This paper studies the health consequences of administrative centralization in healthcare, focusing on the consolidation of Local Health Authorities (LHAs) within the Italian National Health Service. This type of reform fits within a broader set of cost-containment efforts aimed at reducing administrative expenditures and exploiting economies of scale. In the Italian case, the reform centralized governance and expanded the scale of health administration, creating authorities with substantially larger catchment areas and shifting decision-making to more heterogeneous jurisdictions. Such changes may affect the responsiveness of healthcare provision to local needs, the coordination of service delivery, and access to care. Using an event-study Difference-in-Differences design, we estimate the policy’s impact on municipal mortality rates, accounting for heterogeneous treatment effects and co-occurring fiscal adjustment policies. We find a significant increase in mortality starting four years after implementation, with an average treatment effect on the treated of 2.1%. The effects are concentrated in municipalities belonging to absorbed LHAs and in those exposed to mergers involving relatively large pre-reform LHAs and substantial post-merger expansions in catchment areas; they are also unevenly distributed, creating new vulnerable areas. Welfare estimates based on life-years lost indicate that the monetary costs of increased mortality exceed plausible administrative savings by roughly an order of magnitude.

We study how Italy's need-based student-aid system (Diritto allo Studio Universitario, DSU) shapes first-time entrants' choices of where and what to study by linking administrative records on first-time enrolments to university characteristics and DSU service provision. Using a Latent Class Logit model that accounts for heterogeneity in preferences, we find that dormitory capacity for eligible students substantially increases enrolment: adding 100 places raises enrolment at an average-sized institution by 5.3-9.6% (equivalent to about 19 to 34 additional students). By contrast, grants show no statistically significant effect. Dormitory availability matters most for students who lack a nearby university and those in STEM fields. Simulations focused on alternative expansions of dormitory supply suggest that a nationwide increase reallocates enrolment toward central/northern hubs and higher-quality institutions, whereas regionally targeted support in the South only marginally curbs South-to-North flows.

This paper investigates the road safety impact of a restriction in engine power on novice drivers. The restriction, introduced in Italy in 2011, prevents drivers from using high-performance vehicles during the first year they have their license. To estimate the effect on teens' traffic accidents, we leverage the between-cohorts difference in exposure to the reform. When prevented from using high-powered cars, teens are 13 percent less likely to cause an accident and 28 percent less likely to cause a fatal accident, mainly because of fewer speeding violations. This effect persists even after the 1-year restriction ends. These findings highlight the importance of targeted policies-directed at those generating the greatest harm-that limit exposure to specific high-risk settings. These policies stand out as an effective yet feasible alternative to deterrence-based strategies and screening mechanisms, which are often difficult to enforce and sustain.

We study the relationship between energy poverty and subjective well-being by combining objective and subjective indicators in a multidimensional energy poverty index (MEPI). Using the Italian release of the European Survey on Income and Living Conditions, we first assess the identification power of this index vis-a-vis standard ’affordability’ indicators. Subsequently, we use the MEPI in a simultaneous bivariate ordered probit model accounting for the endogeneity between subjective well-being and energy poverty arising from considering subjective indicators. We find a clear additional role by the subjective indicator in the identification of the energy-poor and a relatively low overlapping degree between MEPI and affordability measures. Likewise, econometric estimations detect sizeable and statistically significant negative effects on life satisfaction as the severity level of the MEPI rises. In contrast, virtually no effects are found with affordability indicators. The impact is substantially smaller when the MEPI only considers the subset of objective indicators.

Long-distance hospitalizations may represent an important phenomenon, especially with severe pathologies. In this work, we investigate patients' elective admissions for cancers of the digestive system distinguishing between "local" hospitals (located in the region of residence) and "distant" hospitals (located in long-distances non-boundary regions). We model patient mobility towards alternative hospitals as a discrete choice process determined by geographical distance, clinical quality and other hospital-level characteristics and control for patients' heterogeneity. We exploit data on admissions of patients residing in insular Italy, occurred in 2013 either locally or in central-northern hospitals, and estimate a willingness to travel of at least 14 km to be cured in a distant hospital for a quality increase from the 75th to the 25th percentile. Higher values are found for younger and more educated patients. Clinical quality does not affect the choice of local hospitals. Hospital choice significantly depends on characteristics that proxy hospital attractiveness, with differences between local and distant providers: commitment to research and private ownership show a positive role only for the latter.

We study the effect of top marginal tax rates on turnover and migration patterns of football players in 19 countries between 2006 and 2016. This phenomenon is analyzed both at the international and inter-regional level by exploiting national and regional variation of the effective marginal tax rate. We estimate two-sided matching model using a maximum score matching approach. This allows us to account for the competition on each side of the market, and get rid of factors affecting both the demand and supply side for which information is hardly available (namely, wages of top-level workers). The structural parameters of the underlying decision process are exploited to quantify the sensitivity of tax payers to taxation, the existence of sorting effects and the heterogeneity of these effects based on the ability of the player. Our results suggest that, once controlling for the matching structure and the observed dimension of the market, the estimates of taxpayers’ sensitivity to taxation is lower than the ones presented in the previous literature. The elasticity of migration relative to the net-of-tax rate is 0.04 for natives and 0.80 for foreigners in the top 10% of the quality distribution while is around 0 if we consider all the population. However, the results suggest that lower taxes rates can increase the average quality of the country attracting more high-ability players who displace medium and low-quality players. ∗Mail address: cristian.usala@unica.it †Mail address: brau@unica.it

The paper offers an exploratory empirical analysis of the impact on consumers’ welfare of the reforms of the gas industry in 15 member states of the European Union. After considering some features of the natural gas industry and of its reform in selected countries, we study the relationship between regulatory reform indicators (as summarized by the REGREF database by the OECD) and price dynamics by means of panel data techniques. We then present a simple exercise of welfare evaluation and to what extent price dynamics and the reforms have an impact on subjective consumers’ satisfaction, as reported by three waves of the Eurobarometro survey. We also compare REGREF indicators with the Market Opening Milestones database, prepared by Copenhagen Economics on behalf of the European Commission. We do not find evidence that privatization per se has an impact on productivity, prices or satisfaction, while vertical disintegration seems to be beneficial.

Interregional patient mobility in a decentralized healthcare system. Regional Studies. Interregional patient mobility, measured as origin-destination patient flows between any two regions, is analysed within a dynamic spatial panel data framework using 2001-10 data on Italian hospital discharges. The aim is to assess the effects of the main determinants of patient flows, distinguishing between the impacts of regional health policies and those exerted by exogenous factors (geography, size, neighbouring regions, national policies). Empirical results indicate that the main drivers of mobility are regional income, hospital capacity, organizational structure, performance and technology. Moreover, neighbouring regions' supply factors, specialization and performance largely affect mobility by generating significant local externalities.

The presence of military assets characterizes the landscape of the areas where the asset is located also in socio-economic terms. In our analysis, we first distinguish between “historical” sites covering events up to the Second World War, and “recent sites” related to the Cold War. We also distinguish between tangible heritage, such as constructions and artefacts of various ages, and intangible heritage, mainly areas where battles and major military events took place. Battlefields form the core of a variety of tourism products: from cultural and educational tourism, to commemoration of events with re-enactment of battles, to the so-called “memory tourism”, up to the so-called “dark tourism”. We start with a short analysis of strategies adopted by public administration to dismantle and reuse historical military sites, focusing on the shift from a totally public management to the gradual involvement of privates. Usually, reuse of historical sites is addressed to tourism and cultural purposes. Then, we focus on the Cold War heritage, characterised by larger areas, important infrastructures and high environmental contamination. Private investment is fundamental to the reuse and management of these sites. A wide range of possibility of reuse has been identified. Finally, we analyse battlefield-related tourism megatrends. Our analysis aims to make a review of reuse of military sites, especially where economic data are available to verify the amount of resources used or catalysed by the reuse of a military sites. During the analysis, we will proceed to identify the main characteristics of the reuse process. These and other information will be useful to derive general indications on what are the economic potentials (and limits) of Sardinian military vestments, considered in their dual nature of tangible asset and intangible heritage. In addition, we discuss the application of economic valuation tools to closure and reuse of military sites.

Free patient mobility among autonomous providers has been often considered an effective stimulus for enhancing healthcare. However, some jurisdictions may underperform due to the existence of economies of scale and spatial spillovers. Where regions assume the costs of providing care to residents, this could challenge the sustainability of regional budgets in a decentralised National Health Service (NHS) and put at risk universalism and equity of health care. We use a ten years (2001-2010) panel of Italian data on hospital discharges to assess the determinants of inter-regional mobility and to distinguish between factors related with policies pursued by the regional health authorities from extra-regional (neighbouring regions or national-level) factors. Data on hospital discharges are merged with a set of variables on salient features of hospital care services in each Regional Health System (RHS) and with information on demographic and economic characteristics of Italian regions. We analyse bilateral Origin-to-Destination (OD) flows between any two regions by means of a gravity regression model that includes a rich set of push and pull factors. Compared to previous studies, mainly performed on cross-section samples, the longitudinal dimension of the data enables us to estimate a nonlinear conditionally correlated random effects dynamic model that accounts for region-pair-specific unobservable heterogeneity. Moreover, we address the issue of cross-regional dependence arising from the existence of regional spillovers by applying recent advances in spatial econometrics (Elhorst, 2014; Vega and Elhorst, 2015). The model is estimated for total inter-regional patient flows and for specific types of hospital admission, namely surgery, medicine and cancers. Finally, the estimation results are used to analyse specific what-if scenarios relevant to the health authorities for the national and sub-national management of services. Our main results suggest that, beside regional population and income, local supply factors such as hospital capacity and technology endowment, clinical specialization and performance indicators are important drivers of patient mobility. Moreover, geography matters and spatial proximity plays a relevant role in reinforcing inter-regional mobility patterns. Our econometric analysis has also detected a mildly explosive dynamics in inter-regional patient mobility over time. This result, coupled with the significant role played by factors not directly controlled by regional policy-makers and RHS managers (e.g. population, GDP per capita and spatial spillovers), might induce a polarisation between the group of the richest, most populated and best performing regions, which are increasingly capable of attracting more patients, and the group of the weakest regions, with growing patient outflows and severe financial and organizational problems. These considerations call for a thorough assessment of the long-run sustainability of the current decentralised NHS. RHS budget autonomy could not be entirely consistent with free patient choice. This opens a more general discussion on whether and to what extent the health financing system would require the introduction of appropriate equalising compensation schemes aimed at neutralising the financial consequences of mobility and, eventually, at guaranteeing universalism and equity in healthcare.

Restrictions on hours and day of alcohol sale constitute a command-and control policy tool commonly used by policy makers in order to reduce the negative externalities related to the alcohol abuse. A recent application of this approach is the law n. 120/2010 by the Italian Parliament, which has prohibited the off-trade sale of hard liquor on motorway services areas between 10 pm and 6 am and the on-trade sale of soft alcohol beverage since 10 th August 2010. By exploiting the heterogeneity of the location of hospitals, which are partly contiguous to Italian motorways, and partly located in geographical areas without motorways (which can be viewed as the control group), we evaluate the effect of this policy ban on hospitalization related to car accidents and alcohol intoxications using a difference-in-difference approach. We merge patient level data from the Italian Ministry of Health covering the period 2007-2013 with information regarding hospitals locations and characteristics and with data on the socio-economic characteristics of the surrounding areas. Preliminary exploratory analysis suggests a reduction of hospitalizations for car accidents attributable to the alcohol ban (in hospitals located near the motorways) ranging between 2.1% and 4.5%.

This paper explores the export activities of international firms from seven European countries with a special focus on the neighbourhoods of Europe, where 16 countries have been included in the neighbouring policy. Using a detailed dataset of the internationalisation activities of nearly 15,000 companies, we focus on the best export destinations of European Union firms. In 2008, only 6% of exporters had at least one neighbouring country in their top three export destinations. We subsequently model the export/no-export activity of each firm and the location of the first export destination by means of a nested logit model and find that this process is driven primarily by geography. No reduction (or even an increase) of the strength of the distance effect can be detected for a firm when exporting outside Europe to nearby countries, meaning that European Union firms do not have any particular advantage in exporting their goods in countries near their borders with respect to all the other possible destinations in the world. The ‘repulsive force’ of distance is alleviated only when moving outside of neighbourhoods where the size of the destination market becomes stronger.

This paper investigates long-term home care utilization in Europe. Data from the first wave of the Survey on Health, Ageing and Retirement (SHARE) on formal (nursing care and paid domestic help) and informal care (support provided by relatives) are used to study the probability and the quantity of both types of care. The overall process is framed in a fully simultaneous equation system that takes the form of a bivariate two-part model where the reciprocal interaction between formal and informal care is estimated. Endogeneity and unobservable heterogeneity are addressed using a common latent factor approach. The analysis of the relative impact of age and disability on home care utilization is enriched by the use of a proximity to death (PtD) indicator built using the second wave of SHARE. All these indicators are important predictors of home care utilization. In particular, a strong significant effect of PtD is found in the paid domestic help and informal care models. The relationship between formal and informal care moves from substitutability to complementarity depending on the type of care considered, and the estimated effects are small in absolute size. This might call for a reconsideration of the effectiveness of incentives for informal care as instruments to reduce public expenditure for home care services.

This chapter examines patient mobility across Italian regions using data on hospital discharges that occurred in 2008. The econometric analysis is based on Origin-Destination (OD) flow data. Since patient mobility is a crucial phenomenon in contexts of hospital competition based on quality and driven by patient choice, as is the case in Italy, it is crucial to understand its determinants. What makes the Italian case more interesting is the decentralization of the National Health Service that yields large regional variation in patient flows in favor of Centre-Northern regions, which typically are 'net exporters' of hospital treatments. We present results from gravity models estimated using count data estimators, for total and specific types of flows (ordinary admissions, surgical DRGs and medical DRGs). We model cross-section dependence by specifically including features other than geographical distance for OD pairs, such as past migration flows and the share of surgical DRGs. Most of the explanatory variables exhibit the expected effect, with distance and GDP per capita at origin showing a negative impact on patient outflows. Past migrations and indicators of performance at destination are effective determinants of patient mobility. Moreover, we find evidence of regional externalities due to spatial proximity effects at both origin and destination.

Patient mobility is a crucial phenomenon in contexts of hospital competition based on quality and driven by patient choice. This study examines inter-regional patient mobility in the Italian National Health Service, a regionally decentralised tax-funded system in which in-patient hospital services are provided free at any point of use in the whole country, using administrative data on hospital discharges from 2001 to 2010 in all public and private accredited hospitals. The aim is to understand whether mobility patterns might have consequences for the efficiency and effectiveness of the healthcare provided at the regional level, as well as universalism and equity in healthcare. We specify a gravity model for Origin-Destination (OD) flow data that distinguishes between emissiveness (at Origin) and attractiveness (at Destination) factors affecting bilateral flows. We exploit the longitudinal dimension of the data and estimate a negative binomial conditionally correlated random effects (CCRE) dynamic model that allows for region-pair-specific unobservable heterogeneity. Total and specific types of flow (surgical, medical, acute and cancer-related admissions) are modelled, accounting for the correlation between unobserved region-pair effects and time-variant covariates and their spatial lags. Our main findings indicate that RHSs in the richest regions attract more patients from other regions and that the most effective pull factors are the number of beds and diversification of the organisational structure. We also find that the ability of a RHS to attract patients who reside in other regions decreases with the concentration of the organizational structure. Finally, we have detected a mildly explosive dynamics in inter-regional patient mobility over time, which could have implications for the long-run sustainability of the overall national-regional health system.