Objective To provide new evidence on whether and how patterns of health care utilization deviate from horizontal equity in a country with a universal and egalitarian public health care system: Italy. Data Sources Secondary analysis of data from the Health Conditions and Health Care Utilization Survey 2005, conducted by the Italian National Institute of Statistics on a probability sample of the noninstitutionalized Italian population. Study Design Using multilevel logistic regression, we investigated how the probability of utilizing five health care services varies among individuals with equal health status but different SES. Data Collection/Extraction Respondents aged 18 or older at the interview time (n = 103,651). Principal Findings Overall, we found that use of primary care is inequitable in favor of the less well‐off, hospitalization is equitable, and use of outpatient specialist care, basic medical tests, and diagnostic services is inequitable in favor of the well‐off. Stratifying the analysis by health status, however, we found that the degree of inequity varies according to health status. Conclusions Despite its universal and egalitarian public health care system, Italy exhibits a significant degree of SES‐related horizontal inequity in health services utilization.