中文摘要
本文研究医疗领域行政集中化的健康后果，聚焦于意大利国家卫生服务体系中地方卫生局（LHAs）的合并。此类改革属于更广泛的一类旨在削减行政支出并利用规模经济的成本控制举措。就意大利而言，该改革集中了治理权并扩大了卫生行政的规模，形成覆盖区域显著更大的卫生局，并将决策权转移至更为异质的辖区。这些变化可能影响医疗供给对地方需求的响应性、服务提供的协调以及医疗服务的可及性。我们采用事件研究双重差分设计，估计该政策对市镇死亡率的影响，并处理了异质性处理效应与同期实施的财政调整政策。我们发现，政策实施四年后死亡率显著上升，处理组平均处理效应为2.1%。效应集中于被吸收地方卫生局所辖的市镇，以及那些涉及改革前规模相对较大的地方卫生局合并、且合并后覆盖区域大幅扩张的市镇；这些效应分布不均，并产生了新的脆弱地区。基于损失寿命年的福利估计表明，死亡率上升的货币成本大约超出合理的行政节约一个数量级。
Abstract
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.