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

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.