By PAULO CAPEL NARVAI*

The National Supplementary Health Agency's 'health plan' is a farce. But what does the 'health barter' mean for the direction of the SUS? Who is interested in the 'plan' and the 'barter'?

Upon completing 37 years on May 17, 2025, the Unified Health System (SUS) is once again faced with the dilemma of the Sphinx of Thebes. “Decipher me or I will devour you” was the question that cornered passers-by on the roads of Thebes, the then powerful Greek city-state, the mythological creature that had the body of a lion and the head of a woman. In order not to be devoured, it was necessary – as we know – to decipher a riddle. The rest is mythology.

Since it was created by the constituents of 1988, the SUS has often been haunted by the Sphinx of Thebes, which poses dilemmas to its leaders and defenders, the SUSistas and SUScidas, as I usually call those who defend our universal health system and those who, inside or outside the SUS, attack and suffocate it, seeking its death.

The first of these many dilemmas was raised in the first two years of the SUS by Fernando Collor de Mello, who refused to accept the municipal basis of the health system. He did not accept the transfer of resources from the Union to states and municipalities, much less the possibility of popular participation in the control of health actions and programs. Fernando Collor de Mello went so far as to veto entire articles of what would become Law 8.080, of September 1990, which regulates the 1988 Constitution (CF1988).

However, blocked in this attempt by the National Congress, it was forced to sanction, on December 28 of that year, law 8.142, providing for how the “community participation” enshrined in the Federal Constitution of 1988 should take place in the SUS and how intergovernmental transfers of financial resources from the SUS would be made.

The first was certainly followed by many dilemmas that shaped the SUS, an institution of the Brazilian State, until it became what we know today: a state system, whose public resources allocated to give concrete form to the universal right to health are predominantly managed by private individuals and in which professionals do not have the right to a State career.

I do not want to dwell on the many dilemmas of the SUS, but I will focus on two that, in this historical context, are presented to the consideration of SUS supporters and SUScidas. They are two good bad ideas. To them.

First good bad idea

The proposal for a popular health plan. The “brilliant idea” has been nurtured for over a decade by the most voracious sectors that operate in the health plan segment. A few months after the coup that removed Dilma Rousseff from office, Ricardo Barros, Michel Temer’s Health Minister, announced the support of that government for the proposal, as a way to “relieve the burden on the SUS”. Popular health plans, which cost much less than the average of regular (“comprehensive”) plans, circumvent the list of mandatory procedures (minimum coverage) that the National Supplementary Health Agency (ANS) sets for private companies that do business in the sector.

For Michel Temer's minister, the new business model with health goods could “contribute to the financing of the SUS”. There was a reaction from several social segments to Ricardo Barros’ “little plans” and the proposal was defeated at that moment.

But if the “good idea” of “health” “plans” did not prosper after the coup, it is back now, circling Lula3, as a proposal from the National Supplementary Health Agency. The news was released on April 18, 2025 by the magazine Veja, with the title "Lula considers supporting the creation of a popular health plan worth up to 100 reais”, and was soon echoed in several corporate media outlets.

In several sectors of the base, and even among government leaders, the initiative was not discarded. The proposal for a “small plan” of up to 100 reais, to cover consultations and exams, with the potential to “serve 50 million new clients”, according to the article in Veja, was received as a good idea and something that could contribute to improving Lula's popularity, in addition to "relieving pressure on the SUS". This really does seem to be a good idea, it makes sense and has popular appeal. After all, who doesn't want to have a health plan?

As there was no official denial of the article, Veja, many Lula3 supporters were confused and, finding the official silence strange, spoke out on social media, positioning themselves contrary to the “little plans”. Once again, the reaction was immediate and forceful, from health organizations and social movements that, in things like this, usually go beyond appearances. Soon came the arguments demonstrating the fragility of the “little plans”, because when it comes to health care, they do not solve anything, only redirecting the demand to the SUS.

This practice of “referring to the SUS” is, in fact, the main feature of health plans, even the so-called “comprehensive” ones. When things get complicated, or costs are too high, refusals of care increase. People are simply abandoned in their needs, even if they have paid monthly fees for years and years. The thing is that contracts, which are often mistakenly called “health plans”, do not correspond to any “plan”, much less to “health” – because procedures, operations, exams and even medications are intended to recover patients and not to protect their health.

They are not, therefore, “health plans”, but merely insurance policies that use the SUS as reinsurance, financed with public resources, which guarantees them substantial profits. The net profit of all companies operating in the sector was BRL 11,1 billion in 2024, about 10% of the net profit obtained in the same year by the four largest benches operating in Brazil, in the order of R$ 114 billion. Not bad, from a business point of view. Not even Pollyana, who always tries to see the good side of everything, would believe that, with so much profit, the companies that sell “health plans” would be concerned with “relieving the burden on the SUS” or “contributing to its financing”.

On April 24, 2025, the Federal Public Ministry (MPF) published a “Technical Note”, prepared by the Health Committee of the Consumer and Economic Order Chamber, highlighting that the “little plans” are not provided for in law 9.656/1998, which regulates health plans, and that the proposal by the National Supplementary Health Agency (ANS) presents several gaps, having been prepared without the participation of representatives from the Ministry of Health and SUS managers.

This is considered essential, since “the creation of limited health plans could further burden the SUS instead of relieving it”. The MPF asks the National Supplementary Health Agency (ANS) to “reformulate the proposal and reopen discussions with the Ministry of Health” to find a way to “provide more adequate protection to the 52 million Brazilians who currently have health plans, as well as demonstrate how interconnection with the SUS will serve the public interest and efficiency”.

“Little plans” are therefore a good bad idea.

In fact, to start improving things, which are still very bad in this area, the “comprehensive” plans – and the National Supplementary Health Agency (ANS) that regulates them – should be less and less under the control of the insurance sector and more and more under the control of health councils and conferences, in addition to the public administrative bodies that routinely control activities that affect the health of the population.

For the magazine Veja, “the idea is to include the creation of the plan [the “little plan”] in the package involving the project of the Minister of Health, Alexandre Padilha, which foresees transferring care from the SUS to private hospitals”. And this is the second good bad idea.

Second good bad idea

The good idea is to create a kind of “health barter” (without pejorative connotation) that translates into the following equation: if legal entities owe money to the SUS and the SUS is owned by the government, then they could pay their debts to the government by providing health services to the SUS. Among these legal entities are companies that sell insurance called “health plans,” since their clients are often treated at SUS units, which should, by law, be reimbursed. The mechanisms for this are poor and their precariousness (deliberate, according to some) contributes to continued million-dollar defaults on the SUS.

The good but bad idea is to create a health barter system in which “everyone would win”, since the government would not grant exemptions or forgive debts – which, it is argued, it does in large numbers in all economic sectors – and the population would benefit, having access to private services, instead of waiting weeks, months and even years for services from the SUS. According to this point of view, barter would make it possible to “put an end to waiting lines for exams and surgeries through the SUS”.

With this equation on the table, the Ministry of Health intends to give big boost to the program More Access to Experts. The “purchase” of health services from the private sector would be “paid” with the credits from these debts. It seems like a good idea. But it is not.

The core problem with this good idea is that it is based on “pay per unit of service.” This turns a good idea into a bad idea.

In the book “SUS: a revolutionary reform”, I tell, at one point, the story I heard from Carlos Gentile de Mello, in a lecture he gave in Curitiba, back in the 1970s, in which he once again mentioned the catchphrase that would forever mark him: the statement that “payment per unit of service is an uncontrollable factor of corruption”. He said, in good humor, that after hearing him say so many times that “payment per unit of service is an uncontrollable factor of corruption”, when someone called him on the phone and he wasn’t there, everyone at his house would explain that he wasn’t there and add: “but he told me to say that payment per unit of service is an uncontrollable factor of corruption”.

Carlos Gentile de Mello was a strong and persistent critic of the model that had become consolidated in social security medicine and which, as a model, as we can see, is still very much alive. He was a columnist for several years for Folha de S. Paul, the newspaper published a note on 28/10/1982 when he passed away, stating: “A critic of the social security medicine model adopted in Brazil, Gentile understood that the form of remuneration of private hospitals affiliated with Inamps, based on payment per Service Unit, leads to overbilling and the proliferation of unnecessary medical acts, causing the exhaustion of resources allocated to medical assistance”.

The recognition that the right to health care is also in the interest of the entire society and, for this reason, cannot be commercialized, was one of the values ​​held dear by those who were part of the Health Reform movement that bequeathed us the SUS, enshrined in the Federal Constitution of 1988. A value that continues to be indispensable for contemporary SUS members.

But the proposal for a health barter currently divides those who identify with the defense of the SUS.

For a segment that could be identified as “more institutionalist”, those who owe money to governments must pay their debts – in cash. And the government, in each federative entity, must decide what to do with the resources from the payment of debts.

The proposal for a health barter is seen, in this segment, as undesirable and harmful to the SUS, as it induces, reinforcing it even further, the hegemonic model of health care, which is hospital-centric, centered on medical assistance, and which develops based on what private producers of medical care want to offer the population, via the SUS.

They argue that, on the contrary, the counter-hegemonic health care model, which has been defended since the creation of the SUS, by health councils and conferences, professional entities and health social movements, is the opposite, seeking to strengthen basic health care, centered on the expanded clinic, with priority for health promotion and disease prevention activities and, above all, based not on what producers want to sell to the SUS, but on the health needs of the populations of the different territories.

This implies carrying out and valuing bottom-up local planning, with participatory co-management of SUS units, by representatives of public administration, health workers and users of the public health system.

For the “institutionalist” segment, when acting today, one must think about the consequences of these actions for the SUS, in the medium and long term, implementing solutions that have an epidemiological impact, based on scientific evidence and that do not put the sustainability of the system at risk.

At the other end of the spectrum is the segment that could be called “more pragmatic” and that maintains that the population’s needs are urgent and “cannot wait”. In these situations, it is necessary to implement measures as soon as possible that correspond to effective and efficient responses to popular demands, such as those related to consultations with specialists, exams and surgeries sought by the population, in all municipalities.

Pragmatists believe that in recent years there has been a significant increase in the supply of technological resources in the private sector and that there would be no reason for the SUS not to benefit from these resources, making them available to everyone, but always under the control of the SUS.

According to a matter published by Edjalma Borges, from the Ministry of Health, on the website gov.br, President Lula authorized the Ministry of Health, together with the Civil House and other ministries, to move forward with the development of proposals to make the plan viable. Edjalma Borges also reported that Minister Alexandre Padilha “urgently needs to make these actions happen soon”, such as the “delivery of new radiotherapy equipment to SUS units throughout the country, which will reduce the waiting time for treatment to begin”.

However, there is no information detailing the plan, which has caused great discomfort even in pragmatic sectors that act politically in Lula's support bases3, because as announced, the plan to exchange debts for service units (consultations, exams, surgeries) consolidates and institutionalizes SUS financing mechanisms that are once again centralized in the federal government, as Fernando Collor de Mello wanted in the first two years of the SUS, the country's public health system.

In this “new model”, they say, the SUS would end as a federative, decentralized system, made up of networks of units at different levels of care, and managed under national coordination by the Ministry of Health and local municipal coordination – at least with regard to secondary care (specialty outpatient clinics) and tertiary care (hospitals).

This option, in addition to violating the 1988 Constitution and current legislation that regulates constitutional provisions on the universal right to health, would give a new format to the governance of the SUS, with the federal government taking upon itself decisions on consultations, exams, surgeries and other actions and operations of health care throughout the country.

“But it turns out,” say experts in public management, “that the Ministry of Health is not in a position to manage this in a centralized manner.” They exemplify the impossibility, arguing that “the Ministry cannot even directly manage the Mais Médicos Program, requiring the participation of third parties to manage the program.”

“Nobody understands what the Civil House has to do with the day-to-day management of the SUS,” I heard from a colleague who works in public health. “It’s absurd; it doesn’t make any sense.” I considered that “this direct relationship between the federal government and hospital managers is what has been done for decades with the financial aid to the Santas Casas, to resolve the insolvencies and bankruptcy that characterize these organizations.”

In response, I heard that “well then, that’s what needs to be addressed and resolved. If the federal government wants to remove states and municipalities from the management of the SUS, then it should create a public company, or something similar, to take care of it. The Ministry of Health won’t be able to handle it and will end up dismantling what was built over more than 30 years.” I thanked him for the comment and ended the conversation.

And you, dear reader, what do you think of the positions of institutionalists and pragmatists? Is the health barter really a good bad idea? Or would it really be a good idea?

To help you decide, I would like to say that at the beginning of this article I mentioned the character Pollyanna. I will return, by the way, to a article posted on the website the earth is round, by José Damião de Lima Trindade in which, in a certain passage, he quotes Hegel for whom “we discover what a thing is, not by its good ‘side’ – or bad, it doesn’t matter – but by the main direction, by the determining direction of its movement”.

In our case, considering its consequences for the SUS, to what main direction, determining its movement, does the good bad idea of ​​the proposal of the ANS “little plans” lead us? And to what main direction, determining its movement, does the proposal of sanitary barter lead us?

But don't worry, you are not facing the Sphinx of Thebes. If you don't decipher these riddles, you won't be devoured. Not you, reader. But think about the SUS.

*Paulo Capel Narvai is senior professor of Public Health at USP. Author, among other books, of SUS: a revolutionary reform (authentic). [https://amzn.to/46jNCjR]

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