Geographical variation in the use of private health insurance in a predominantly publicly-funded system

•The role of private insurance in public funding dominated systems is under-investigated.•We analysed claims from over 200,000 private insurance holders residing across Italy.•Residents in internal areas and southern regions use private health insurance much less than those residing in metropolitan areas and central–northern regions.•Both supply and demand factors can explain these large differences. We provide evidence of geographical variations in the use of private health insurance (PHI) in Italy. Our study offers an original contribution, using a 2016 dataset on the use of PHI amongst a population of more than 200,000 employees of a major company. The average claim per enrolee was €925, representing approximately 50% of public health expenditure per capita, primarily for dental care (27.2%), specialist outpatient services (26.3%) and inpatient care (25.2%). Residents in northern regions and metropolitan areas respectively claimed reimbursements for €164 and €483 more than those in southern regions and in non-metropolitan areas. Both supply and demand factors can explain these large geographical differences. The study suggests the urgency for policymakers to address the considerable disparities in the Italian healthcare system, revealing the overall social, cultural and economic conditions that shape the demand for healthcare.