Through prepaid compulsory insurance managed by the central government, Italy's National Health Service (NHS) provides full coverage, free accessibility, and no or limited copayment by individuals when receiving health services. Although Italy spends less than other countries on health care (< 8% of the country's gross national product), the present NHS faces considerable difficulties, and its performance regarding quality, outcome, and spending has come under question. ICUs account for < 2% of total hospital beds, and the proportion of ICU patients is < 2.5% of all hospital patients (2.5% of all Italian hospital patients receive ICU care at some time during their hospital stay). Information from administrative databases and epidemiologic studies gives an interesting national picture of the situation in Italy regarding admission criteria case mix, and outcomes when compared with data from other countries. Important changes in the financial and institutional framework of the NHS are underway, yielding an unpredictable scenario for the future. Innovations focus mostly on cost containment and quality initiatives. These innovations will likely produce a new health service in which regions will have a more important role than in the past. Actions planned in a large Italian region by the local government are used as an example to explain the potential impact of this new trend on critical care medicine.