Italy's Prime Minister Silvio Berlusconi is at risk of losing his stronghold in Milan to the left for the first time in 20 years, following local elections that have exposed the vulnerability of his centre-right coalition. The focus is on key battlegrounds in Milan and Naples, with voting starting at 7 a.m. and results expected in the evening. The government is under pressure to reduce the budget deficit by 40 billion euros after Standard and Poor's downgraded Italy's rating, making the outcome of these elections crucial. A defeat in Milan would further weaken Berlusconi, who is already facing challenges from scandals, trials, and a struggling economy. Italy has a high public debt of around 120 percent of gross domestic product, but it has not experienced the same financial market problems as Greece and Portugal. However, a recent warning from S&P served as a reminder of the consequences of not taking action. The newspaper Il Sole 24 Ore questioned whether the current government would be able to effectively address this issue. Berlusconi faced defeat in the first round of voting in May, with the center left easily maintaining power in Turin and Bologna and forcing the center right into run-offs in Naples and Milan. A defeat would likely worsen tensions with his key ally, the Northern League, and could lead to challenges to his established leadership of the center right, although senior ministers have stated that there will be no change in direction until the next national elections in 2013. Defence Minister Ignazio La Russa, a loyal supporter of Berlusconi, expressed confidence that there is no possibility of an alternative government or early elections. In Milan, where Berlusconi built his wealth and political career, outgoing center-right mayor Letizia Moratti is trailing behind leftist Giuliano Pisapia in the first-round vote. Some Milan residents believe that the city is experiencing a noticeable shift in political climate. Voters in Italy have been influenced by regional issues such as transportation problems 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. The government had to lower its growth forecast for the year and next year due to economic challenges. Despite concerns about Italy's debt and slow growth, the Treasury was able to sell long-term bonds successfully. Berlusconi, facing criticism for his handling of the elections, has been using his usual tactics to attack his opponents in the media. He predicted that if the left wins, Milan will turn into an "Islamic gypsyland." He also stated that leftist voters lacked intelligence, leading to Internet spoofs and a lawsuit from an offended voter. A rant against Italian magistrates at the Group of Eight summit in Deauville, France caused Economy Undersecretary Daniela Melchiorre, a former magistrate, to resign in protest.