IDEAS home Printed from https://ideas.repec.org/p/arx/papers/2508.13102.html
   My bibliography  Save this paper

Testing health expenditure rationing under universal healthcare coverage: the case of Italy

Author

Listed:
  • Leonardo Becchetti
  • Nazaria Solferino

Abstract

We investigate the phenomenon of (private, out-of-pocket) "health expenditure rationing", or whether out-of-pocket health expenditures are shaped by income independently of actual health needs. Using microdata from an Italian Health Interview Survey, we assess the extent to which income explains variation in private health spending, after controlling for objective health conditions, self-assessed health, and a comprehensive set of socio-demographic factors. We find that individuals in the highest income brackets spend approximately 300 euros more annually than those in the lowest. Our findings point to a structural inequity in access and highlight the need for policy measures that address not only formal coverage but also the underlying role of income in shaping healthcare use.

Suggested Citation

  • Leonardo Becchetti & Nazaria Solferino, 2025. "Testing health expenditure rationing under universal healthcare coverage: the case of Italy," Papers 2508.13102, arXiv.org.
    • Handle: RePEc:arx:papers:2508.13102
    as

    Download full text from publisher

    File URL: http://arxiv.org/pdf/2508.13102
    File Function: Latest version
    Download Restriction: no
    ---><---

    References listed on IDEAS

    as
    1. Daron Acemoglu & Amy Finkelstein & Matthew J. Notowidigdo, 2013. "Income and Health Spending: Evidence from Oil Price Shocks," The Review of Economics and Statistics, MIT Press, vol. 95(4), pages 1079-1095, October.
    2. F. Moscone & E. Tosetti, 2010. "Health expenditure and income in the United States," Health Economics, John Wiley & Sons, Ltd., vol. 19(12), pages 1385-1403, December.
    3. O'Donnell, Owen & van Doorslaer, Eddy & Rannan-Eliya, Ravi P. & Somanathan, Aparnaa & Adhikari, Shiva Raj & Akkazieva, Baktygul & Harbianto, Deni & Garg, Charu C. & Hanvoravongchai, Piya & Herrin, Ale, 2008. "Who pays for health care in Asia?," Journal of Health Economics, Elsevier, vol. 27(2), pages 460-475, March.
    4. David Cutler & Angus Deaton & Adriana Lleras-Muney, 2006. "The Determinants of Mortality," Journal of Economic Perspectives, American Economic Association, vol. 20(3), pages 97-120, Summer.
    5. Giannouchos, Theodoros V. & Ukert, Benjamin & Vozikis, Athanassios & Steletou, Evangelia & Souliotis, Kyriakos, 2021. "Informal out-of-pocket payments experience and individuals’ willingness-to-pay for healthcare services in Greece," Health Policy, Elsevier, vol. 125(6), pages 693-700.
    6. Victoria Fan and William Savedoff, 2014. "The Health Financing Transition: A Conceptual Framework and Empirical Evidence - Working Paper 358," Working Papers 358, Center for Global Development.
    7. Brenna, Elenka, 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, Elsevier, vol. 154(C).
    8. Paul Gertler & Jonathan Gruber, 2002. "Insuring Consumption Against Illness," American Economic Review, American Economic Association, vol. 92(1), pages 51-70, March.
    9. Waitzberg, Ruth & Allin, Sara & Grignon, Michel & Ljungvall, Åsa & Habimana, Katharina & Kantaris, Marios & Thomas, Steve & Rice, Thomas, 2024. "Mitigating the regressivity of private mechanisms of financing healthcare: An Assessment of 29 countries," Health Policy, Elsevier, vol. 143(C).
    10. Janet Currie & Enrico Moretti, 2003. "Mother's Education and the Intergenerational Transmission of Human Capital: Evidence from College Openings," The Quarterly Journal of Economics, President and Fellows of Harvard College, vol. 118(4), pages 1495-1532.
    11. Cylus, Jonathan & Thomson, Sarah & Tayara, Lynn Al & Cerezo, José Cerezo & Martínez, Marcos Gallardo & García-Ramírez, Jorge Alejandro & Karanikolos, Marina & Gregori, María Serrano & Evetovits, Tamás, 2024. "Assessing the equity and coverage policy sensitivity of financial protection indicators in Europe," LSE Research Online Documents on Economics 124416, London School of Economics and Political Science, LSE Library.
    12. Krishna, Anirudh, 2004. "Escaping Poverty and Becoming Poor: Who Gains, Who Loses, and Why?," World Development, Elsevier, vol. 32(1), pages 121-136, January.
    13. Joseph P. Newhouse, 1977. "Medical-Care Expenditure: A Cross-National Survey," Journal of Human Resources, University of Wisconsin Press, vol. 12(1), pages 115-125.
    14. Abhijit V. Banerjee & Esther Duflo, 2007. "The Economic Lives of the Poor," Journal of Economic Perspectives, American Economic Association, vol. 21(1), pages 141-168, Winter.
    15. World Health Organization & World Bank, 2021. "Global Monitoring Report on Financial Protection in Health 2021," World Bank Publications - Reports 36723, The World Bank Group.
    16. Grossman, Michael, 1972. "On the Concept of Health Capital and the Demand for Health," Journal of Political Economy, University of Chicago Press, vol. 80(2), pages 223-255, March-Apr.
    17. Cylus, Jonathan & Thomson, Sarah & Tayara, Lynn Al & Cerezo, José Cerezo & Martínez, Marcos Gallardo & García-Ramírez, Jorge Alejandro & Karanikolos, Marina & Gregori, María Serrano & Evetovits, Tamás, 2024. "Assessing the equity and coverage policy sensitivity of financial protection indicators in Europe," Health Policy, Elsevier, vol. 147(C).
    18. Adam Wagstaff & Eddy van Doorslaer, 2003. "Catastrophe and impoverishment in paying for health care: with applications to Vietnam 1993–1998," Health Economics, John Wiley & Sons, Ltd., vol. 12(11), pages 921-933, November.
    19. Fan, Victoria Y. & Savedoff, William D., 2014. "The health financing transition: A conceptual framework and empirical evidence," Social Science & Medicine, Elsevier, vol. 105(C), pages 112-121.
    20. Raj Chetty & Nathaniel Hendren & Patrick Kline & Emmanuel Saez, 2014. "Where is the land of Opportunity? The Geography of Intergenerational Mobility in the United States," The Quarterly Journal of Economics, President and Fellows of Harvard College, vol. 129(4), pages 1553-1623.
    21. Joseph Piscopo & Wim Groot & Milena Pavlova, 2024. "Determinants of public health expenditure in the EU," PLOS ONE, Public Library of Science, vol. 19(3), pages 1-19, March.
    Full references (including those not matched with items on IDEAS)

    Most related items

    These are the items that most often cite the same works as this one and are cited by the same works as this one.
    1. Bernal, Noelia & Carpio, Miguel A. & Klein, Tobias J., 2017. "The effects of access to health insurance: Evidence from a regression discontinuity design in Peru," Journal of Public Economics, Elsevier, vol. 154(C), pages 122-136.
    2. Jay Dev Dubey, 2021. "Measuring Income Elasticity of Healthcare-Seeking Behavior in India: A Conditional Quantile Regression Approach," Journal of Quantitative Economics, Springer;The Indian Econometric Society (TIES), vol. 19(4), pages 767-793, December.
    3. Badi H. Baltagi & Raffaele Lagravinese & Francesco Moscone & Elisa Tosetti, 2017. "Health Care Expenditure and Income: A Global Perspective," Health Economics, John Wiley & Sons, Ltd., vol. 26(7), pages 863-874, July.
    4. Declan French, 2012. "Causation between health and income: a need to panic," Empirical Economics, Springer, vol. 42(2), pages 583-601, April.
    5. Bernal Lobato, N., 2014. "Essays in applied microeconomics," Other publications TiSEM 9b638b3d-2f83-452a-b2c8-c, Tilburg University, School of Economics and Management.
    6. Gabriela Flores & Jaya Krishnakumar & Owen O'Donnell & Eddy van Doorslaer, 2008. "Coping with health-care costs: implications for the measurement of catastrophic expenditures and poverty," Health Economics, John Wiley & Sons, Ltd., vol. 17(12), pages 1393-1412.
    7. Guglielmo Maria Caporale & Juncal Cunado & Luis A. Gil-Alana & Rangan Gupta, 2018. "The relationship between healthcare expenditure and disposable personal income in the US states: a fractional integration and cointegration analysis," Empirical Economics, Springer, vol. 55(3), pages 913-935, November.
    8. Mohammad Abu-Zaineh & Habiba Romdhane & Bruno Ventelou & Jean-Paul Moatti & Arfa Chokri, 2013. "Appraising financial protection in health: the case of Tunisia," International Journal of Health Economics and Management, Springer, vol. 13(1), pages 73-93, March.
    9. Bratti, Massimiliano & Mendola, Mariapia, 2014. "Parental health and child schooling," Journal of Health Economics, Elsevier, vol. 35(C), pages 94-108.
    10. Ji, Sisi & Zhu, Zheyi, 2022. "Does higher education matter for health?," Cardiff Economics Working Papers E2022/4, Cardiff University, Cardiff Business School, Economics Section.
    11. Francesco Ricci & Marios Zachariadis, 2013. "Education Externalities on Longevity," Economica, London School of Economics and Political Science, vol. 80(319), pages 404-440, July.
    12. Hyejin Lee & Dong-Yop Oh & Ming Meng, 2019. "Stationarity and cointegration of health care expenditure and GDP: evidence from tests with smooth structural shifts," Empirical Economics, Springer, vol. 57(2), pages 631-652, August.
    13. Gabriel Picone & Assi José Carlos Kimou & Désiré Kanga, 2023. "Medical emergencies and farm productivity in Côte d'Ivoire," Review of Development Economics, Wiley Blackwell, vol. 27(3), pages 1630-1648, August.
    14. Awad Mataria & Firas Raad & Mohammad Abu-Zaineh & Cam Donaldson, 2010. "Catastrophic healthcare payments and impoverishment in the occupied Palestinian territory," Applied Health Economics and Health Policy, Springer, vol. 8(6), pages 393-405, November.
    15. Felipa de Mello-Sampayo & Sofia de Sousa-Vale, 2014. "Financing Health Care Expenditure in the OECD Countries: Evidence from a Heterogeneous, Cross-Sectional Dependent Panel," Panoeconomicus, Savez ekonomista Vojvodine, Novi Sad, Serbia, vol. 61(2), pages 207-225.
    16. Andrea M. Leiter & Engelbert Theurl, 2021. "Determinants of prepaid systems of healthcare financing: a worldwide country-level perspective," International Journal of Health Economics and Management, Springer, vol. 21(3), pages 317-344, September.
    17. Keegan, Conor & Brick, Aoife & Bergin, Adele & Wren, Maev-Ann & Whyte, Richard & Henry, Edward, 2020. "Projections of expenditure for public hospitals in Ireland, 2018–2035, based on the Hippocrates Model," Research Series, Economic and Social Research Institute (ESRI), number RS117, December.
    18. Akbulut-Yuksel, Mevlude & Kugler, Adriana D., 2016. "Intergenerational persistence of health: Do immigrants get healthier as they remain in the U.S. for more generations?," Economics & Human Biology, Elsevier, vol. 23(C), pages 136-148.
    19. Bahadır Dursun & Resul Cesur & Inas R. Kelly, 2022. "Mandatory Schooling of Girls Improved Their Children's Health: Evidence from Turkey's 1997 Education Reform," Journal of Policy Analysis and Management, John Wiley & Sons, Ltd., vol. 41(3), pages 824-858, June.
    20. Mehdi Barati & Hadiseh Fariditavana, 2020. "Asymmetric effect of income on the US healthcare expenditure: evidence from the nonlinear autoregressive distributed lag (ARDL) approach," Empirical Economics, Springer, vol. 58(4), pages 1979-2008, April.

    More about this item

    NEP fields

    This paper has been announced in the following NEP Reports:

    Statistics

    Access and download statistics

    Corrections

    All material on this site has been provided by the respective publishers and authors. You can help correct errors and omissions. When requesting a correction, please mention this item's handle: RePEc:arx:papers:2508.13102. See general information about how to correct material in RePEc.

    If you have authored this item and are not yet registered with RePEc, we encourage you to do it here. This allows to link your profile to this item. It also allows you to accept potential citations to this item that we are uncertain about.

    If CitEc recognized a bibliographic reference but did not link an item in RePEc to it, you can help with this form .

    If you know of missing items citing this one, you can help us creating those links by adding the relevant references in the same way as above, for each refering item. If you are a registered author of this item, you may also want to check the "citations" tab in your RePEc Author Service profile, as there may be some citations waiting for confirmation.

    For technical questions regarding this item, or to correct its authors, title, abstract, bibliographic or download information, contact: arXiv administrators (email available below). General contact details of provider: http://arxiv.org/ .

    Please note that corrections may take a couple of weeks to filter through the various RePEc services.

    IDEAS is a RePEc service. RePEc uses bibliographic data supplied by the respective publishers.