Who Pays, Who Gets Care? Public and Private Healthcare in Italy
Italy’s National Health Service, the Servizio Sanitario Nazionale (SSN), was founded in 1978 on a clear promise: access to care should depend on need, not on the ability to pay. Anyone who has waited months for a specialist appointment or a scan knows that the promise now comes with fine print. Paying privately usually brings an earlier date. An employer’s health plan may reimburse the bill. People with neither can wait, or go without.
This is no longer a marginal experience. In 2023 more than 30% of outpatient specialist visits, diagnostic tests and rehabilitation in Italy were paid for privately (Carminati et al., 2024). Households pay 23.6% of all health spending out of their own pockets, about nine points above the EU average. Membership of health funds rose from 5.8 million in 2013 to 16.3 million in 2023 (UPB, 2026).
Italy is privatising healthcare without ever having decided to. The shift runs less through who owns hospitals than through who pays, and part of the private bill is quietly picked up by the public budget through tax relief. That is a political choice. It should be made in the open.
When universal coverage meets limited capacity
Ageing, expensive innovation and slow growth put pressure on every universal system. Italy faces them with less room than its neighbours. Public health spending fell to 6.3% of GDP in 2024 (UPB, 2026) and to 6.2% in 2025, the lowest share in the G7 (GIMBE Foundation, 2026). Pensions absorb more than twice as much, at around 15%.
The regions run the SSN, and they must reconcile their budgets with the LEA (livelli essenziali di assistenza), the package of services every resident is entitled to. The results can be perverse. In 2022 Emilia-Romagna and Tuscany, with some of the strongest public networks in the country, ran deficits, while several southern regions under financial recovery plans balanced their books with far thinner services. A balanced budget says little about whether people actually get care.
Waiting lists then do the rationing. Waiting is acceptable when clinical priority decides who goes first. In practice the SSN is most accessible to those who can navigate it, those who can pay for an alternative, and those who happen to live near a less congested provider. The people who get care are not necessarily the people who need it most. Italy can set priorities deliberately, to get the most health out of its resources, or let them emerge by accident. At present it is mostly doing the latter.
Who provides care, and who pays?
The public–private debate often merges two separate questions: who delivers care and who finances it (Figure 1). A private clinic accredited by the SSN treats patients for the price of a co-payment, and the region pays the rest. A doctor employed in a public hospital can see private patients in the same building, outside working hours, under the intramoenia regime. These visits made up about 7.6% of the volume of visits and tests in 2022. Public ownership does not make that route universal.
Private provision under public contract is not the problem. Accredited private providers deliver around €34 billion of publicly financed care each year, against roughly €23 billion of care sold on the private market (Mapelli, 2025). The condition is that the public side sets the terms. Italian law already lays down three rules: the SSN plans, commissions and controls (Legislative Decree 229/1999, art. 8-quinquies). Where these are enforced, private capacity extends the public guarantee.
Private financing is a different matter. According to Istat, in 2022 households paid directly for €36.8 billion of the €41.5 billion spent privately on health, almost nine euros in every ten. Out-of-pocket payment is the least protective form of financing, because it requires money at the moment illness strikes. By international standards, Italy relies on it heavily (Figure 2).
What does additional coverage actually add?
Private coverage can play three roles. It can be supplementary, paying for services the public package leaves out, such as dental care or long-term care. It can be complementary, covering co-payments. Or it can be duplicative, buying a faster or more comfortable route to services the SSN already guarantees.
Italian law tried to separate these roles. The reforms of 1992–93 and 1999 created “integrative” funds of the SSN, with the most favourable tax treatment, which were meant to cover only services outside the LEA. Funds set up before 1999 (enti, casse and mutual societies) were allowed to cover LEA services too. They keep their tax relief provided that at least 20% of their resources go to dental care, long-term care and rehabilitation (ministerial decrees of 2008 and 2009).
In practice, the exception became the rule. Of the 324 funds registered with the Ministry of Health in 2023, the enti and casse account for more than 16 million members; the exclusively integrative funds for about 24,000. In 2022 the funds paid out just over €3 billion, of which around €1 billion went on integrative services (Ministry of Health, 2025). Roughly two thirds therefore bought services the SSN already provides, mostly faster specialist visits and diagnostics. Calling the whole sector “integrative” is generous.
Does private insurance relieve the public system?
The case for private coverage is that insured patients leave the public queue and free up capacity for others. Economists call this “opt out”. The alternative is “top up”: insured people add private care while continuing to use the SSN.
Italian evidence suggests that opting out does happen. Fabbri and Monfardini (2016) find that wealthier, higher-income people with voluntary insurance use more private and fewer public specialist services. Brenna (2025) finds that insured people are 7.3 percentage points more likely to use private specialist and diagnostic care, and less likely to use the public route with a co-payment. However, the same studies show who opts out: people with higher incomes, more education and stable jobs. Fabbri and Monfardini conclude that the private market weakens the redistribution the SSN would otherwise achieve, from better-off, doubly insured people to everyone else.
Fewer public visits also do not add up to a saving. The calculation has to include the tax relief granted to the coverage, the costs that public facilities continue to bear, and any care that follows later in the SSN. Supply matters as well. When private activity draws on the same scarce specialists, much of it is a change in who pays rather than extra capacity. Finally, insurance lowers the price patients face and so encourages use. Nerina Dirindin (2019) has described a system of overlapping coverage, in which the same specialist visit may be backed by the SSN, by the 19% tax deduction for medical expenses, and by a health fund. That is inefficient as well as unequal.
A benefit at work, a distributional choice for society
Occupational health funds suit everyone at the bargaining table. For employees covered by a collective or company agreement, contributions of up to €3,615.20 a year are excluded from taxable income, and employer contributions pay a 10% solidarity levy instead of full social security contributions. For firms, a health plan is cheaper than an equivalent pay rise. For unions, it is an easy win in contract negotiations. For workers, it is valuable protection. Since 2016, when productivity bonuses could be converted tax-free into welfare benefits, intermediated private spending has grown rapidly.
Society as a whole pays for this. The Parliamentary Budget Office estimates that tax and contribution relief for supplementary health coverage cost €1.5 billion in 2023, on top of €4.6 billion for medical-expense deductions (UPB, 2026). That money is drawn from all taxpayers, including the self-employed, pensioners and people out of work, who are largely excluded from occupational plans. Because relief takes the form of a deduction from taxable income, it is worth more to people in higher tax brackets. It also favours large firms, which can pool risk more cheaply. And because lower social contributions mean lower pensions later on, workers trade part of their future pension for faster appointments today.
There is an irony here. In 1978 the SSN replaced the old system of occupational sickness funds, the mutue, precisely to stop health protection from depending on a person’s job. Through tax incentives, Italy is gradually rebuilding a version of that system.
Making cooperation serve universal access
The risk is not that private actors take part in Italian healthcare. They always have. The risk is a disorderly privatisation that nobody has chosen. Avoiding it requires the state to do four things.
First, make the public guarantee credible. The state needs to say clearly what the SSN can sustainably provide, with timely access according to clinical priority, and fund it. Until it does, every other arrangement is filling gaps nobody has defined.
Second, enforce planning, commissioning and control with private providers. Accreditation should be tied to waiting-time targets, as the 2022 ministerial decree on accreditation begins to do. All contracted capacity should appear in public booking systems (CUP), and records should flow through the electronic health record.
Third, complete the regulation of health funds that was left unfinished in the 1990s. This means rules on governance and the qualifications of those who run funds, clear information for members on exclusions and limits, standardised service codes, a ban on risk selection that is actually enforced, and proper supervision.
Fourth, review tax relief against what coverage adds. Relief is easiest to justify for supplementary cover, such as dental care and long-term care, where public protection is thin. Subsidising faster access to services the SSN already guarantees requires a much stronger case than has been made so far.
Every claim that private coverage saves public money should be tested on the same terms, counting tax expenditure, shifts between public and private use, and effects on waiting times and health. Universal healthcare is measured by whether people with the fewest resources can still get the care they need. Italy is drifting from that standard, and the drift is subsidised. That is the conversation it needs to have.
Key references
Brenna, E. (2025). Public versus private access in the Italian NHS: the use of propensity score matching to provide more insight on the increasing adoption of voluntary health insurance. Health Policy, 154, 105271. https://doi.org/10.1016/j.healthpol.2025.105271
Carminati, F., Guerra, F., Palvarini, A., Ricci, A., Longo, F. (2024). Il SSN tra risorse scarse e bisogni crescenti: un problema di equità e sostenibilità. Secondo Welfare.
Dirindin, N. (2019). Fondi sanitari e nuovi livelli essenziali di assistenza: un intreccio potenzialmente pericoloso. Politiche Sanitarie, 20(1): 33–39.
Fabbri, D., Monfardini, C. (2016). Opt out or top up? Voluntary healthcare insurance and the public vs. private substitution. Oxford Bulletin of Economics and Statistics, 78: 75–93. https://doi.org/10.1111/obes.12107
GIMBE Foundation (2026). Report on public health spending, September 2026.
Mapelli, V. (2025). L’eterna querelle pubblico-privato in sanità. lavoce.info, 21 January 2025.
Ministry of Health (2025). I fondi sanitari integrativi in Italia: 3° Rapporto 2021–2023.
Ufficio parlamentare di bilancio (2026). Pubblico e privato nella sanità in Italia: il finanziamento, la produzione e le imprese. Focus n. 3/2026.
