Simplified healthcare plans: international evidence and a regulatory agenda for Brazil

Luciana Mayumi Sakamoto
Souto Correa, São Paulo
luciana.sakamoto@soutocorrea.com.br

Maria Luísa Matos
Souto Correa, São Paulo
maria.matos@soutocorrea.com.br

Anderson Ribeiro
Souto Correa, São Paulo
anderson.ribeiro@soutocorrea.com.br

Introduction

Simplified healthcare plans have emerged as a pragmatic response to the contemporary challenge of aligning access, sustainability and innovation in healthcare. This new model prioritises outpatient services, such as medical consultations, diagnostic exams and clinical follow-ups, while intentionally excluding highly complex procedures and hospitalisations, thereby reducing premiums, as well as contractual complexity, and even offering a reduced network.

From an economic perspective, the rationale follows a ‘pay-for-what-you-use’ logic, mitigating cross-subsidies and enabling greater predictability of risk and claims ratios. From a care perspective, the design promotes prevention, chronic condition management and the effective coordination of care, particularly when anchored in strong primary healthcare processes and effective gatekeeping mechanisms.

It is important to note that some companies already provide healthcare services at lower or more affordable costs, on an out-of-pocket basis. These services, however, are not regulated and should not be confused with a healthcare plan. The recent regulatory literature issued by the National Supplementary Health Agency (Agência Nacional de Saúde Suplementar or ANS) reflects this approach by proposing the creation of an experimental regulatory sandbox, designed specifically to formulate a ‘Plan for strictly elective medical consultations and exams’. Its explicit purpose is to simplify and broaden individual access to private healthcare plans by granting temporary regulatory flexibility to participating entities.

The public policy rationale is twofold. On one hand, the Unified Health System (Sistema Único de Saúde or SUS) remains universal and foundational, yet faces structural capacity limitations and long waiting lists for elective procedures. On the other hand, the supply of individual private healthcare plans has declined in the last few years, while group plans, subject to restrictive eligibility criteria, have become the primary channel for accessing private coverage.

In general, this structure benefits beneficiaries, who gain predictability and autonomy, as well as private health insurance companies, which operate with lower actuarial risk and greater control over claims ratios and can compete with stakeholders that provide low-cost private healthcare services. The adoption of simplified models is driven by three main forces: the personalisation of healthcare services, as contemporary beneficiaries increasingly seek tailored, flexible and technology-enabled solutions; the need to rationalise costs and reduce waste for both health insurance companies and consumers; and the pursuit of innovation, both in regard to products and incentive mechanisms.

International experiences and operational lessons

Comparative experience demonstrates that simplifying does not necessarily mean weakening, but rather involves the redesign of incentives to enhance patient access and efficiency. In the United States, Medicare Advantage^[1] exemplifies the value of public–private integration guided by care coordination and additional benefits, while Direct Primary Care^[2] operates outside traditional insurance schemes, offering fixed monthly fees and expanded access to primary healthcare, thereby reducing administrative costs and strengthening disease prevention and the longitudinal relationship between patients and physicians.

In the United Kingdom, private products directed at young adults emphasise digital health, mental health and rapid access, using language and pricing strategies that reflect different demographic profiles and yield low claims ratios and high beneficiary retention. In the Netherlands, a modular structure combining a mandatory basic plan with optional add-ons enables consumer autonomy, while fostering competition based on quality and cost transparency. In Australia, ‘extras only’ products cover supplementary benefits, such as dentistry, ophthalmology and physiotherapy, complementing the public system with clarity of purpose and a favourable cost–benefit ratio.

These international experiences converge around three fundamental design principles. The first is the prioritisation of outpatient coverage through the provision of strong primary healthcare and coordinated care. The second is the use of modular structures and cost-sharing mechanisms, including deductibles, restricted networks and copayments, to align the incentives and promote efficiency. The third is contractual transparency, which reduces information asymmetry and litigation. When institutionally adapted, these principles produce several benefits: for beneficiaries, they provide customised healthcare coverage, lower prices, simplicity and improved chronic care management; for health insurance companies, they ensure greater cost predictability, more accurate risk segmentation, lower default rates and stronger incentives for innovation.

Brazil: evidence of need and proposed regulatory design

Based on sectoral assessments and public consultations, the ANS has identified three primary drivers of the current problem facing the sector: the contraction of individual private healthcare plan offerings, eligibility rules that exclude individuals from the regulated market and the proliferation of unregulated solutions. These trends generate some consequences, including the overburdening of the SUS, the expansion of small-scale group private health insurance contracts and a growing backlog of unmet demand.

The impasse is significant. Traditional private healthcare plans have become prohibitively expensive for most Brazilians, and this challenge is even more acute when it comes to individual plans. Although SUS remains a universal system, it struggles to provide timely responses to elective care demands. As a result, a grey zone of unmet needs has emerged, made up of individuals who could afford a low-cost plan offering essential coverage, but who are currently left without adequate access. The lack of intermediate options deepens healthcare inequalities and places excessive pressure on the public health system.

From a policy perspective, the declared rationale includes expanding the beneficiary base, thereby increasing mutualism and risk dilution, ensuring contractual predictability and promoting competition and efficiency through a single annual adjustment calculated by the health insurance company, subject to transparent regulatory oversight. This discussion is critical because, as of December 2024,^[3] only one-quarter of Brazil’s population was covered by supplementary healthcare, predominantly through group private health insurance. Barriers to entry for individuals exacerbate the burden on the SUS and encourage the growth of unregulated markets. A well-designed simplified healthcare plan, operating under regulatory supervision and with transparent contractual communication, represents an effective instrument to fill this gap by ensuring adequate consumer protection, coordinated care delivery and ex post data collection for regulatory evaluations to take place.

International evidence demonstrates that it is possible to balance personalisation, accessibility and sustainability without compromising consumer protection. The Brazilian path necessarily involves modular healthcare coverage that allows beneficiaries to combine basic and additional plans, the strengthening of primary healthcare as a tool for prevention and cost control and the development of products targeted at specific groups, such as young adults, older persons or patients with chronic conditions, whose actuarial and clinical designs are compatible with their respective patient profiles.

Conclusion

In Brazil, the quality of implementation of a simplified healthcare plan will depend on the precision of the contractual language to prevent asymmetries and litigation, the design of care networks and pathways centred on primary healthcare and chronic disease management, interoperable data governance in tandem with the Digital SUS to maximise the public value derived from regulatory learning and transparent evaluations of the outcomes, including access, waiting times, appropriate utilisation, adverse events, user satisfaction and the cost per health outcome. Executed with technical prudence and transparency, the simplified healthcare plan has the potential to relieve pressure on the SUS and provide an intermediate, financially sustainable and socially protective alternative to the current ‘all-or-nothing’ model of healthcare coverage.

However, it is important to note that, according to the ANS, the regulatory sandbox initiative is currently suspended. Upon a recommendation issued by the ANS Federal Attorney’s Office, any measure related to this issue, including the launch of a public consultation, shall only proceed after the Superior Court of Justice (Superior Tribunal de Justiça or STJ) issues a final ruling on the matter.