How Healthcare Should Be (More or Less)

Dear Ginny wrote a rant on America's healthcare system, and I started to respond, but my comment got way too long, so I just brought it over here. I thought I'd explain the Brazilian healthcare system.... or at least my understanding of it.  

DISCLAIMER: This is what Dr. Alexandre has explained to me and what I've gleaned from my own experience. Some details are probably wrong, and what I see here in my region may not be the same in other parts of the country. Feel free to comment to correct me. I'm going to try to convince Alexandre to come on here and explain it better (guest post! guest post!). But for now, this is how (I think) the Brazilian healthcare system works:


Seeing the Brazilian healthcare system always makes me really embarrassed about the system that we Americans accept in the US.

First, Brazil has public healthcare. Of course it's not perfect. Here are some of the most common problems:

1. Higher income taxes
2. Long waits for an appointment
3. Multiple people in hospital rooms
4. When a surgery is not something that has a high risk of infection, multiple surgeries in the same room
5. Hypochondriacs (think about it... if you don't have to pay to go to the doctor, you don't think twice about it, especially if you are a lonely old woman with no one to complain to and nothing better to do...or an overconcerned mother who takes her child in for every sneeze)
6. Immigrants coming from poorer surrounding countries just to use the system (however, this is a much smaller problem than in the US)

But here are some things that never happen in Brazil:

1. People's lives being ruined over healthcare debts
2. Healthcare debts.
3. People going to work even when they're sick because they are afraid of losing their jobs or they need to pay for their medications
4. People waiting to go to the doctor because of the cost/bureaucracy and then something treatable becomes untreatable
5. People not calling an ambulance because it's too expensive and then dying at home or on the way to the hospital
6. Kids without health insurance
7. People don't get a transplant just because of money (all transplant situations are automatically covered by the public healthcare option. Whether or not the organs are available is another story, but money is not an issue for the patients).

And there are some problems that DO occur here, but would very likely not happen in the US, just because of the differences between Brazil and the US:

1. People live in the rainforest or tiny village and are hours away from any hospital
2. People live far away from a hospital, but not too far to get there. But the only way to get there is a single dirt road. And then it rains and floods the road and now there is no way to get there.
3. People try witchcraft, Indian medicine, and old wive's tales as healthcare that can make them worse. For example, I think I mentioned on here once about the fact that (too) many Brazilian women believe that, if they put raw meat up there you-know-whats, leave it for a day, and then cook it for their poor unknowing husbands, he will be somehow spiritually bound to them and will never cheat. The result? Women get infections after having raw meat shoved up their wazoos for a day.

Barring the meat-filled wazoos, benefits obviously outweigh the costs. Also, Brazil has set up different ways to avoid the problems listed above, particularly the long waits.

The centers themselves are basically "triaged", like this:

a) There's the emergency room, obviously. 

b) Then there's 24-hour the urgent care place, for things that are less serious than the ER but too serious to wait for an appointment. (Alexandre does many of his 12-hour overnight shifts (plantões) here.)

c) Then there are these, like... "medical stations" scattered around the city. They're for small problems and questions, like "does this cut need a stitch?" or "can you refill my dandruff shampoo prescription?" or "this rash hasn't gone away for a couple of weeks." Some are specifically for the elderly or for children. (Alexandre gets put on rotation at these places during the day for a couple of weeks every few months.)

d) Finally, there's the "ambulatory" right by the hospital. It's appointment only. (Alexandre works here in the afternoons.) Usually, you go to either (c) or (d) above, and they help you / advise you to make an appointment at the "ambulatory." Or you can just call yourself. This is the place for normal doctor's appointments. Yeah, it has long waits, but the country tries to offset the wait by offering (a) (b) and (c).

I would like to point out that mental health is more or less treated the same way as physical health, so psychological and psychiatric problems follow the same rules listed above. Brazil seems to be less socially accepting than the US of respecting mental health as well, a health issue, but the US is arguably the most advanced socially in its acceptance of mental health problems as diseases and not moral/will/religious afflictions. The result in Brazil? You can go to a psychologist for free, but you may have to wait a while to get an appointment, and you can't tell your friends about it.

The main reason this system doesn't always work is because people are impatient and/or unaware and they go to the wrong place. But with proper education and enough PSAs, it'll eventually work better.

Did I mention all of this part is free? Oh, and medication for any chronic illness is free (AIDS medication, diabetes medication, etc). And most other medications are subsidized. This may be overshare, but we're all adults here: Birth control is 54 cents a month with a prescription, and 4 reais without. That's another thing: a lot of medicines don't need a prescription, but they're more expensive without one in order to motivate people to go to the doctor to get him to put it in writing that it's the one that they need.

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Then there's the private option: it's like American insurance, but better. 

You pay a flat monthly rate-- no hidden fees. The price depends almost completely on your age, and there are no ideas of "preexisting conditions" or any of that crap (because the private insurance companies know that if they get too picky or expensive, their customers can just use the public option... amazing concept!). Because I'm 24, I pay 80 reais a month.  Alexandre's grandfather, however, had to pay 400 reais a month while he was still living. So most elderly people use the public option, unless, like in Alexandre's case, the elderly person's 5 kids pitch in to pay for it.

The private insurance companies have their own hospitals, but also a wing in the public hospital in case you are closer to that when you have a life-threatening accident. For example, when I fainted while giving blood and had to get stitches, I asked to go to the public hospital, because it's in walking distance of our house. But they said that, since it wasn't a life-threatening emergency, they'd take me to the hospital that is connected to my private insurance.

For normal, day-to-day appointments under private insurance, you get a big book with a list of doctors' names in your region, just like in the US. A really nice difference is that you don't have to go to a general practitioner to get a referral. Come on. That system is such a waste of time. If you've got a rash, you know you need a dermatologist. If you can't see as well in your old age, you know you need an ophthalmologist. You choose a doctor from the book and call to make an appointment. You have to give an explanation of why you're going in, obviously. If you say something completely different, they'll tell you what kind of doctor to call.

And from the doctor's side, if you have a private practice, you can choose whether to be part of the private insurance lists or not. You make less per consult under the private insurance, but you have a lot more clients. (Yes, there are quite a few Brazilians who just pay the doctors directly and avoid the insurance all together. I'm not sure how legal all this is, tax-wise.) As a licensed doctor, it's also easier to open your own practice here in Brazil than it is for a doctor to open one in the US. There's more of a free-market economy feel to it. You base your price on the price that other doctors in the region are charging. And most importantly, you become successful by good old-fashioned word of mouth.

Frequently, doctors group together with other doctor friends to open a private practice. This saves on building costs, receptionists/marketing costs, and also, if the doctor friends are the same kind of doctor, on the cost of machines/surgical equipment. Doctors can perform surgical procedures in their own buildings if they have enough of the equipment. If not, it is my understanding that they can pay to use equipment in the hospitals. Usually, things that require anesthesia are done in the actual hospital.

Yes, Brazil's surgical equipment is usually not as advanced as it is in the US. They don't have all of the latest -scopy suffixed procedures available. But the life expectancies in industrialized regions here in Brazil are roughly the same as in the US.

The private insurance has some stipulations in your first months as a member to prevent people from paying for one month, doing a bunch of really expensive stuff, and canceling. But any serious problems or long-term hospital stays are never decided in terms of cost.

So yeah. That's the main stuff. Alexandre comes home from work complaining about annoying mothers in pediatrics, or really sad cancer cases, or snobby attendings, but never about bureaucracy or unfair or incorrect medical decisions that were made solely for money.

Despite its problems, Brazil should be really proud of itself for its healthcare system.