Italy's Prime Minister Silvio Berlusconi is at risk of losing his strong political support in Milan to the left for the first time in twenty years. The results of local elections have highlighted the vulnerability of his center-right coalition. Around 6 million Italians are eligible to vote in mayoral contests in 90 towns and six provinces, with particular focus on Milan and Naples. Voting started at 7 a.m. on Monday with results expected in the evening. The government is planning to implement budget cuts, following a negative outlook on Italy's rating by Standard and Poor's. A defeat in Milan would be a significant setback for Berlusconi, who is already facing challenges from various scandals and a sluggish economy. This loss could also raise doubts about his government's ability to enforce necessary austerity measures. Despite Italy's high public debt, which is around 120 percent of the gross domestic product, the country has managed to avoid the financial market instability experienced by Greece and Portugal. However, a recent warning from S&P serves as a reminder of the consequences of not taking action. An editorial in the business daily Il Sole 24 Ore questioned whether the current government would be able to effectively handle the situation. Berlusconi faced defeat in the initial round of voting in May, as the centre left easily maintained power in Turin and Bologna, pushing the centre right into run-offs in Naples and Milan. A defeat would likely worsen tensions with his main ally, the Northern League, and could lead to challenges to his unchallenged leadership of the center right, although senior ministers have said there will be no change in direction before the next national elections in 2013. Defense Minister Ignazio La Russa, a loyal supporter of Berlusconi, stated that he does not see any possibility of a different government forming and believes that early elections are not desired by anyone. In Milan, outgoing center-right mayor Letizia Moratti is trailing behind leftist Giuliano Pisapia in the first-round vote. Residents of Milan have noted a shift in the political climate in the city. Voters in Italy have been influenced by regional issues such as transport and the ongoing garbage crisis in Naples, but the struggling national economy has been the main focus during the elections. Italy has had a slow economy for more than ten years, with high youth unemployment and the average Italian now poorer than a decade ago. Berlusconi's government recently had to lower its growth forecast for the year, and S&P's downgraded Italy's outlook due to failure to reduce debt and increase growth. Despite initial concerns, the Treasury was able to sell long-term bonds successfully. Berlusconi has been aggressively targeting his political rivals in the media after facing criticism for initially framing the election as a referendum on his leadership. If the left wins, Milan will turn into an "Islamic gypsyland," he warned. He also stated that leftist voters were lacking intelligence, leading to internet parodies and a lawsuit from an outraged voter. During a rant against Italian magistrates to President Barack Obama at the Group of Eight summit in Deauville, France, Economy Undersecretary Daniela Melchiorre, a former magistrate, resigned in protest.