Public health systems and private expenditure in non-US countries. Toward a regulated health insurance model?

Traditional healthcare models (National Health System and Social Health Insurance) are increasingly converging into mixed systems as advanced economies seek to balance equity with fiscal sustainability. Despite long-standing debates on regulated competition, systematic evidence regarding its multidimensional effects remains fragmented. This study aims to identify the regulatory principles governing private health insurance markets and determine the contextual conditions necessary for their successful implementation, with a particular focus on applicability to the Italian context. A systematic literature review (SLR) was conducted, focusing on OECD countries, identifying some possible solutions to be studied in depth. Inclusion criteria prioritized European and international cases transferable to the Italian paradigm, while U.S.-based evidence was excluded due to significant institutional and structural divergences. The study proposes a novel conceptual framework suggesting that a system’s expenditure profile (specifically per-capita spending, private expenditure share, and intermediated pooling) is a more robust predictor of regulatory efficacy than its formal institutional type. While high-expenditure systems like Germany and the Netherlands demonstrate sophisticated oversight, mixed models like Switzerland underscore the necessity of institutional reforms to safeguard universal access. Our findings suggest that transitioning toward regulated competition requires a sequenced policy approach, characterized by the establishment of robust intermediaries and dedicated regulatory authorities to mitigate risks such as adverse selection and provider backlash. This study proposes an innovative framework that bridges the benefits and risks of emerging models with diverse national contexts.