A comparison between the Brazilian and the American Health Care System (2024)

Introduction

Brazil and the United States of America have some similarities but also a lot ofdifferences related to many aspects. The USA is a developed country that hasapproximately 312 million inhabitants and the most important economy in theworld, being its Gross Domestic Product (GDP) around $15.4trillion (1).The Americans are so proud of The USA because they consider their country as amulticultural place full of opportunities, good jobs and natural beauties. Onthe other hand, Brazil is an emergent country, with more than 196 million ofinhabitants and characterized by ethnic diversity that contrastsrich anddeveloped regions with some places that are extremely poor. In the last 15years, Brazil has improved its economy and nowadays it is considered a stablecountry not only economically but also politically and socially. The BrazilianGDP is around 2.08 trillion, in other words, more than 7 times less than TheAmerican one (2).

When we think about Health Care System, both countries are criticized. The USAis recognized as a rich country that spends lots of money in Health Care but theoutcomes are poor. Brazil has experienced a new way to provide health care,through an integrated systemcalled SUS (Sistema Único de Saúde).

This article has two parts: in the first one, we will describe the structure ofboth countries health care systems (Chart 1). In the second part we willanalyze some aspects related to both systems.

Development

TheAmerican Health Care System

The USA, as well as many countries, has its health care system based in bothprivate and public insurance. The public health insurance is mainly representedby the Medicare and Medicaid. These are government programs that were created toprovide health assistance to people that were uninsured. On the other hand,there are 2 types of private insurances: Employer-sponsored insurance andprivate non group.

Medicare

Medicare is a federal program that covers especially elderly (65 and over). People under 65 years old can be covered only if they are permanently physically disabled or if they have a congenital physical disability. This program is administered by the government and the financing is based on federal income taxes, a payroll tax shared by employers and employees (3).

Medicaid

Medicaid is another US program designed for people and families with low income and resources. Different from Medicare, Medicaid is financed not only by the federal level but also by the states through taxes, so the states can expand eligibility,for example increasing income eligibility levels. There are other eligibility categories and within each category there are requirements other than income that must be met (4).

PrivateSystem

Employer-sponsored insurance

This is the main form that Americans receive health insurance. In this way, employers provide health insurance as part of the benefits package for employees. The administration of these Insurance plans is made by private companies, being either for-profit or non-for-profit. Employer-sponsored insurance is financed by both employers and employees being that, the employers pay the majority of the premium and the employees the remainder (5).

Individual market

See Also

United States: #11 in the 2022 World Index of Healthcare Innovation - FREOPPU.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening OutcomesHow Does the U.S. Healthcare System Compare to Other Countries? - Century GoalUnited States

The individual market is delivered to the population that is self-employed or retired. One important characteristic related to this private system is the fact that the individual market allows health insurance companies to deny people coverage, charge higher premiums, and/or refuses to cover that particular medical condition based on pre-existing conditions, for example Cancer and others that need more expenditures and resources. These plans are administered by private insurance companies and they are financing by the own Individuals that pay an insurance premium out-of-pocket for coverage. Generally, healthy or low-risk patients have a low premium, whereas the high-risk or sick patients have a high premium (5).

American Health Reform

The U.S.A is a country essentially capitalist. The spirit of liberalism economic has impacted in the way people get access to health care in this country. After the big American crisis in 1929, the private sector became stronger and after the Second World War, it was seen a “boom” in the hospital industry, faced as a great field of benefit by big companies. People could have access to health care if they had a paid health insurance, setting aside those did not have a private one. In this way, the Americans experienced in 1965 the first health reform, which culminated in the creation of the main governmental efforts to provide the minimum of coverage for aged people (Medicare) and people with low income (Medicaid). Despite the creation of Medicare and Medicaid, a great number of Americans continued without coverage, because the eligibility criteria. The increasing expenditures in the health sector, the poor health outcomes faced by population and the high number of uncovered Americans have outlined the need for a new reform in the health sector.

After the unsuccessful Health Reform attempt during Clinton’s government, the current president Barak Obama proposed a new Reform Project, being approved in 2010 throw the “Compilation of patient protection and Affordable Care Act” and recently considered constitutional by the U.S Supreme Court. This law aims to improve the present health care system by expanding access to health coverage for Americans and providing new benefits for people who already have health insurance. Some important topics of this law are presented as follow: Young adults can now stay on their parent’s health plan up to age 26; Insurance companies can’t deny health coverage to kids with pre-existing conditions; Those in Medicare can get preventive services and screenings, such as mammograms and colonoscopies, at no cost to them; Creation of Pre-existing Condition Insurance Plans (6).

TheBrazilian Health Care System

As well as the North American, the Brazilian health system consists of a varietyof public and private organizations. Nowadays, the Brazilian health system is aresult ofa large modification in this sector that began in the 1970’sand finished in the end of the 1980s with the creation of Unified HealthcareSystem (SUS). We can divide the Brazilian health system in 3 subsectors: public,private health insurance and private with payment out-of-pocket. Thesesubsectors are distinct but sometimes they are interconnected, and people arefree to use any of them, depending on the facility to access and the capacity topay.

Brazil was pioneer in some aspects related to public health. The approval of thelaws that regulateSUS occurred in the end of the1980’s andthebeginning of the 1990’s, being the laws number 8080 and 8142 thefirstand the main ones. Since its creation, the statement that symbolizesthe SUS has been “Health is a right to everybody and an obligation of thegovernment”. Some of the principles related to SUS are decentralized policy,universality, equity, humanization, community participation in decision-making,good access and continuous care. SUS offers to the Brazilian population not onlybasic health care, but also complex and expensive treatments, exams and somemedications. The expenses from SUS are financed through tax revenues and socialcontributions from the federal, state, and city budgets (7).

The main effort to reorganize the Brazilian public health system which wasconsidered fragmented until 1994 was the creation of the Family Health Program.Basically, this program was created to extend theaccess and promoteequality. It is based in health care (preventive, promotional and treatment)provided by a multiprofessional team (7).

Since the implementation of Family Health Program, Brazil has experienced manychanges in its morbidity and mortality profile, especially reducing childmortality and increasing the life expectancy (2). Brazil isalsoknown to have one of the most effective preventive and controlprograms related to HIV in the world. Recent programs in public health includethe Mobile Emergency Care Service (SAMU) and the National Oral HealthPolicy (Brasil Sorridente) (7).

Privatesystem

This system is composed basically of diagnostic and therapeutic clinics, privatehospitals, and private health insurance companies. Commonly, people with privatehealth plans and insurance policies also receive vaccines, high-cost services,and complex procedures such as haemodialysis and transplants throughSUS(8).

Private health insurance

The majority of private health insurances are delivered to employees of public and private companies. The private plans offer different levels of benefits and health care providers. In many companies, the package of benefits depends on the position of the employee in the company, varying from executive-type plans that offer the best services to less-costly plans. Inhabitants that do not work at companies can contract a private plan to themselves or to all the family paying directly to the insurance companies (8). In 2011, 47.6 million of Brazilians are enrolled in a private plan, and more than three quarters of beneficiaries (62.6% of the total) of medical aid schemes are collective plans (group market). It is noteworthy that individual plans tend to be contracted by non-workers or retired, being the aged people the most representative in this category (9).

Payment out-of-pocket

This is another way to receive health care. The person has the optionnot tomake a contract with insurance companies. Instead, the medical expenses are paid directly to the private health care unit when the service is used (8).

See Also

United Kingdom: #15 in the 2022 World Index of Health Innovation - FREOPP

Comparingthe health care systems

Structurally, both Brazilian and American health care systems are similar havinga private system consigning for those that can pay their medical, exams anddrugs expenses and a public system for those that do not have capacity to pay.So, why are they so criticized? In a report showing the ranking of the countriesconcerned to health care systems published by the World Health Organization(WHO) in 2000 highlighted Brazil being the 125th and USA the 37th (10).

First of all, we will talk about the USA. This country spends around 16% of itsGDP in its health system, the largest percentage among all countries in theworld. Nevertheless, almost 46 million of people declare not havingcoverage for their medical expenses. When we think about some health indicators,we realize that USA has to improve a lot to reach the “gold standard”observed in other countries that spend less money than the USA in their healthsystems. For example, life expectancy at birth increased by 7.3 years between1960 and 2002, which is less than the increasing of 14 years in life expectancyin Japan. In 2002, the infant mortality rate in the USA was 7 deaths per 1.000live births, higher than in Japan and in the Nordic countries (Iceland, Sweden,Finland and Norway), which all have infant mortality rates below to 3.5deaths per 1,000 live births. Other serious problem faced by the USA isthe obesity and its consequences like diabetes and cardiovascular problems. Inthe United States, the obesity rate among adults was 30.6% in 2002 (11).

It is so controversial, because the USA is the country that spends the highestamount of money in the health system, but the health outcomes are not the bestones. So we can conclude that the problem is not the amount of money, but how touse it. The economists say that the American medical system is highlyfragmented, with complicated rules and the solution to the problem isrationalizing the healthcare system. Rationalizing the system is to discover howto save money while delivering better care to more people (11).

Another problem is the capitalism. Insurance companies are known for their powerand the ability to make money, because of that many times they do not careabout the population, especially when they either deny certain types ofcoverage or they demand absurd values to a specific coverage. Even thoseenrolled in public insurances generally have to obtain supplemental insurance,because of the incomplete coverage provided by the public programs (5,11).

The range in healthcare outcomes in the USA can be explained as a product ofboth public health and socio-cultural issues. As a society, Americans arefatter, under more stress and less active than people in other countries, andtheir medical system does not support the high number of diseases caused by thislife style, totally different from the south American or European model, forexample, with more vacations and fewer possessions (11).

The reform in the health sector newly approved by the American Supreme Court hassought out to reduce costs and diminish the inequalities in health. Althoughsome critics by oppositions, the reform has been considered an important steptoward to an equal health care system in the United States of America

In Brazil the problems are other ones. In the past, Brazil had bad sanitaryconditions, poor technologies in health, bad wealth distribution, poorallocation of public money and consequently bad outcomes in health.

This profile has changed recently, because nowadays, Brazil has a strongeconomy, more money is applied in Health (8,4% of the GDP in 2007) (12), bettersanitary conditions and a great growing potential. Just to exemplify, in 27years (1980 - 2007) the proportion of households with piped water supplyincreased from 52% to 84% and the proportion with access to sewerage or a septictank increased from 25% to 74% (2)

On the other hand, some problems remain, like thewealth distribution(especially when we compare the northern to the southern region), and poorallocation of public money. Frequently, corruption and bad-administration can beseen in the public sectors not only in the city level but also in state andfederal ones.

Although all the problems faced by Brazil in the past, Brazilian health statushas improved in the recent years, especially after the creation of SUSandthe Family Health Program. Brazil experienced a growth around 10 yearssince 1980 in life expectancy, reaching a current value near to 74 years (2).The same occurred in infant mortality rate, declining from 69,12 in 1980 to 19,4in the present days. However, these indicators still remain high when comparingto the USA and developed countries like Japan, Canada and Europe in general(2,13).

Theoretically, SUS is internationally recognized as one of the best publichealth systems in the world presenting particularities that nowadays are copiedin many countries. Indubitably, SUS represents the major advance in publichealth in Brazil so far, showing important results in a small length of time,but it already has gaps to be filled and new insights to be made. It isknown that the USA spend 10 times more money than Brazil in the health sectorand besides, the outcomes are not so discrepant (13,14).

Conclusion

In conclusion, we can observe that health care systems from 2 differentcountries present similarities in their structures but differences in theirideology. While the American system counts with advanced technologies and modernunits working in a capitalist perspective, the Brazilian one works in a socialperspective seeking a fortification of SUS and consequently a universal coveragefor all inhabitants, independently of age, medical problem or social position.

Chart1. The structure of the American and Brazilian health care systems

References

1. U.S. Department of Commerce. Bureau of Economic Analysis:Gross Domestic Product. Available on: http://www.bea.gov/iTable/iTable.cfm?ReqID=9&step=1.

2. Instituto Brasileiro de Geografia e Estatística. Sériesestatísticas & Séries históricas. Available on: http://www.ibge.gov.br/series_estatisticas/

3. Kaiser Family Foundation. “Medicare at a Glance.” Fact Sheet #1066?14. 2011.

4. Kaiser Family Foundation. “Medicaid: A Primer.” Report #7334-04. 2010.

5. Bodenheimer T; Grumbach K. Understanding health Policy: A Clinical Approach. Lange Medical/McGraw-Hill. 2012. 231 p.

6. Compilation of patient protection and Affordable Care Act: Public Law 111–148, May 2010

7. Brasil, Ministério da Saúde. Secretaria de Vigilância em Saúde. Saúde Brasil 2008: 20 anos de Sistema Único de Saúde no Brasil. Brasília: Ministério da Saúde. 2009. 416p.

8. SANTOS, I. S. O Mix Público-Privado no Sistema de Saúde Brasileiro: elementos para a regulação da cobertura duplicada. [Tese]. Rio de Janeiro; 2009.

9. Agência Nacional de Saúde Suplementar. Foco Saúde Suplementar. Março, 2012.

10. The World Health Report 2000 – Health systems: Improving performance. Published by the World Health Organization, Geneva, Switzerland.

11. Cutler, D. M. The American Healthcare System. Medical Solutions. Essay Series: Healthcare Systems. 2008.

12. Instituto Brasileiro de Geografia e Estatística.Conta-Satélite de Saúde Brasil - 2005- 2007. Available on: http://www.ibge.gov.br/home/presidencia/noticias/noticia_visualiza.php?id_noticia=1514&id_pagina=1.

13. Paim J, Travassos C, Almeida C, Bahia L, Macinko J. The brazilian health system: History, advances, and challenges. Lancet 2011;377: 1778-97.

14. Barreto M.L; Teixeira, M.G; Bastos, F.L; Ximenes, R.A.A; Barata, R.B; Rodrigues, L.C. Successes and failures in the control of infectious diseases in Brazil: social and environmental context, policies, interventions, and research needs. Lancet 2011; 377: 1877–89.