The migration phenomenon continues to have global effects, with increasing waves of migration since the end of the COVID-19 emergency [1,2], and this development is particularly evident in Europe [3].

Along with the increase of flows, distrust towards immigrants has increased. For instance, scholars have documented a new wave of populism, which interprets the presence of immigrants as a threat to the traditional identity and values of the host country [4], with an increase of anti-immigration policies in western countries (e.g. the United States [5]). In this scenario, it is not easy for policymakers to launch new integration policies if the country is not inclined to implement them.

As a consequence of the increasing inflows, host countries are interested in their impact, primarily in the economic dimension. Concerning health expenditure in OECD countries, it has recently been demonstrated that the spending increase due to annual influxes of immigrants would be recorded only to their out-of-pocket and not public healthcare expenditure [6]. Other studies have shown that, at the same time, immigration leads to a redistribution of expenditure in host countries, increasing defence and public order spending and decreasing that for welfare [7]. Studies have meanwhile underlined the need to evaluate the phenomenon with respect to longer time periods, so as to be able to appropriately address the issue of endogeneity with respect to the predictive models already being used [6].

With reference to the ‘quality’ of current health policies, Dourgnon et al. [8] highlighted that better health conditions and a lower demand for health services that are unsatisfied for non-financial reasons (i.e. long waiting times or distance/transport limitations) are associated with ‘immigrant-friendly’ health policies and the author therefore invites policymakers to formulate such policies.

In this context, the analysis of the Italian case is interesting for both scholars and policymakers for several reasons. First, Italy is a country of interest regarding its demographic dynamics and their impact on health expenditure. Lopreite and Mauro [9] have highlighted that longevity affects Italian health expenditure more than other variables such as life expectancy and per capita GDP. More recently, Lopreite et al. [10] have concluded that policies focused on the elderly and new technologies have the potential to moderate expenditure growth. Related to the changing demographics, Italy has also been affected by an intense wave of immigration since the 2000s. The phenomenon is recent, and it is interesting to observe its impact over time [11], especially concerning the ageing of migrants, their access to care and the impact on spending. Second, Italy is one of the European countries with a longer tradition in defining health policies for migration [12,13] and performs well in terms of the response of the national health service to the needs of migrants, as evidenced by the score of 79 out of 100 in the ‘Health’ area of the Migrant Integration Policy Index 2020 [14]. However, the general perspective of the country and the political initiatives for immigration have not always been favorable to integration, and a reflection on the possible ‘mixed’ effect of these different attitudes towards immigrants is interesting for the community of policymakers. Third, with respect to the impact on Italian health expenditure, Bettin and Sacchi [15] recently estimated that an increase of 1% in the share of immigrants would lead not to an increase in public spending, but rather to a reduction of almost 4%: a result even better than that estimated by the recent abovementioned research. However, the intersection between the ‘quality’ of the policy and the impact on the expenditure has not been sufficiently investigated.

Given the above, the aim of the study is twofold: a) to reconstruct, on the one hand, the national health and integration policies over time, promoted by a country reputed to be ‘immigrant-friendly’ [8], highlighting their strengths and weaknesses; b) on the other hand, to study, in the same context, the impact of regular immigration on healthcare expenditure, with a predictive model that overcomes some of the limitations of those already used in the literature. This analysis is aimed at estimating whether Italy's choice to implement integration policies has been transmuted into an increase in healthcare expenditures.

With reference to the previous aims, the study is organised as follows. In section 2, through the analysis of the legislation and the policy documents, the work highlights the essential features of the Italian legislation and of the policies developed for the integration and healthcare of migrants. Section 3, through a quantitative approach, examines the impact of regular immigration on health expenditure using the PVAR model, which has the advantage of allowing the analysis of panel data at cross-section and time-series levels. Section 4 presents discussion, draws conclusions and suggests improvements to healthcare policies for migrants.