A comparison between the Brazilian
Uma comparação entre o sistema de saúde brasileiro e o norte-americano
Una comparación entre el sistema de atención en salud brasileño y el norteamericano
*M.D. Health Science Program. Universidade Estadual de Montes Claros,UNIMONTES
**Nurse.Health Science Program. Universidade Estadual de Montes Claros, UNIMONTES
***Lawyer. Department of law. Faculdade Santo Agostinho
****Undergraduate student. Biologist.Universidade Estadual de Montes Claros, UNIMONTES
*****Undergraduate student. Medicine.Universidade Estadual de Montes Claros, UNIMONTES
Danilo Cangussu Mendes*
Marcos Vinícius Macedo de Oliveira*
João Marcus Oliveira Andrade*
Alanna Fernandes Paraíso**
Maria Fernanda Oliveira Maia Amorim***
Deborah de Farias Lelis****
Lucas Henrique Lopes Mendes de Figueiredo*****
Structurally, both Brazilian and American health care systems are similar having a private system consigning for those that can pay their medical, exams and drugs expenses and a public system for those that do not have capacity to pay. While the United States has experienced an important crisis in the health system, Brazil has expanded access to majority of population and has improved health outcomes. The USA is the country that spends the highest amount of money in the health system, but the health indicators are not the best ones. The Brazilian Unique Healthcare System (SUS) is internationally recognized as one of the best public health systems in the world presenting particularities that nowadays are copied in many countries. Indubitably, SUS represents the major advance in public health 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. So we can conclude that the problem in health is not only the amount of money, but how to use this resource.
Keywords: Health systems. Brazil. United States of America.
Estruturalmente, o sistema de saúde brasileiro e o norte-americano são similares, tendo um sistema privado caracterizado principalmente por exames e despesas com medicamentos convivendo com um sistema público direcionado para aqueles que não têm capacidade para pagar. Enquanto os Estados Unidos têm passado por uma importante crise em seu sistema de saúde, o Brasil tem ampliado o acesso das pessoas aos cuidados em saúde e melhorado os resultados em saúde. Os Estados Unidos têm a maior quantia financeira aplicada no setor saúde, mas os indicadores não são os melhores. O Sistema Único de Saúde brasileiro é reconhecido internacionalmente como um dos melhores sistemas públicos do mundo, apresentando particularidades que atualmente são copiadas em vários outros países. Sem dúvida, o SUS representa o maior avanço em saúde pública até o momento, mostrando importantes resultados em um curto período de tempo, mas ainda apresenta lacunas a serem preenchidas e novos caminhos a percorrer. Dessa forma, podemos concluir que o problema na saúde não é unicamente a quantidade de dinheiro, mas sim a forma como se utiliza esse recurso.
Unitermos: Sistemas de saúde. Brasil. Estados Unidos da América.
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Brazil and the United States of America have some similarities but also a lot of differences related to many aspects. The USA is a developed country that has approximately 312 million inhabitants and the most important economy in the world, being its Gross Domestic Product (GDP) around $15.4 trillion (1). The Americans are so proud of The USA because they consider their country as a multicultural place full of opportunities, good jobs and natural beauties. On the other hand, Brazil is an emergent country, with more than 196 million of inhabitants and characterized by ethnic diversity that contrasts rich and developed regions with some places that are extremely poor. In the last 15 years, Brazil has improved its economy and nowadays it is considered a stable country not only economically but also politically and socially. The Brazilian GDP is around 2.08 trillion, in other words, more than 7 times less than The American one (2).
When we think about Health Care System, both countries are criticized. The USA is recognized as a rich country that spends lots of money in Health Care but the outcomes are poor. Brazil has experienced a new way to provide health care, through an integrated system called SUS (Sistema Único de Saúde).
This article has two parts: in the first one, we will describe the structure of both countries health care systems (Chart 1). In the second part we will analyze some aspects related to both systems.
The American Health Care System
The USA, as well as many countries, has its health care system based in both private and public insurance. The public health insurance is mainly represented by the Medicare and Medicaid. These are government programs that were created to provide health assistance to people that were uninsured. On the other hand, there are 2 types of private insurances: Employer-sponsored insurance and private non group.
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 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).
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).
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).
The Brazilian Health Care System
As well as the North American, the Brazilian health system consists of a variety of public and private organizations. Nowadays, the Brazilian health system is a result of a large modification in this sector that began in the 1970’s and finished in the end of the 1980s with the creation of Unified Healthcare System (SUS). We can divide the Brazilian health system in 3 subsectors: public, private health insurance and private with payment out-of-pocket. These subsectors are distinct but sometimes they are interconnected, and people are free to use any of them, depending on the facility to access and the capacity to pay.
Brazil was pioneer in some aspects related to public health. The approval of the laws that regulate SUS occurred in the end of the 1980’s and the beginning of the 1990’s, being the laws number 8080 and 8142 the first and the main ones. Since its creation, the statement that symbolizes the SUS has been “Health is a right to everybody and an obligation of the government”. 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 only basic health care, but also complex and expensive treatments, exams and some medications. The expenses from SUS are financed through tax revenues and social contributions from the federal, state, and city budgets (7).
The main effort to reorganize the Brazilian public health system which was considered fragmented until 1994 was the creation of the Family Health Program. Basically, this program was created to extend the access and promote equality. 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 many changes in its morbidity and mortality profile, especially reducing child mortality and increasing the life expectancy (2). Brazil is also known to have one of the most effective preventive and control programs related to HIV in the world. Recent programs in public health include the Mobile Emergency Care Service (SAMU) and the National Oral Health Policy (Brasil Sorridente) (7).
This system is composed basically of diagnostic and therapeutic clinics, private hospitals, and private health insurance companies. Commonly, people with private health plans and insurance policies also receive vaccines, high-cost services, and complex procedures such as haemodialysis and transplants through SUS (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).
This is another way to receive health care. The person has the option not to make a contract with insurance companies. Instead, the medical expenses are paid directly to the private health care unit when the service is used (8).
Comparing the health care systems
Structurally, both Brazilian and American health care systems are similar having a private system consigning for those that can pay their medical, exams and drugs 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 countries concerned 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 its GDP in its health system, the largest percentage among all countries in the world. Nevertheless, almost 46 million of people declare not having coverage 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 health systems. For example, life expectancy at birth increased by 7.3 years between 1960 and 2002, which is less than the increasing of 14 years in life expectancy in Japan. In 2002, the infant mortality rate in the USA was 7 deaths per 1.000 live births, higher than in Japan and in the Nordic countries (Iceland, Sweden, Finland and Norway), which all have infant mortality rates below to 3.5 deaths per 1,000 live births. Other serious problem faced by the USA is the obesity and its consequences like diabetes and cardiovascular problems. In the 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 highest amount of money in the health system, but the health outcomes are not the best ones. So we can conclude that the problem is not the amount of money, but how to use it. The economists say that the American medical system is highly fragmented, with complicated rules and the solution to the problem is rationalizing the healthcare system. Rationalizing the system is to discover how to save money while delivering better care to more people (11).
Another problem is the capitalism. Insurance companies are known for their power and the ability to make money, because of that many times they do not care about the population, especially when they either deny certain types of coverage or they demand absurd values to a specific coverage. Even those enrolled 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 of both public health and socio-cultural issues. As a society, Americans are fatter, under more stress and less active than people in other countries, and their medical system does not support the high number of diseases caused by this life style, totally different from the south American or European model, for example, with more vacations and fewer possessions (11).
The reform in the health sector newly approved by the American Supreme Court has sought out to reduce costs and diminish the inequalities in health. Although some critics by oppositions, the reform has been considered an important step toward 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 sanitary conditions, poor technologies in health, bad wealth distribution, poor allocation of public money and consequently bad outcomes in health.
This profile has changed recently, because nowadays, Brazil has a strong economy, more money is applied in Health (8,4% of the GDP in 2007) (12), better sanitary conditions and a great growing potential. Just to exemplify, in 27 years (1980 - 2007) the proportion of households with piped water supply increased from 52% to 84% and the proportion with access to sewerage or a septic tank increased from 25% to 74% (2)
On the other hand, some problems remain, like the wealth distribution (especially when we compare the northern to the southern region), and poor allocation of public money. Frequently, corruption and bad-administration can be seen in the public sectors not only in the city level but also in state and federal ones.
Although all the problems faced by Brazil in the past, Brazilian health status has improved in the recent years, especially after the creation of SUS and the Family Health Program. Brazil experienced a growth around 10 years since 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 19,4 in the present days. However, these indicators still remain high when comparing to the USA and developed countries like Japan, Canada and Europe in general (2,13).
Theoretically, SUS is internationally recognized as one of the best public health systems in the world presenting particularities that nowadays are copied in many countries. Indubitably, SUS represents the major advance in public health 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 is known that the USA spend 10 times more money than Brazil in the health sector and besides, the outcomes are not so discrepant (13,14).
In conclusion, we can observe that health care systems from 2 different countries present similarities in their structures but differences in their ideology. While the American system counts with advanced technologies and modern units working in a capitalist perspective, the Brazilian one works in a social perspective seeking a fortification of SUS and consequently a universal coverage for all inhabitants, independently of age, medical problem or social position.
Chart 1. The structure of the American and Brazilian health care systems
THE AMERICAN HEALTH CARE SYSTEM
THE BRAZILIAN HEALTH CARE SYSTEM
Government-funded healthcare for over-65s
Unique Healthcare System (SUS)
Brazilian National Public Health System is characterized by some principles that aims to provide integral care (including preventive and therapeutic interventions) for all citizens, independently of age or social position. The main principles are universal access, equity, decentralization, democratic governance and comprehensive care.
Government-funded healthcare for those on low incomes
Receive healthcare via government-run scheme
State Children's Health Insurance Programme
coverage for children whose parents do not qualify for Medicaid
Employer-sponsored insurance (group market)
Employers provide health insurance as part of the benefits package for employees.
Private health insurance
The majority of private health insurances is delivered to employees of public and private companies.
Destined to self-employed or retired people.
Individual healthcare plan
Citizens also can contract an individual or familiar medical insurance
Payment out of pocket
Medical expenses are paid directly to the private health care
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