More families forced to pay out of pocket: private health spending rises as equity in Italy’s National Health Service declines. The new CREA Report

Italy’s National Health Service (SSN) is becoming less equitable, as a growing share of healthcare costs is shifted onto households—especially the most fragile families and those living in central and southern regions.

This is the picture drawn by the 21st CREA Health Report, presented at the CNEL, which calls for a paradigm shift: from a traditional “health service” to a broader “health system” capable of responding to new needs linked to chronic illness and non-self-sufficiency. According to CREA, only a joint commitment by government and institutions can guarantee an equitable and sustainable future for the SSN.

Private healthcare spending has become a structural component of access to care in Italy. Today, seven out of ten families pay healthcare expenses out of pocket. The share of households affected has risen from 50.8% in the 1980s to about 70% today, undermining the promise of universal coverage. Most of this increase occurred in the 1990s, a decade that alone accounted for 84% of the growth in the number of families paying privately. During that period, public health spending grew by an average of 4.4% per year (+0.8% in real terms), while private spending surged by 10.7%. After 2000, public and private spending followed similar growth paths (around 2.7% annually), suggesting that the shift toward private expenditure predated health federalism.

At the same time, the burden of healthcare costs on household budgets has increased sharply. Health spending now absorbs an average of 4.3% of family income, rising to 6.8% among less-educated households. The impact is regressive: the poorest 60% of families now account for 37.6% of total private health spending, a share that has grown significantly over time. Territorial disparities reinforce these trends. In central and southern Italy, private spending has grown faster than in the north, indicating that recourse to private care is often a necessity driven by gaps in public provision rather than a matter of choice.

As a result, more than four million families face so-called “catastrophic” health expenditures, largely related to dental care and long-term care for non-self-sufficient people—two areas where public coverage remains insufficient. In addition, 2.3 million people delay or forgo care for financial reasons, a figure that has steadily increased over the life of the SSN.

The CREA report argues that the sustainability of the system has been maintained through implicit rationing rather than true efficiency gains. Public coverage of total health spending has fallen from an initial 81% to 72.6%, below the average of comparable EU countries. Although health federalism initially helped restore some public coverage, the effects of the 2008–09 financial crisis and prolonged economic stagnation have widened the gap again. Today, Italy’s public health spending is estimated to be nearly 45% lower than that of core European peers, while private spending—though lower in absolute terms—exceeds what would be expected given household income levels.

Demographic and social changes compound these challenges. Since the creation of the SSN, Italy has added nearly five million people aged over 75, seen a sharp rise in multi-chronic patients, and recorded a 10% increase in non-self-sufficient individuals over the past decade. At the same time, social structures have changed, with more single-person households and higher educational attainment, reshaping expectations toward healthcare services.

CREA concludes that simply increasing funding will not be enough. A structural reform is needed—one that strengthens integration between health and social care, redefines appropriateness in the context of chronic and complex needs, and moves from implicit to explicit prioritisation to protect equity. Without a decisive shift toward a comprehensive “health system” approach, the SSN risks becoming increasingly unable to meet the evolving needs of the population while preserving its founding principles of universality and fairness.