The use of voluntary health insurance in the access to specialist care: Evidence from the Italian NHS

We examine whether the endorsement of voluntary health insurance (VHI) in a Beveridge-oriented healthcare system may increase the probability of visiting a specialist. We use data from the 2019 European Health Interview Survey, which includes information on demographics, socioeconomic characteristics, health status, and healthcare access of over 30,000 Italian households. We also apply data from the Health for All dataset to measure the supply of physicians at regional level. In order to account for endogeneity and unobserved heterogeneity, data is modeled through a simultaneous equation model for binary variables, specifically a trivariate recursive probit. Findings show a positive impact of VHI on the probability of accessing specialist care, after controlling for physician distribution. A socioeconomic gradient is also detected in the probability of both holding VHI and visiting a specialist, with wealthier and better educated individuals showing more likelihood to do so; these results raise concern on the equity of access granted by a Beveridge-oriented system. The role of the GP in filtering the need for care and referring patients to specialists is also recognized. Both supplier inducement effects and macroregional fixed effects are detected in the access to either category of physicians.