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This work aims at identifying the determinants of health spending differentials among Italian regions and at highlighting potential margins for savings. The analysis exploits a data set for the 21 Italian regions and autonomous provinces starting in the early 1990s and ending in 2006. After controlling for standard healthcare demand indicators, remaining spending differentials are found to be significant, and they appear to be associated with differences in the degree of appropriateness of treatments, health sector supply structure and social capital indicators. In general, higher regional expenditure does not appear to be associated with better reported or perceived quality in health services. In the regions that display poorer performances, inefficiencies appear not to be uniformly distributed among expenditure items. Overall, results suggest that savings could be achieved without reducing the amount of services provided to citizens. This seems particularly important given the expected rise in spending associated with the forecasted demographic developments.

The experience of other successful monetary unions and economic theory suggest that the euro area would benefit from the establishment of a supranational fiscal capacity. Institutional reforms prompted by the crisis (e.g., the European Stability Mechanism and the banking union) are introducing -though to a limited extent -elements of cross-country risk sharing. Nevertheless, further steps are probably needed. Proposals to create a sort of rainyday fund present major practical difficulties -associated, inter alia, to the uncertainty characterizing the identification of shocks in real time. A more appropriate solution, consistent with how risk sharing operates in existing federations, may be centralizing specific public functions (for instance, by introducing a common unemployment benefit scheme). We argue that consideration could also be given to the creation of a euro-wide, notional defined-contribution pension scheme.