An analysis of the dynamics of health care policy in Italy suggests that in recent years the pace of change in the health care system has accelerated. Although the basic features of universalism, comprehensiveness, and funding from general taxation have remained remarkably constant, the capacity to innovate policy tools and their settings and to take account of domestic and international experience seems to have increased. The political will and capacity to combat entrenched interests may also have increased, although implementation is still weak. The imperative to contain public expenditure has heavily conditioned health policy and will continue to do so. This has occurred mainly at the national level, but as the principal locus of health-policy making progressively shifts to the regions, so too will the constraining effect of this imperative move downward. If the decentralization process continues, problems could arise due to interregional differences in capacities to formulate and implement appropriate policies and to tackle special interest groups.