Ticket o franchigia? Considerazioni per una riforma delle compartecipazioni alla spesa sanitaria

Following the recent debate on the Italian National Health Service (NHS) revision of the copayment system, this chapter provides a theoretical analysis of the effects of moving from a cost-sharing system based on copayments, with exemptions for low income and chronic conditions (like the current Italian one), to a system based on a deductible without exemptions. In principle, the system based on the deductible would have two advantages: 1) it could limit patients’ cost-sharing total expenditure, protecting them against the high financial risk they would incur in the event of severe or frequent illness episodes; 2) it could cut the admininistrative cost of cost-sharing exemptions. However, the system with a deductible presents drawbacks both in terms of allocative efficiency (the control of moral hazard is less effective) and in terms of equity (higher probability that low income patients reduce their health care consumption below the appropriate level). Other two systems of cost-sharing are then analysed: a system of copayments differentiated according to patients’ income and a maximum NHS coverage system based on patients’ characteristics and health needs. Both systems are effective in limiting moral hazard, while ensuring higher equity than systems without income differentiation in cost-sharing. However, both systems are characterised by higher administrative costs.