Chapter 2

lisation of health care differs according to the socio-economic standing of the household
members, thus determining forms of horizontal inequality.
In particular, in the case of basic services, such as general practitioner the horizontal inequality
index is negative, i.e. people in a lower socio-economic position make greater use
of these services, compared to their degree of need. On the contrary, the index is positive
for specialist examinations and diagnosis, which means that these are more than proportionately
used by the better off.
In terms of health policies, these results highlight both the need of commitment in removing
inequality to access, but above all the causes of inappropriate response, and also
the need to rethink the capitation system.
The current capitation formula, implemented in accordance with Law 662/1996, in fact
does not take account of the above mentioned factors. On the contrary, it is based, inappropriately,
on the frequency of health care consumption, thus appearing outdated and
a potential source of unfairness.
Government of the health care system cannot be limited to the control of public expenditures.
Our analysis has confirmed the presence of a considerable amount of OOP, fueled
by opting out decisions, but also by co-payments and intra-moenia services.
A response to these problems - consistent with developments in Europe - must be searched
for in the mechanisms of supplementary insurance (second pillar).
The analysis of the current levels of insurance coverage of households provides some useful
elements for the purpose of an effective development of supplementary insurance.
In the present conditions of scarce encouragement and regulatory uncertainty, the supplementary
health insurance market is not only growing very slowly, but is very much at
risk of finally collapsing with damage both for the companies and the households.
This is the conclusion reached by Borgia and Doglia (see chapter 3.8), who observe how
OOP expenditure of insured households is substantially similar, in level and composition,
to that of non-insured households.
This apparently paradoxical phenomenon is the result of both a sort of adverse selection,
i.e. only the wealthier households, and among those only those with a greater propensity
to health care spending, take out policies today, and of the substantially duplicative nature
of these policies.
Private health insurance, however, should not be a prerogative of the wealthier households;
consequently public actions should aim at introducing a doubly selective system
of incentive in favour of lower-income households and based on the type of service covered.
This would have the twofold positive effect of increasing the amount of health policies
taken out and, thanks to the ensuing larger pooling of the risk, of lowering the policy
premiums applied by the insurance companies, finally countering the previously mentioned
adverse selection.
6 The benefits of the system: the management of quality (and other dimensions)
Health care schemes have significant costs, but they also produce important direct and
indirect benefits.
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CEIS Health Report 2006