Who gets treated, and why: Brazil’s SUS next to the NHS, Canada, Germany and the new US Medicaid rule

By Ramon Martins Andrade, attorney (OAB/RJ 188.374)

Every health system answers one question before all others: what gives a person the right to be treated? Countries differ in a thousand details, but they diverge on that single point — and the answer explains almost everything else.

The United States has just given a new answer to it. Under Section 71119 of Public Law 119-21, implemented by an interim final rule issued on 1 June 2026, from 1 January 2027 states “must condition Medicaid eligibility” for certain individuals on demonstrating community engagement — unless a state chooses to start earlier. In practice: 80 hours per month of qualifying activity (employment, certain work programmes, community service, or at least half-time enrolment in education), for non-pregnant adults aged 19 to 64 in the Medicaid adult group. Forty-three states and the District of Columbia must implement it; the territories are not subject to the law. Exemptions cover pregnancy and the postpartum period, disability or medical frailty, parents and carers of children under 14, American Indians and Alaska Natives, among others. Where a state cannot verify compliance, it must give the individual 30 days to prove it.

If you are reading this from abroad and wondering how Brazil sits on that spectrum, the short answer is: at the opposite end, in its constitutional text — and closer than you would expect, in its private market.

Brazil’s answer is written into the Constitution

Article 196 of the Brazilian Constitution provides that health is “a right of all and a duty of the State, guaranteed through social and economic policies aimed at reducing the risk of disease and other conditions and at universal and equal access to actions and services for its promotion, protection and recovery”. The translation is the author’s own; the authentic text is in Portuguese.

Three expressions carry the weight: right of all, duty of the State, universal and equal access. There is no condition of income, contribution, residence or activity. That is why Brazil’s public system, the SUS, treats people who are not Brazilian nationals — a point covered separately in this article, in Portuguese.

Article 199 then opens the second door: “health care is open to private enterprise”. Brazil therefore runs a two-storey arrangement — a universal public system underneath, and a private market above it that supplements rather than replaces it.

How other countries answer the same question

By residence or citizenship. The NHS Constitution for England opens with two principles: “The NHS provides a comprehensive service, available to all”, and “access to NHS services is based on clinical need, not an individual’s ability to pay”, with services “free of charge, except in limited circumstances sanctioned by Parliament”. Canada writes the same logic into federal statute: the Canada Health Act declares in section 3 that the primary objective is to protect and restore the well-being “of residents of Canada” and to facilitate reasonable access “without financial or other barriers”; section 10 requires provincial plans to cover “one hundred per cent of the insured persons of the province” on uniform terms.

By contribution. Germany’s Social Code, Book V, organises compulsory insurance by category of person. Section 5 begins with employed workers and trainees who work for remuneration — which confirms the intuition that this is a system built around employment. But the list does not stop there: it expressly includes people for the period in which they receive unemployment benefit, and those receiving basic subsistence support. In the archetypal contributory system, losing your job does not cost you your health insurance; you are covered through a different door.

By residence, after starting from contribution. France began in the same contributory model as Germany and then moved its axis. Article L160-1 of the French Social Security Code, in force since 14 May 2022, does it in a single sentence: “Toute personne travaillant ou, lorsqu’elle n’exerce pas d’activité professionnelle, résidant en France de manière stable et régulière bénéficie, en cas de maladie ou de maternité, de la prise en charge de ses frais de santé dans les conditions fixées au présent livre.” — in the author’s translation, “any person who works or, where they carry on no professional activity, who resides in France on a stable and regular basis is entitled, in case of illness or maternity, to have their health costs covered”, under the conditions set out in that book. Read the structure carefully: work appears as one of two doors, not as a condition. Having no professional activity does not close the right; it opens the other one. The same article also refers to decree the conditions under which someone who stops meeting the residence requirements keeps the cover for up to one year. Placed next to the American rule, this is the sharpest contrast in the comparison: both texts speak of work, and do opposite things with it.

By purchase, mostly through an employer. That is the American arrangement, with targeted public programmes filling defined gaps. Seen from inside that logic, conditioning a targeted programme on activity is not an anomaly — it is a decision about who belongs inside the target.

The Brazilian numbers, and the one that surprises people

Figures below are published by ANS, Brazil’s national regulator for private health plans, on its official sector-data page, updated on 16 September 2026.

In June 2026 Brazil had 53,080,809 beneficiaries of private medical plans, plus 36,766,931 in dental-only plans. Coverage by medical plan stood at 25.0% of the population in July 2026. Read that slowly: one in four Brazilians has a private plan; three in four rely on the public system alone.

Now the number almost nobody quotes. Of those 53 million, 38,791,344 are in corporate group plans, 5,832,136 in membership-association plans, and only 8,434,495 hold individual or family plans bought directly. Roughly three in four private medical plans in Brazil exist because somebody holds a job — not by statute, but by market design.

So “health care for those who work” is not only a foreign proposal. It is a fair description of the upper storey of Brazilian health care — with one decisive difference: here, losing the plan does not mean losing the system. The person falls back on the SUS, which by constitutional text cannot turn them away.

What this means if you are a foreign patient in Brazil

Two practical consequences. First, emergency and public care do not depend on nationality or on holding a plan: the constitutional wording is “all”, and it has been applied that way. Second, if you buy private care or travel-linked coverage while in Brazil, you are dealing with a regulated market and with consumer law — a different body of rules from the public system, with its own remedies.

Where this article stops

Only countries whose official texts were actually opened and read for this piece appear here: the United Kingdom, Canada, Germany, France, the United States and Brazil. No system is described here without the law that organises it having been read. Foreign provisions are quoted as comparative law; none of them is binding in Brazil, and the translations are the author’s own. Coverage figures are those published by the Brazilian regulator, calculated against official population estimates, and change with each release. The American rule described sits in an interim final rule open to comment and may be altered before 2027. Finally, this article compares criteria for entry, not quality, waiting times or clinical outcomes — those are different questions, requiring data not gathered here.

Ramon Martins Andrade (OAB/RJ 188.374) is a Brazilian attorney who graduated in law from UFRJ in 2011 and holds master’s degrees from Université Sorbonne Nouvelle and from the Naval War College (EGN, Brazilian Navy). He is currently a researcher in Human Rights and Health at ENSP/Fiocruz.

This content is for information and education only. It does not constitute legal advice, advertising of results or any guarantee of outcome, under Rule 205/2021 of the Brazilian Bar Association (OAB).