by Plinio Corrêa de Oliveira
I received an interesting letter from my dear friend, Dr. Antônio C. Lara Duca, which is of great interest to the general public. With his permission, I am sharing it in full, which can only benefit my usual, indulgent readers.
Dr. Duca discusses the grim outlook for state-run healthcare mandated by our new Constitution. I now pass the floor to him.
As an occupational physician who has worked for twenty-three years at a major company in this capital and who has always been concerned with the medical care of the country’s working population, I ask for your attention to an issue that troubles many of my colleagues in the field, as well as myself.
“Our new Constitution — and its architects — appear to be setting up one of the biggest ‘bluffs’ in Brazil’s history for this poor and suffering nation.
“By the 1960s, it was already clear — based on the facts — that the Brazilian Social Security system had completely collapsed.
“Our administrators then wisely aimed to reduce the negative effects of statism by outsourcing services to the private healthcare network under a fee-for-service payment model. Initially, agreements were made with hospitals and diagnostic laboratories; later, in the 1970s, with outpatient clinics themselves.
“Everyone benefited from this ‘functional privatization’.”
“1. INAMPS managed to lower its costs because it started paying private providers rates lower than what it had been spending on its own services. It also benefited from the fact that it could fulfill its mission of providing universal care — for all types of medical conditions — to an ever‑growing population without having to invest in hospitals or equipment.[1]
“2. Private medicine, which grew and improved significantly, thanks in part to the revenue it received for services rendered to INAMPS patients.
“3. The population ultimately benefited from receiving an acceptable standard of care.
“Over the past twenty or thirty years, the Social Security system has encouraged the development of so‑called agreements — covering both health care and workplace injuries — through which companies can opt out of INAMPS’s medical services and establish, or contract, their own healthcare systems, receiving a partial refund of their Social Security contributions.
“All of this has benefited the Brazilian working class. To sum up, I mention only three points:
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The possibility of receiving somewhat better medical care through employer‑funded health plans (approximately 90 percent of union demands in the ABC region of São Paulo, in collective bargaining agreements over the past five years, required employers to establish such plans).
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The elimination of the legendary lines at public hospitals (the old IAPs), which were a source of shame and embarrassment for governments before 1964. Today, under a free-choice system, a worker can obtain a medical certificate or see a doctor in roughly 60 minutes.
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Consequently, the justification of absences from work became easier and faster.
“Those outside the field find it hard to believe. Yet the truth is that the leftists entrenched in Brazil’s current health administration regard the ‘deregulation’ process described above as a perverse system. They accuse us of:
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Forcing employees to return to work prematurely after medical treatment, thereby favoring the alleged ‘greed and oppression’ of employers.
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Allowing medical professionals and companies to profit from the misfortune of others — in this case, illness.
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Undermining what they claim to be the state’s duty and right to care for the health of its citizens.
“The hysteria from the left on this issue is so intense that, without a brief explanation, it becomes impossible to understand what the advocates of nationalization are really trying to achieve. Just as, according to traditional Catholic doctrine, parents have both the duty and the right to educate their minor children according to the dictates of their conscience, so in the socialist conception the individual ‘belongs’ to the State — an analogy to a child’s belonging to his family. From this premise would follow an inalienable and non‑transferable right of the State to care for the health of its citizens.
“If any of the three arguments above were presented by an individual alone, they would be dismissed as delusional. I will refrain from refuting them here and instead focus on the consequences of applying them from the workers’ interests’ perspective.
“The process of ‘re-nationalization’ has already started. Hospitals are struggling due to unfair reimbursement rates. A doctor’s visit paid by INAMPS costs less than a haircut. The daily hospital rate — including a companion — is worth half of what the government spends on a single day for a prisoner. This starvation wage is often paid to hospitals 90 or 120 days late. As a result, at least 10 hospitals in the state capital have already closed, and 4 of them are under state intervention — effectively expropriated due to bankruptcy. Those that remain are being gradually ‘phased out’ because the government’s goal is to resume direct ‘management’ of healthcare for the population.
“Many have warned the advocates of state‑run healthcare about the risk that the government simply lacks the infrastructure to assume such responsibilities. But the architects of the plan remain unconcerned, claiming there is a surplus of public funds… All that is required is that Brazilians abandon their ‘capitalist’ habits and accept a simpler, more ‘accessible’ healthcare system — one stripped of the supposedly superfluous and discriminatory refinements of the ‘elitist and individualistic’ philosophy that, in their view, dominates modern medicine.
“Consequently, our Brazilian workers are losing the very benefits that modern medicine has provided them in healthcare, sick leave, and related protections — benefits that previous administrations secured over the past twenty years. And all of this is happening amidst a general atmosphere of euphoria.”
[1] INAMPS (Instituto Nacional de Assistência Médica da Previdência Social) was the federal agency responsible for providing medical care to workers insured by Brazil’s Social Security system. It existed from the mid‑1970s until its extinction in 1993.