Legislative Decree no. 502 of 1992. The main object of the latter provision would, in fact, be the provision of the right of the healthcare manager, who has opted for the exclusive employment relationship with the SSN, to carry out professional activities outside working hours and within the company facilities.

Finally, Article 1, paragraph 4, of Law no. 120 of 2007, as amended by Article 2, paragraph 1, letter b), of Decree-Law no. 158 of 2012, as converted, evoked by the appellant as an interposed parameter, would allow the regions to find spaces suitable for the exercise of intramural activity both at private non-accredited facilities, but still authorized (and therefore in possession of the minimum technical and structural requirements required by law), and ‒ subject to an agreement ‒ with "other public entities", among which would also be included the facilities accredited with the SSN, as part of the public health service, in line with the latest National Plan for the Governance of Waiting Lists for the three-year period 2019-2021.

In any case, even if the aforementioned prohibition was deemed to exist, it could not in any case constitute a fundamental principle of the matter "health protection", pursuant to Article 117, third paragraph, of the Constitution, as such binding and non-derogable by the regions. The choice of the most suitable instruments to ensure the finding of premises necessary for carrying out intramural activity would, in fact, fall within the regional legislative competence of detail.

Nor would there be the hypothesis of a detailed regulation in a relationship of coessentiality and necessary integration with the principle rules that characterize the sector. In fact, the prohibition of carrying out intramural activity in suitable premises at accredited private facilities would not at all guarantee the objective of making effective and concrete the right to carry out intramural private professional activity following the option of the healthcare manager for the exclusive relationship. Such a prohibition would, on the contrary, in the event of the absence of further adequate spaces, constitute an unjustified limitation of the same fundamental principle that one would want to guarantee.

The regional legislative intervention would not only be compatible with the legislative power of detail in the matter of health protection, pursuant to Article 117, third paragraph, of the Constitution, but would also be reasonable and consistent with the objective pursued, namely to allow the provision of a greater number of services and, therefore, to determine a reduction in pressure on the SSN and a reduction in waiting lists. This is in line with some of the most recent legislative interventions in healthcare, including that contained in Article 3-quater of Decree-Law no. 127 of 21 September 2021 (Urgent measures to ensure the safe performance of public and private work through the extension of the scope of application of the COVID-19 green certification and the strengthening of the screening system), converted, with amendments, into Law no. 165 of 19 November 2021, which has provided a derogation, until the end of 2025, to the principle of uniqueness of the employment relationship with the SSN for the operators of health professions.

2.1.1.‒ On a subordinate basis, the appellant requests that this Court ‒ should it consider the prohibition of carrying out intramural activity at private healthcare facilities accredited with the SSN to be in force ‒ raise the question of constitutional legitimacy of the aforementioned provisions before itself, for violation of Articles 3, 32, and 117, third paragraph, of the Constitution, regarding the matter of "health protection".

According to the Liguria Region, it would in fact be completely unreasonable, irrational, and discriminatory, with reference to Article 3 of the Constitution, to derogate from the constraint of uniqueness of the relationship with the SSN for the operators of health professions and, on the contrary, to even prohibit medical managers ‒ in the absence of suitable premises at the public facility where they work ‒ from carrying out intramural activity at private accredited facilities, subject to an agreement with the entity to which they belong. This defect would be revealed at least in the form of a supervening constitutional illegitimacy, taking into account the regulation introduced by Article 3-quater of Decree-Law no. 127 of 2021, as converted, and subsequently extended.

The prohibition of carrying out intramural activity at private accredited healthcare facilities, if it exists, would be detrimental to Article 117, third paragraph, of the Constitution, due to its detailed nature, which is also not functional to achieving the objectives that the intramural regulation sets itself, identified in the right of the healthcare manager to carry out intramural private profession, in the balance between institutional activity and private profession, and in the reduction of waiting lists.

In these terms, the prohibition in question would also be a harbinger of unjustified disparities in treatment between authorized private healthcare facilities and accredited facilities, despite the fact that the latter are also authorized and, in addition, have the additional accreditation requirements. These defects would reflect on the exercise of regional attributions in the matter of health protection pursuant to Article 117, third paragraph, of the Constitution, as would happen for the defect of violation of Article 32 of the Constitution, which would be inferred from the circumstance that the challenged Article 47, on the one hand, would compromise the objectives of streamlining waiting lists and, on the other hand, would also compress the possibility for users to opt for intramural activity in a short time.

2.2.‒ As regards, then, the issue concerning the violation of the exclusive state legislative competence in the matter of civil law, also raised against paragraph 1 of Article 47 of the Liguria Regional Law no. 20 of 2023, the Region supports its inadmissibility and, in any case, its lack of foundation, since the area CCNL would have been approved only after the entry into force of the challenged regional provision and would not be, in any case, in contrast with the latter, not contemplating the prohibition of the exercise of intramural activity at private accredited facilities.

2.3.‒ Also, the question of constitutional legitimacy raised against paragraph 2 of the same Article 47 would be, on a preliminary basis, inadmissible due to lack of specificity and motivation and, on the merits, unfounded.

The provision of the possibility for healthcare facilities, once the working hours of their managers have expired, to purchase services from them under the intramural private profession regime, with the declared purpose of reducing waiting times, as well as falling within the regional legislative competence of detail, would find its normative coverage in various state provisions of principle on the matter. Among them, the Region indicates Article 15-quinquies, paragraphs 1 and 2, of Legislative Decree no. 502 of 1992, which, in regulating the types of exercise of the private professional activity of healthcare managers, within the framework of the exclusive employment relationship, would not exclude the possibility that the service be provided at the request of the healthcare facility, and not only of the user, using specific resources of the SSN. Article 2 of the Decree of the President of the Council of Ministers of 27 March 2000 (Act of address and coordination concerning the intramural private professional activity of the personnel of the healthcare management of the National Health Service) would confirm this interpretation, in particular in paragraph 1, placing on the supplementary funds of the SSN the intramural services provided in favor of the company where the medical manager is working, as well as in paragraph 5, which includes among the aforementioned services also those "requested, in integration of the institutional activities, by the companies to their managers in order to reduce waiting lists or to acquire additional services, especially in the presence of staff shortages, in agreement with the teams concerned". Similarly, this provision would be further confirmed by Articles 24, paragraph 6, and 115, paragraph 2, of the CCNL of the health area signed on 19 December 2019, relating to the three-year period 2016/2018, in force on the date of approval of the provision under consideration, as well as by Articles 27, paragraph 8, and 89, paragraph 2, of the CCNL signed on 23 January 2024, relating to the three-year period 2019/2021.

The challenged regional provision, contained in Article 47, paragraph 2, would therefore constitute a specification, fully reasonable, adequate, and justified, of the principles already found in the state legislation.

2.4.‒ The identified inadmissibility and/or lack of foundation of the issues raised by the President of the Council of Ministers against paragraphs 1 and 2 of Article 47 of the Liguria Regional Law no. 20 of 2023, would consequently lead to the inadmissibility and/or lack of foundation of the constitutional illegitimacy defects attributed to paragraph 3 of the provision in question, which instructs the Regional Council to establish criteria and procedures for carrying out the professional activity referred to in paragraph 2.

2.5.‒ Finally, even the issue, raised against the entire Article 47 of the aforementioned Regional Law no. 20 of 2023, with reference to Article 3 of the Constitution, would be inadmissible due to vagueness and in any case unfounded, taking into account that, when the regional legislator legitimately exercises its own legislative powers, possible differences between the regions constitute a natural effect of the exercise of the same powers.

3.‒ At the hearing, the parties insisted on the acceptance of the conclusions formulated in the defensive acts.

Considered in law

1.‒ The President of the Council of Ministers, represented and defended by the State Attorney General, has challenged Article 47 of the Liguria Regional Law no. 20 of 2023, entitled "Provisions regarding the intramural private profession of healthcare management", for violation of Articles 3 and 117, second paragraph, letter l), and third paragraph, of the Constitution.

1.1.‒ In particular, on the assumption that the rules relating to the performance of intramural private professional activity (ALPI) must be attributed, predominantly, to the matter of health protection, the appellant challenges, with reference to Article 117, third paragraph, of the Constitution, first of all, paragraph 1 of the aforementioned Article 47, in the part in which it provides that, on a temporary basis and until 2025, healthcare managers employed by the Ligurian Regional Health Service (SSR) who have opted for the exercise of the ALPI may operate in private accredited healthcare facilities, even partially, with the SSR. This provision would, in fact, be in contrast with the fundamental principles established by the state legislator, in particular in Article 1, paragraph 4, of Law no. 120 of 2007, according to which the ALPI must be exercised in internal or external outpatient facilities of the healthcare company, public or private non-accredited, with which the company stipulates a specific agreement. This is in line with the principle of the uniqueness of the employment relationship of doctors employed by the National Health Service (SSN), sanctioned by Article 4, paragraph 7, of Law no. 412 of 1991 and aimed at preventing the emergence of a conflict of interest with the private accredited healthcare facilities, as well as at guaranteeing maximum efficiency and operational functionality to the public healthcare service itself.

Similar censures of violation of the fundamental principles in the matter of health protection are, then, addressed to paragraph 2 of the same Article 47, where it establishes, on a temporary basis and to reduce waiting lists, that healthcare companies, bodies, and institutions of the SSR are authorized, until 2025, to acquire from their healthcare management employees bound by an exclusive employment relationship, individually or as a team, healthcare services under the intramural private profession regime pursuant to Law no. 120 of 2007 "also in the manner referred to in paragraph 1" and therefore also at accredited private facilities.

This provision, in fact, would be in contrast with Article 15-quinquies, paragraph 2, of Legislative Decree no. 502 of 1992 and with the provisions of Law no. 120 of 2007, which would not allow SSN companies to purchase services provided under the ALPI regime by their healthcare managers, requiring that the same be provided on the basis of a direct choice, by the user, of the individual professional to whom the service is requested, with costs borne by the assisted person. Furthermore, the possibility for public healthcare companies to purchase healthcare services from their healthcare managers, under the intramural private profession regime, even at private accredited healthcare facilities, would reiterate the violation of the fundamental principle contained in the aforementioned Article 1, paragraph 4, of Law no. 120 of 2007, according to which the ALPI can only be exercised in internal or external outpatient facilities of the healthcare company, public or private non-accredited, with which the company stipulates a specific agreement.

From the acceptance of the aforementioned issues would also arise the declaration of the constitutional illegitimacy of paragraph 3 of the same Article 47, which assigns to the Regional Council the task of establishing, with its own resolution, the criteria and procedures for carrying out the private professional activity "referred to in paragraph 2".

1.2.‒ The appellant also denounces the violation of the sphere of exclusive state legislative competence in the matter of civil law, with exclusive reference, however, to paragraph 1 of the aforementioned Article 47. The latter, impacting on already existing employment relationships and determining, in detail and with immediate effects, essential and qualifying aspects, would realize an undue substitution of the regulation dictated by collective bargaining, to which state law reserves the regulation of the public employment relationship. This is in contrast, in particular, with Article 89, paragraph 1, letter c), of the CCNL of 23 January 2024 of the health area which establishes that the exercise of private professional activity must take place outside of the service commitment and only in facilities of another SSN company or of another non-accredited healthcare facility, subject to an agreement with the same.

1.3.‒ Finally, the appellant challenges the entire text of Article 47, for violation of Article 3 of the Constitution, since, through the expansion of the scope of operation of the ALPI for healthcare managers employed by the SSR, the needs for uniformity underlying the state regulation of the intramural private profession would be betrayed, giving rise to an unreasonable disparity of treatment compared to the medical healthcare personnel who work in other regions.

2.‒ As a preliminary matter, it is necessary to examine the exceptions of inadmissibility raised by the defense of the Liguria Region.

2.1.‒ First of all, the Region raises the inadmissibility of the issue raised, with reference to Article 117, second paragraph, letter l), of the Constitution, against Article 47, paragraph 1, of the Liguria Regional Law no. 20 of 2023, since the CCNL of 23 January 2024, in contrast with which the challenged provision would be, would have been approved on a date subsequent to its adoption, so that no modification of a contractual regulation that was still non-existent on the date of entry into force of the challenged provision could have occurred.

2.1.1.‒ The exception is unfounded.

The assumption from which the appellant starts is that the regional provision, impacting on already existing public employment relationships, determining in detail and with immediate effects essential and qualifying aspects, has invaded the sphere of exclusive state legislative competence in the matter of civil law, which reserves the regulation of such relationships to collective bargaining. The issue is, therefore, raised on the assumption that the Region, in any case, could not have dictated a regulation in a matter reserved to the state legislator and by the latter delegated exclusively to collective bargaining. Such a censure therefore exists, regardless of the alleged specific contrast with Article 89, paragraph 1, letter c), of the CCNL signed on 23 January 2024, and therefore makes it superfluous to ascertain the priority of the signing of the same collective agreement compared to the entry into force of the regional law no. 20 of 2023. Moreover, the contract in question has only replaced the previous CCNL signed in 2019, which, on this point, already dictated, in particular in Article 115, a regulation that is also coincident.

In any case, the alleged unsuitability of the rule of the collective agreement to act as an interposed parameter ratione temporis, for the purposes of evaluating the violation of the sphere of exclusive state legislative competence, is relevant, not for the purposes of the admissibility of the issue, but for the purposes of the merits, considering that "any "incongruence of the parameter indicated by the appellant with respect to the substantive content of the complaint constitutes a reason for the lack of foundation of the issue (judgments no. 132 of 2021 and no. 286 of 2019)" (recently judgments no. 163 and no. 53 of 2023), so that the exception concerns the merits and not the rite" (judgment no. 69 of 2024).

2.2.‒ The Liguria Region also raises the inadmissibility of the censure addressed to paragraph 2 of Article 47 of the Liguria Regional Law no. 20 of 2023, with reference to Article 117, third paragraph, of the Constitution, with regard to the matter of health protection, for lack of specificity and motivation. The appellant, in addition to indicating as an interposed parameter an entire normative act (the provisions of Law no. 120 of 2007), escaping the burden of a precise identification of the interposed parameters, would not even explain what the allegedly violated fundamental principle is, that could be inferred from these rules.

2.2.1.‒ The exception is unfounded.

According to the constant orientation of this Court, "in proceedings by way of principal, the appellant has the burden of identifying the challenged provisions and the constitutional parameters of which he complains of the violation and of presenting a motivation that is not merely assertive, which indicates the reasons for the conflict with the evoked parameters, through a concise argument on the merits in support of the censures (among the many, judgments no. 57 of 2023, no. 135 and no. 119 of 2022). This burden also extends to the identification of the specific interposed state provisions that are assumed to be violated (among the many, judgments no. 58 of 2023 and no. 279 of 2020)" (judgment no. 82 of 2024).

In this case, the aforementioned burden has been fulfilled, albeit succinctly.

In fact, the appellant identifies, first of all in Article 15-quinquies of Legislative Decree no. 502 of 1992, in particular in paragraph 2 ‒ with respect to which the provisions of Law no. 120 of 2007 would only be specific ‒ the principle of the exclusion of the possibility for SSN companies to purchase services from their healthcare managers provided under the ALPI regime, inferring it from the provision that the intramural private profession is characterized by the direct choice, by the user, of the individual professional to whom the service is requested, with costs borne by the assisted person.

As for the possibility that these services are provided by healthcare managers at accredited healthcare facilities, the appellant identifies its contrast with the same interposed provisions, specifically evoked in reference to the issue raised against paragraph 1 of the same Article 47 of the Liguria Regional Law no. 20 of 2023, to which the same refers.

3.‒ We can now move on to examine the merits of the individual issues.

3.1.‒ As already anticipated, the appellant challenges, first of all, paragraph 1 of