The Report

Private healthcare spending: the heavier bill for fragile and poor families calls for a re-founding of the care system

Private health expenditure stands at 37.6% for the most disadvantaged households with an impact especially in the South: the analysis by Crea di Tor Vergata calls for a rewriting of public health care to meet the new welfare needs and the challenges of ageing and galloping technological innovation

by Barbara Gobbi

21 January 2026

7' min read

Translated by AI

Versione italiana

7' min read

Translated by AI

Versione italiana

A fairer healthcare system depends on the full integration of health and welfare: this is not a slogan, but the course traced - starting from an analysis of 40 years of data - by the 21st Report of Crea, the Centre for Applied Economic Research in Healthcare, which launches a real call for a paradigm shift capable of bringing together health and welfare. And of countering private spending on health, which weighs most heavily on the poorest and most fragile families, in spite of the criteria of equity and inclusion at the basis of the National Health Service, but which are still heavily disregarded today. The call to enhance those principles by creating a new 'Constituent Assembly' capable of rewriting the health system comes on the heels of new data from the State General Accounting Office that certify a new record of 46 billion euros paid directly out of their own pockets by families, an increase of 7.7%, to pay for visits and examinations.

You don't just put money

it is not just a question of adding resources, which in any case do not have decisive margins for expansion and would not be able to bridge the gap with other European countries," warned the director of the Crea, Federico Spandonaro, during the presentation of the report at the CNEL headquarters in Rome, "but rather of setting up a sort of constituent body that would bring together all the political parties to create an integrated health system that includes health and social needs. A request fully welcomed by the president of the CNEL, Renato Brunetta: 'I wish a constituent moment could be formed in the footsteps of that of Camaldoli,' he said: 'We are in the midst of a series of transitions, from the demographic one with longevity that is changing the economic and social organisation to the technological one and the geopolitical one, such as to have effects that change the paradigms that have been valid until now.

For our National Health Service, which was created in 1978 (Law 833/78) when the demographic structure of the population, health needs, and technological innovation were markedly different from today, it would therefore be necessary not to deal with maintenance but with a transformation right from the foundations and with a OneHealth approach, i.e. health in all policies, including industrial policies, and reviewing the welfare mechanism in the country. Crea's request starts precisely from the data that undermine the promises of equity, efficiency and response to the needs of the population. These are 'sacrosanct' principles that must be maintained at the basis of public health," the experts stress, "but unfortunately they have not been fulfilled if it is true, as emerges from the detailed analysis conducted this year by Crea on the last forty years of Italian health history, that it is now more than ever the fragile segments of the population, i.e. the less affluent, the largest families, the elderly and those who live in southern Italy, who pay the bill.

Federalism 'exonerated'

But if the rift between North and South unfortunately remains plastically confirmed despite the recovery plans, the Crea experts exonerate health federalism. The failure to fulfil the promises of public healthcare with a 'creeping privatisation' of health protection that has increased the burden on the shoulders of families would have started in the previous decade: 84% of the increase in the number of families subject to private healthcare spending was accumulated in the 1990s and in that decade public spending increased by an average of 4.4% per year (+0.8% in real terms) while private spending more than doubled (+10.7%). After the 2000s, therefore, after the reform that brought in health federalism in 2001, public and private expenditure grew at the same rate: +2.7% on average per year equal to +0.7% in real terms. A positive effect that then had to be confronted with the economic crisis and the minimal growth of the country's GDP in the years that followed and up to the present.

Household spending

Compared to the 1980s, the proportion of households spending privately on healthcare has increased from 50.8% to 70%, in defiance of the 'promise' of universal and global coverage of health needs, intrinsic to the establishment of the National Health Service. Expenditure soared above all in the following decade and then grew at the same rate after 2000, but with an increase in the number of households spending privately that parallels that of expenditure: the incidence of health consumption on household budgets has more than doubled, reaching an average of 4.3% and touching 6.8% for the least educated. The share of private expenditure borne by the 60% of households with the least economic means has risen from 27.6% to 37.6%. The worsening of equity levels would be the most dramatic effect of the "implicit forms of rationing" that the NHS has had to resort to in order to guarantee its financial sustainability despite the declared choice to rationalise by "corporatising" healthcare, "then substantially failed in its intentions", Spandonaro noted.

What equity

"All equity indicators have failed, with 70 per cent of households now having private consumption," warns Barbara Polistena of Crea. "Even if they were inappropriate consumption, which they are not, the public service should be able to reverse them. But above all," she explained, "families incurring healthcare costs have increased by a good 26% in the first quintile, i.e. the poorest, and by only 8% in the fifth, and the increase in consumption is greater where the head of the family has a low level of education. All elements that run counter to the promises of a fair NHS'.

"The long-term dynamics," reads the Report, "have shown a dystopic trend compared to what should be on the basis of 'legitimate expectations' for the impact generated by a universalist public service, founded on principles of equity of access". The data: the share of families that have resorted to health care consumption by paying privately has increased by 19.2% since 1985 and today over 70% of Italian families go 'out of pocket'. Today this burden is paradoxically worse on those who live in the Centre (75.9%) and the South (70.8%) while the North stands at 68.7%. In the South, private expenditure mostly translates into pharmaceuticals and preventive visits - probably as a result of the difficulty of access to the SSN - while expenditure for long-term care is transversal to all geographical areas. Outlays for dentistry, specialist care and diagnostics are the prerogative of the wealthiest. The incidence of private health expenditure on consumption has reached 4.3%, but even in this case it weighs more heavily on the most fragile: the least educated households now allocate 6.8% of their consumption to health expenditure, compared to 4.6% for the richest households, while for the poorest households the figure is as high as 4%.

On the whole, today in the first three quintiles (the poorest) of households, private healthcare expenditure has risen to 37.6 per cent, with effects on impoverishment and renunciation of care: 367,528 households are impoverished in order to pay for healthcare, and in Southern Italy the incidence is about three times that of the North and double that of Central Italy. The causes? The purchase of drugs, specialist care and dentist, which rises to the top for families with children, while the elderly bear the brunt of Long Term Care. Consumption sacrifices in this scenario are just around the corner, with economic hardship affecting 1.25 million families, equal to 2.3 million residents, while on the other hand there is the phenomenon of catastrophic expenditure (those exceeding 40% of the family's monthly spending capacity) affecting 2.3 million families (+2.1% in ten years), mostly in the South and the North-East, and here too the first items are the dentist and, for the elderly, as can be guessed, Long Term Care.

Which efficiency

The rationalisation of the public health service does not seem to have avoided rationing, which, moreover, is implicit and which has 'offloaded' the burden of health expenditure onto households for an expenditure that is certified at 43.3 billion, i.e. almost a quarter of the total, with a slow but constant growth of the intermediate share to the detriment of the out-of-pocket share. Italy's public health expenditure, which is more than 44% lower than the average of the founding EU countries, today manages to guarantee a public coverage of 72.6%, which is also lower than the EU average and in fact insufficient to close the gap with international standards.

The proposal is to move from implicit rationing to a courageously 'explicit' one, excluding from the Essential Levels of Care (LEA) therapies if they have a limited impact on the family budget, 'despite the well-known difficulties linked to the non-credibility of the Italian tax system in terms of demonstrating the real means of households', the experts cautiously warn.

The inability to respond to needs

The new key-word is 'hybridisation': today we are in the presence of health and social needs together, and the system must take this into account in order to respond to expectations, in a context in which - as a survey conducted by Crea and reported in the Report certifies - the entire area of non-self-sufficiency, long waiting lists and the 'loss of time' in the use of services generate dissatisfaction in the population. "If in the 1980s the paradigm on which the SSN was built was the response to acute cases, now health policies must be revised and also oriented towards non-deferrable needs such as non-self-sufficiency. But we are at a standstill: the strategy applied has remained the same instead of attempting to reconcile the need with the expectation of users. Above all, without integration between social and health, it is impossible to protect frailty,' Polistena continues. In this context, the criterion of appropriateness must also change: everyone should be able to make the most of the opportunities in the field - of which only galloping technologies have managed to carve out a crucial role - in order to optimise outcomes, including the satisfaction of citizens who demand personalised and humanised care, capable of minimising the effects of the disease on their daily lives. Two data above all clash with this scenario that has yet to be realised and on which 'the very recent reform proposal launched by the Council of Ministers seems inadequate', the experts observe: just 13 hours of annual home care equal to one hour per month for those who are cared for at home, and an extreme variability in nursing services for the elderly in RSAs: from 72 minutes per day in Valle d'Aosta to 6 in Friuli Venezia Giulia, and from 147 minutes of social welfare support in Emilia Romagna to 27 minutes in Calabria.