The use of cost-sharing to control demand and the implications for equity: some theoretical and empirical evidence for Italy

The existence of barriers to access to health care depends in the complex interaction of supply and demand-side factors, and both these factors will determine the extent to which access is equitable, based on the principle of equal utilization for equal need. Among these barriers we have cost-sharing that represents a well established tool to control demand, in many OECD countries. Many contributions in literature highlight arguments pro and against user charges: on one side, advocates of them claim that they can reduce demand by encouraging a more responsible use of health services, and raise revenue to sustain and expand the provision of health care, on the other side there is some evidence suggesting that they have a detrimental effect on the utilization of health services, and by extension on health status. The aim of the paper is to assess the extent to which the imposition of statutory user charges deter individuals from using health services and whether they result in health care systems characterized by unequal utilization for equal need. A special attention is given to the case of Italy, where tickets rules have been piling up in recent years, we do have some evidence of inequity of access and a stronger regional autonomy due to the process of federalism could exacerbate local disparities in access to essential assistance level. Can tickets have a positive role in this scenario? A moderate level, coupled with right exemption schemes seems to induce positive effects for equity, with the possibility of widening the range of health services within the public coverage and preserving the distributional function of the national health system.