The Seventh Report on the Budget of the Social Security System edited by the Center for Studies and Research Itineraries Social Security offers an interesting insight also on the state of health of public and complementary health of our country: while the out-of-pocket expenditure supported by Italian families continues to grow, supplementary health care struggles to impose itself.

In 2018 – before tax benefits – more than 98.134 billion euros were spent to supplement public benefits for pensions, health and care. In detail, 44.96 billion (i.e. 45.7% of the total) were allocated to health care and health care both directly and brokered by funds and health funds; 33.98 billion have in fact been absorbed by "non-self-sufficiency" between home or residential care; 16.2 billion were used to build a supplementary pension form; 3.096 billion were finally directed to individual insurance protections.

Even taking into account the tax benefits provided by the current legislation, the proportions do not change and the so-called out-of-pocket expenditure remains the most significant of the expenditure items incurred for private welfare. Excluding tax deductions and deductions, Italians have paid for more than 36 billion euros of services, services or health products out of their own pockets. This is a growing value that has been growing in recent years, and to which we must also add the value of the intermediate expenditure, namely 4.9 billion costs incurred for contributions to supplementary health funds or insurance premiums. Over the same period, public health spending – financed by general taxation – reached 115.41 billion. In the last 5 years, from 2013 to 2018, it has grown by 4.87%, or just over inflation (3.55%). A modest increase, while taking into account both the effects of the progressive ageing of the population as well as the reduction in the population recorded (-0.7%), mainly "attributable" to the growth in spending on intermediate consumption and market purchases. On the other hand, the expenditure on staff is decreasing, although the shortage of specialist and basic doctors, anesthesiologists and nursing staff is one of the main issues that loom over the system; and even more – as some of the "coronavirus" emergency is already pointing out – it will be in the coming years due to both the impact of Quota 100 and, more generally, the very high average age of the workers currently employed in Italian hospitals.

Thus, far from being (perhaps apparently) cold, the numbers with which the Seventh Report describes Italian public and private health testify to a state apparatus that is likely to suffer with difficulty the pressures exerted by new demographic trends and supplementary health care still not enough

ready to adequately fill in possible voids and areas of shadow. While it is true that the Italian health service can still define itself as a good level despite some obvious critical issues (in addition to those already mentioned, it is worth remembering, the length of waiting lists and consequent delays in access to care, health migration phenomena, the management of resources not always efficient), it is in fact also difficult in the future to overcome these difficulties by further increasing spending on welfare. Welfare, which, in 2018, has already absorbed a share equal to 26% of GDP, 56.62% of contribution and tax revenues, and 54.14% of total expenditure.

And so, while it seems to be quite easy to explain why Italians increasingly prefer to pay for care out of their own pockets, a further conclusive reflection can only be due to supplementary health care that, in the heavy absence of a framework law, is struggling to take off. Just 10.5% of the approximately 44.96 billion euros spent on private health in 2018 was conveyed through intermediaries. The estimate of the members, on the other hand, is about 13.5 million assisted and offers further proof that much can still be done in terms of the extension of the audience of beneficiaries, using for example the tool of collective bargaining where possible and, in parallel, increasing the degree of awareness of potential members about the importance of turning to qualified spending intermediaries.

Given that a greater use of organized forms of brokerage would result not only in a lower cost for individuals and families, but also in a more effective control of the quality of benefits, it is then to be asked what is the brakes on Italians from opting for intermediate spending solutions, on paper potentially more tax-advantageous from a fiscal and organizational point of view than having to take completely autonomous examinations , specialized visits or other social and health benefits?

If a first reason is to be identified in a kind of cultural resistance, not to benefit according to the Center for Studies and Research Itineraries Social Security is then undoubtedly the lack of a real discipline on the subject, on which periodically hang proposals or "threats" of reordering and downsizing, which tend to discourage citizens eager for clear rules, certain and valid in the same way for everyone. Aid in this regard could, for example, come from overcoming the "discrimination" in terms of tax benefits between employees and non-employees (self-employed, etc.): while the former have the option of deducting up to 3,615.20 euros, the latter can only deduct the membership contribution to 19%, up to a maximum of 1,300 if they choose to join a mutual aid company. In fact, in order to qualify for tax deductibility, non-employees can only apply to type A health funds (those "doc") with the right to reimbursement of only benefits that are not obtainable by the National Health Service. Experience that, moreover, the numbers show us not to grasp the interest of the Italian population, considering also the difficulty of understanding the limits of LEA (Essential Levels of Assistance) to be integrated within a health system with profound differences from region to region.

Regardless of the tools with which to pursue it, the objective to be chased is still clear: provided an effective activity of coordination of the respective actions (and conventions) to maximize the activity of professionals and the use of the tools, the future of Italian health passes – also – from a healthy development of integrative health care.