There is a less obvious way to measure the importance of Brazil’s public healthcare system, known as SUS: look at the people who, in theory, should need it the least.
More than 50 million Brazilians have private health insurance. Yet hundreds of thousands of treatments involving privately insured patients are carried out every year in the public system. And the cases captured by Brazil’s private health insurance regulator, ANS, through its SUS reimbursement mechanism are far removed from basic primary care. They include hospital admissions and medium- and high-complexity outpatient procedures, with surgeries, transplants, dialysis and cancer treatment featuring prominently.
That matters at a time when Brazil is once again debating whether to loosen constitutional rules that set minimum spending levels for areas such as healthcare.
The fiscal argument is familiar: mandatory spending floors make the federal budget more rigid, reduce policymakers’ ability to shift resources as priorities change and can perpetuate inefficient expenditure.
There is merit to that debate. Earmarking money does not guarantee that it will be well spent, and no constitutional spending requirement should shield public policy from scrutiny over productivity, quality or waste. But before treating the healthcare floor as just another fiscal constraint to be removed, it is worth understanding the infrastructure it helps sustain.
ANS data offer a useful window into that question.
In 2024, treatments provided by SUS to beneficiaries of private health plans and identified for reimbursement generated R$1.17 billion in identified reimbursement value, the highest figure in the series shown in the regulator’s new dashboard. The comparable figure was R$1.08 billion in 2023, an increase of roughly 8%.
That number requires some care. “Identified value” is neither the actual cost incurred by SUS nor a final debt owed by a private health insurer. Under ANS methodology, the original value attached to a hospital or outpatient authorization is multiplied by 1.5 to establish the reimbursement amount. Private health insurers may also challenge individual cases before a final charge is issued.
Still, the existence of the reimbursement mechanism is revealing in itself.
It acknowledges that Brazil’s public healthcare infrastructure continues to be used by people who already have private coverage — and that, when a treatment falls within the scope of reimbursement rules, money should flow back to SUS once the regulatory process is completed.
Even more revealing is what SUS is doing for these patients.
In 2024, roughly 41% of hospital admissions involving privately insured patients identified in the public system were surgical cases. Internal medicine accounted for another 30%. Together, the two categories represented more than seven out of every ten such admissions.
Dialysis stands out among outpatient procedures. Around 62,000 authorizations generated almost 747,000 hemodialysis sessions during the year. Hormonal and other treatments for breast and prostate cancer also rank among the most frequently identified procedures.
At the other end of the spectrum are less frequent but highly complex and expensive interventions. The average identified value of a bilateral cochlear implant was close to R$136,000. Liver transplants and hematopoietic stem-cell transplants exceeded R$100,000. Implantable cardiac devices also feature among the procedures with the highest values.
The numbers challenge a common perception about healthcare in Brazil. SUS is not simply the healthcare system for Brazilians who cannot afford private insurance. It is also part of the healthcare infrastructure available to those who can.
Private health insurance may pay for the cardiologist appointment, the imaging exam or a hospital admission in the private network. But the private health insurance sector operates alongside a public system that maintains transplant centers, dialysis programs, university hospitals, blood banks, intensive-care units, oncology services and high-complexity facilities across the country.
Even when private health insurers ultimately reimburse SUS, that infrastructure still has to exist. Reimbursement can pay a bill. It cannot replicate a healthcare network.
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