The health levy and the ristorni dispute of 2026

An Italian contribution on the old cross-border workers

The transitional regime of the 2020 agreement left Italy with a group of residents, the old cross-border workers, whose employment income it may not tax and who nonetheless use Italian public services, including the national health service. Italy's Budget Law for 2024 introduced a "contribution to the national health service" payable by these workers. Its rate is set between 3 and 6 per cent of the net salary earned in Switzerland, with a minimum of EUR 30 and a maximum of EUR 200 a month. The revenue is to be used to increase the salaries of doctors, nurses and other health workers in the border areas, where Swiss hospitals and clinics attract Italian staff with much higher pay.¹ The regions concerned, Lombardy, Piedmont and Aosta Valley, were to fix the rates within the statutory range and to organize the collection. An implementing measure was published in the Gazzetta Ufficiale in December 2025.²

The levy has proved difficult to apply. In July 2025 Lombardy announced that it would apply a rate of 3 per cent and proposed to use up to 30 per cent of the expected revenue, about EUR 30 million, for a welfare system for cross-border workers. Penalties for evasion were to double the amount owed.³ The Italian tax authorities do not have complete data on the Swiss incomes of the old cross-border workers, precisely because those incomes are not taxed in Italy. The regions therefore considered asking the workers to declare themselves through a dedicated portal.⁴ By April 2026 the levy had existed in law for twenty-seven months without being collected. Only Lombardy was still pursuing it. Piedmont had decided not to apply it, while the Autonomous Province of Bolzano and the Aosta Valley had not taken it up. The Italian trade union CGIL, through its coordinator for cross-border workers, Giuseppe Augurusa, called the levy a "trick of labels" and argued that it violated the agreements.⁵

The Swiss reaction

In Ticino the levy was perceived as an indirect tax on income that the agreement reserves exclusively to Switzerland. The cantonal government argued that a charge calculated as a percentage of the Swiss salary of the old cross-border workers was a tax on that salary, whatever its name, and that it breached Art. 9 of the agreement. It threatened to respond by withholding the compensation payments, as it had done in 2011.⁶ The Confederation took a different view. On 17 June 2026, after a meeting with the Ticinese members of the Federal Assembly, the head of the Federal Department of Finance, Karin Keller-Sutter, confirmed the Federal Council's opposition to any blocking of the payments. According to the president of the Ticino delegation, Bruno Storni, she had stated that the levy "is not a tax, is not in force" and that it was not appropriate to act on the ristorni. Storni warned that if the canton insisted, there would be a break with Italy and with the Confederation.⁷

On 30 June 2026 the Ticino government nevertheless decided unanimously to withhold part of the compensation due to Lombardy as a precautionary measure. It paid CHF 58.9 million and retained CHF 50.2 million, equal to 46 per cent of the share due to the Lombard municipalities. The compensation due to the Piedmontese municipalities was paid in full, because Piedmont had renounced the levy. The decision was announced by the President of the Council of State, Claudio Zali, together with the Finance Director, Christian Vitta, and the Health Director, Raffaele De Rosa. On the same day Karin Keller-Sutter met the Italian Minister of Economy and Finance, Giancarlo Giorgetti, in Rome.⁸ A few days later the former president of the Liberal Radical Party, Fulvio Pelli, defended the canton: the cross-border workers' regime had been negotiated by Bern and Rome without the cantons, and "the Confederation cannot blame the canton" for using the only means of pressure it had. The Federal Council expressed its regret about the decision.⁹

Notes

1. "La 'tassa sulla salute' a carico dei frontalieri è legge", RSI, https://www.rsi.ch/info/ticino-grigioni-e-insubria/La-%E2%80%9Ctassa-sulla-salute%E2%80%9D-a-carico-dei-frontalieri-%C3%A8-legge--3378192.html; "Svizzera, tassa sulla salute in arrivo dalla Lombardia: nessun passo indietro", ItaliaOggi , 23 July 2025, https://www.italiaoggi.it/economia-e-politica/svizzera-tassa-sulla-salute-in-arrivo-dalla-lombardia-nessun-passo-indietro-hptq65o7 (origin in the Budget Law for 2024; rate of 3 to 6 per cent of net pay, minimum EUR 30, maximum EUR 200 a month). ↩
2. RSI, "La 'tassa sulla salute' … è legge" (above), which dates the publication in the Gazzetta Ufficiale to 22 December 2025 and names Lombardy, Piedmont and Aosta Valley as the regions that fix the rates; ItaliaOggi, 23 July 2025 (above), reporting that the implementing decree was then being finalized at the Ministry of Health. ↩
3. ItaliaOggi, 23 July 2025 (above). ↩
4. RSI, "La 'tassa sulla salute' … è legge" (above). ↩
5. "La tassa? Un trucco. Siamo preoccupati dalle ritorsioni sui ristorni", Tio.ch, 10 April 2026, https://www.tio.ch/ticino/politica/1917297/la-tassa-un-trucco-siamo-preoccupati-dalle-ritorsioni-sui-ristorni. ↩
6. Ibid.; RSI, 30 June 2026 (above). ↩
7. RSI, 17 June 2026 (above). ↩
8. RSI, 30 June 2026 (above). ↩
9. "Blocco dei ristorni: 'La Confederazione non può dar la colpa al Cantone'", RSI, 5 July 2026, https://www.rsi.ch/info/ticino-grigioni-e-insubria/Blocco-dei-ristorni-%E2%80%9CLa-Confederazione-non-pu%C3%B2-dar-la-colpa-al-Cantone%E2%80%9D--3868544.html. ↩

For general information only. This article does not constitute legal or tax advice, does not replace advice on an individual case and creates no lawyer-client relationship. It reflects the legal position as of October 2026.