Among the measures being studied to achieve a balanced budget in 2013 there is a further tightening of co-payments, especially in the case of "improper" hospital admissions. It is easy to predict that this will fuel a new hornet's nest of controversy. In the wake of the increase already decided with the July maneuver, for weeks the Regions have been complaining about the umpteenth meddling of the central government in a sector of their competence. The opposition and the trade unions have denounced the socially unfair nature of the new tickets. The League has asked to eliminate the increases by introducing a new excise duty on tobacco. Finally, experts and commentators have pointed the finger at a tool considered to be ineffective, which also creates unequal treatment between residents of different regions. There is a grain of truth in each of these positions. However, they all evade a question that lies ahead of any specific criticism: can Italy afford unconditionally free public health care? The answer is no. Not with the budgetary constraints we have and not with our demographics. It may well be that the tickets currently in force are not the most equitable and efficient ones: it is therefore useful to discuss them. But without the illusion of being able to eliminate them and clearly explaining the terms of the question to the citizens. Italian health expenditure has grown rapidly in the last decade and is now in line with the EU average. Compared to other countries, we spend more on medicines and hospitals, less on local services, especially those for non-self-sufficiency. Demographic aging will increase the demand for services, but the margins for increasing public resources are very narrow. The State and the Regions could make the following proposal to those who have the possibility (a large part of the middle class): today I ask you for a higher contribution on all services, but I will not leave you alone if tomorrow you become non self-sufficient. Tickets exist throughout Europe and are generally higher than in Italy. Let's take Sweden, a generous and inclusive welfare model. There you pay the full cost of the medicines up to 94 euros. Only when the expenditure exceeds 450 euros per year do the medicines become completely free. Each visit to the general practitioner costs between 10 and 20 euros, 35 from specialists. Finally, the ticket is also paid for hospital admissions: 10 euros per day. The quality standards of Swedish healthcare are high, but more or less comparable to those of our Centre-North. However, the internal articulation of the health service is different, much better equipped to respond to chronic-degenerative pathologies. The Swedish lesson is clear: universal healthcare does not mean free services for all, but balanced coverage of the full range of health-related needs, with appropriate 'entrance fees'. It goes without saying that many ingredients are needed to build a Swedish-style system, but financial contributions from users are one of them. An increase in excise duties on tobacco is also welcome: not in place of co-payments, but to find additional resources that we desperately need. In all countries, partnerships have exemption rules. However, our system leaks everywhere. Almost half of Italians do not pay the ticket. On the basis of the available data, it is difficult to make precise estimates: but it is highly probable that among the 28 million exempt citizens there are many "false positives", i.e. people who declare lower incomes than the real ones or who, despite being exempt due to disease or age, would have the means to pay part of the costs. It should be noted that in the face of
