Health spending in Italy: The impact of immigrants

The welfare impact of immigration is a highly debated issue especially for countries on the external borders of the European Union. This paper studies how immigrants affect public health expenditure across Italian regions during the period 2003–2016 using NUTS II level data. Identification strategy is based on shift–share instruments, which are made robust to pull factors that might attract immigrants in Italy and to internal migration of natives. We find that a 1 percentage point increase in immigrants over total resident population leads to a decrease in public health expenditure per capita by about 3.8% (i.e. around 69 euro per capita). Among possible channels, we find no support for any crowding out effect from public to private health services by natives due to increasing immigration or for any role played by different levels of efficiency across regional health systems. Our results are driven by immigrants' demographic structure: they are mostly males and younger workers that call for less health spending, according to a positive selection mechanism. Moreover, linguistic barriers contribute to limiting the immigrants' reliance on public healthcare, which is confirmed also by the use of the European Health Interview Survey microdata.