Abstract

This study aims to present the percentages of the Brazilian population holding health insurance plans, itemized by social-demographic characteristics, based on the data of the National Health Survey carried out in 2013, and to compare this information with the administrative data of the National Supplementary Health Agency for the same year. Data from the National Health Survey, and from the Beneficiaries Information System of the National Health Agency for the year 2013, were used. The percentage of people having a health plan was described according to stratification for: all of Brazil, urban/rural, Brazilian official Regions, Brazilian States and state capitals, gender, age group, level of schooling, position in the workforce, ethnic classification, and self-assessed state of health. Results include the following: The percentage of people saying they had some health plan in Brazil was 27.9% (CI 95%: 27.1-28.8). A significant difference was found relating to level of schooling – the percentage being highest for those who stated they had complete secondary education (68.8% CI 95%: 67.2-70.4) and for those who said they were currently in work (32.5% CI 95%: 31.5-33.5). The increase in health plan coverage in the Brazilian population reflects the improvement of the suply of employment and the growth in the country's economy.

Key words
Pre-paid health plans; Prevalence of private health plans; Epidemiological surveys; Health services; Brazil

Introduction

Brazil's Unified Health System (SUS) was brought into existence by the Federal Constitution of 1988¹1. Brasil. Constituição da República Federativa do Brasil de 1988. Diário Oficial da União 1988; 5 out., which is based on the principles of: universality, full coverage, and equity. It was further established that the private sector would organize itself in a manner complementary to the public sector²2. Malta DC, Cecílio LCO, Merhy EE, Jorge AO, Franco T, Costa MA. Perspectivas da regulação na saúde suplementar diante dos modelos assistenciais. Cien Saude Colet 2004; 9(2):433-444.. Since then, rules and regulations have been established for the functioning of the supplementary sector, among them Law 9656 of 1998³3. Brasil. Lei n° 9.656, de 3 de junho de 1998. Regulamenta a Saúde Suplementar no Brasil e dá outras providências. Diário Oficial da União 1998; 2 jun. (‘Law 9656/98’), which sets rules for the functioning of the sector, and Law 9961/2000⁴4. Brasil. Lei n° 9.961, de 28 de janeiro de 2000. Cria a Agência Nacional de Saúde Suplementar - ANS e dá outras providências. Diário Oficial da União 2000; 28 jan., which created the National Supplementary Health Agency (ANS), which was given the duty of preparing rules for the operators and inspecting them, including in relation to their content and their care models.

Health plan providers have been operating in Brazil since the 1940s⁵5. Santos FP, Merhy EE. A regulação pública da saúde no Estado brasileiro: uma revisão. Interface (Botucatu) 2006; 10(19):25-41.^,66. Bahia L. As contradições entre o SUS universal e as transferências de recursos públicos para os planos e seguros privados de saúde. Cien Saude Colet 2008; 13(5):1385-1397.; the Supplementary Health subsector comprises the market for private healthcare plans. The commercial segment comprises cooperatives for medical work, dental care cooperatives, group medicine companies, self-management companies and the insurance companies²2. Malta DC, Cecílio LCO, Merhy EE, Jorge AO, Franco T, Costa MA. Perspectivas da regulação na saúde suplementar diante dos modelos assistenciais. Cien Saude Colet 2004; 9(2):433-444.^,77. Malta DC, Jorge AO. Modelos assistenciais na saúde suplementar: o caso de uma operadora de autogestão. Cien Saude Colet 2008; 13(5):1535-1542.. Another segment, the non-profits, is not covered by the regulations of the sector and the ANS, and is part of the segment of Public Institutions, including institutions providing healthcare to government workers (municipal, state or military).

The sector has expanded and, at the end of the 1990s, the National Household Sampling Survey (Pesquisa Nacional por Amostra de Domicílios, or PNAD, of 1988⁸8. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional por Amostra de Domicílios. Acesso e utilização de serviços de saúde 1998. Rio de Janeiro: IBGE; 2000., estimated that approximately 38.7 million Brazilians were covered by at least one health plan – then corresponding to 24.5% of the population. In the PNAD of 2003⁹9. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional por Amostra de Domicílios. Acesso e utilização de serviços de saúde 2003. Rio de Janeiro: IBGE; 2005., it was estimated that 24.6% of the Brazilian population had at least one health plan, and in the year 2008¹⁰10. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional por Amostra de Domicílios. Um panorama da saúde no Brasil. Acesso e utilização de serviços, condições de saúde e fatores de risco e proteção à saúde 2008. Rio de Janeiro: IBGE; 2010. this had increased to 25.9%, or 49.2 million people. In 2013, in continuation of the health survey of the PNAD of previous years, the National Health Survey (Pesquisa Nacional de Saúde – PNS) was held, which included in its scope information about the characteristics of the Supplementary Health Sector, especially on coverage by territory. The PNS further expanded the subjects – including items such as chronic diseases, and lifestyle, among others¹¹11. Santos IS, Ugá MAD, Porto SM. O mix público-privado no Sistema de Saúde Brasileiro: financiamento, oferta e utilização de serviços de saúde. Cien Saude Colet 2008; 13(5):1431-1440.

Information on coverage of health plans in Brazil is important for monitoring regional trends, and social-demographic distribution, providing the possibility of improvement of the public regulation measures¹¹11. Santos IS, Ugá MAD, Porto SM. O mix público-privado no Sistema de Saúde Brasileiro: financiamento, oferta e utilização de serviços de saúde. Cien Saude Colet 2008; 13(5):1431-1440^,1212. Santos FP, Malta DC, Merhy EE. A regulação na saúde suplementar: uma análise dos principais resultados alcançados. Cien Saude Colet 2008; 13(5):1463-1475..

The objective of this article is to show the extent of coverage of the population by private health plans in Brazil, separated according to social-demographic characteristics, based on the data of the National Health Survey made in 2013, and to compare these data with administrative data from the National Supplementary Health Survey for the same year.

Methods

The data of the National Health Survey (PNS) were analyzed. This is a household-based survey carried out in Brazil in 2013 by the Brazilian Geography and Statistics Institute (Instituto Brasileiro de Geografia e Estatística – IBGE), in partnership with the Health Ministry. The PNS is part of the IBGE's Integrated Home Survey System (SIPD), and uses the Master Sample of that System, which has greater geographical spread and higher precision of estimates.

Cluster sampling was used, divided into three stages: The primary sampling unit was census sectors; the secondary unit, homes; and as the third unit, one adult member of the household (aged 18 or over). The homes and residents were selected by simple random sampling. The minimum size of the sample decided was 1,800 households per state of the Brazilian Federation; 81,767 households were initially selected, and the interviews obtained in 64,348 of them. Taking closed households into account, the proportion of losses was 20.8%, and the proportion of non-replies, 8.1%¹³13. Szwarcwald CL, Malta DC, Pereira CA, Vieira MLFP, Conde WL, Souza Júnior PRB, Damacena GN, Azevedo LO, Azevedo e Silva G, Theme Filha MM, Lopes CS, Romero DE, Almeida WS, Monteiro CA. Pesquisa Nacional de Saúde no Brasil: concepção e metodologia de aplicação. Cien Saude Colet 2014; 19(2):333-342..

The estimates supplied by the PNS were weighted taking into account the weighting of the Primary Sampling Unit (UPA) in relation to the probability of being part of the survey, weighting of the household, with adjustments for correction for non-response and calibration of the population totals, and weighting of the residents selected, which further took into account the probability of selection of the resident, non-response adjustments by gender, and calibration for the population totals by gender and age groups estimated with the weight of all the residents. Other details on the process of sampling and weighting are available in prior publications¹³13. Szwarcwald CL, Malta DC, Pereira CA, Vieira MLFP, Conde WL, Souza Júnior PRB, Damacena GN, Azevedo LO, Azevedo e Silva G, Theme Filha MM, Lopes CS, Romero DE, Almeida WS, Monteiro CA. Pesquisa Nacional de Saúde no Brasil: concepção e metodologia de aplicação. Cien Saude Colet 2014; 19(2):333-342.^,1414. Instituto Brasileira de Geografia e Estatística (IBGE). Acesso e Utilização dos Serviços de Saúde, Acidentes e Violências. Rio de Janeiro: IBGE; 2015..

The interviews were made using handheld computers (Personal Digital Assistants – PDAs), programed for critical entry of input values. The questionnaire of the PNS was divided into three blocks: 1) information about the home: one for each home; 2) information on all the residents: one for each resident (the ‘proxy’ answered for the others living in the same household); and 3) resident selected: an adult resident (aged 18 or over) who was selected to answer the specific blocks of the questionnaire¹⁴14. Instituto Brasileira de Geografia e Estatística (IBGE). Acesso e Utilização dos Serviços de Saúde, Acidentes e Violências. Rio de Janeiro: IBGE; 2015..

The information on possession of a health plan was obtained in the block for all the residents in the home. By this means the PNS collected valid information for 205,000 residents¹⁴14. Instituto Brasileira de Geografia e Estatística (IBGE). Acesso e Utilização dos Serviços de Saúde, Acidentes e Violências. Rio de Janeiro: IBGE; 2015..

Information on possession of health plans was processed to produce the indicator:

1) Percentage of people having some health plan (medical or dental), in which the numerator was: Number of people who have some health plan; and the denominator was the sum of the number of residents of all the households visited. This indicator was analyzed according to social-demographic characteristics: Gender (male, female), age group (0 to 17, 18 to 29, 30 to 39, 40 to 59, 60 and over), level of schooling (none, or primary incomplete; primary complete and secondary incomplete; secondary complete and higher incomplete; and higher complete); status in the workforce (working, unemployed, or outside the workforce); state of health (very good and good, average, bad and very bad); location (urban, rural); Brazilian Region (North, Northeast, Southeast, South and Center-West); and finally for the whole of Brazil.

The figures for percentage of people having health plans, in the whole of Brazil and in the Brazilian States, were compared with administrative data of the Beneficiaries Information System of the National Supplementary Health Agency (ANS)¹⁵15. Agência Nacional de Saúde Suplementar (ANS). Caderno de Informações. [acessado 2015 mar 13]. Disponível em: http://www.ans.gov.br/portal/site/
http://www.ans.gov.br/portal/site/... of December 2013, for comparison with the data collected by the PNS in 2013.

Other indicators were also investigated, also itemizing by social-demographic characteristics:

2) Percentage of people who have some health plan (medical or dental) as primary holder. Numerator: Number of people who have some health plan and are the nominal owner of the plan. Denominator: Number of people who have some health plan.

3) Percentage of people who have more than one health plan (medical or dental). Numerator: Number of people who have more than one health plan. Denominator: Sum of the number of residents of all the households visited.

4) Percentage of people who have some health plan only for dental care. Numerator: Number of people who have some health plan only for dental care. Denominator: Sum of the number of residents of all the homes visited.

5) Percentage of people whose principal (or sole) health plan is from a government workers’ healthcare institution (municipal, state or military). Numerator: Number of people whose principal health plan is a government workers’ healthcare institution. Denominator: Sum of the number of residents of all the households visited.

6) Percentage of people who have had a health plan for more than one year without interruption. Numerator: Number of people who have held a health plan for more than one year without interruption. Denominator: Sum of the number of residents of all the households visited.

7) Percentage of people with a plan who evaluate the principal health plan (medical or dental) as good or very good. Numerator: Number of people with a plan who assess the principal health plan (medical or dental) as good or very good. Denominator: People with a health plan.

Additionally, the formats for financing of the plan were described:

8) Percentage of people whose health plan is paid by the holder's employer; (Numerator: Number of people whose plan is paid by the employer. Denominator: People with a health plan).

9) Percentage of people whose health plan is paid by the holder through present or prior employment. Numerator: Number of people whose plan is paid by the holder through present or prior employment situation. Denominator: People with a health plan).

10) Percentage of people whose health plan is paid directly by the holder or another resident in the same home. Numerator: Number of people whose plan is paid directly by the holder or by another resident of the household. Denominator: People with health plans.

These indicators were analyzed by: Gender (male, female); age group (0-17, 18-29, 30-39, 40-59, 60 and over); and level of schooling (no schooling, or primary incomplete; primary complete and secondary incomplete; secondary complete and higher incomplete; and secondary complete).

The software Stata, version 11.0, was employed, using the Survey module, which takes into account effects of the sampling plan, presenting prevalences and respective 95% confidence intervals (CI 95%). The differences between the categories were evaluated by superposition of the confidence intervals.

The PNS was approved by the National Research Ethics Committee. All the individuals were consulted, informed and agreed to take part in the survey.

Results

Of the total of those interviewed by the PNS, the proportion who said they had some health plan (medical or dental) in Brazil was 27.9% (CI 95%: 27.1-28.8), there being no difference by gender. In age groups, the proportions were lower in the 0-17 and 18-29 age groups than in the older age groups (30-39, 40-59 and 60 and over). In level of schooling, the proportions increased according to the years of study. Thus, the proportion of people who said they had completed higher education and a health plan was 68.8% (CI 95%: 67.2-70.4), while for those without schooling or with incomplete primary education this proportion was 16.4% (CI 95%: 15.7-17.1) (Table 1).

For this same indicator, there were also significant differences for status in the workforce: The proportion of people who said they had a health plan was greater for those in work (32.5% – CI 95%: 31.5-33.5) than those out of work (16.3% – CI 95%: 14.4-18.1), or outside the workforce (24.7% – CI 95%: 23.6-25.7). Differences were also found: between those reporting their state of health to be good and very good (31.3% – CI 95%: 30.3-32.3) in relation to the others; and between those with urban and rural homes, the proportion being higher in those living in an urban area (31.7% – CI 95%: 30.7-32.7). By Brazilian Region, the largest proportion of people having a health plan was in the Southwest (36.9% – CI 95%: 35.2-38.6), and the lowest in the Northeast (13.3% CI 95%: 12.2-14.4) (Table 1).

The data obtained were also compared with administrative data of the ANS, relating to the same period investigated. Both the PNS and ANS showed the Region and State with highest percentage of health plans to be, respectively, the Southeast and São Paulo State. Correspondence and/or proximity was also observed between the data of the PNS and ANS in other locations, such as in the Northern Region, and in the states of Maranhão, Rio Grande do Norte and Alagoas. However, some states had quite different values: these included Paraná, Rio Grande do Sul, Mato Grosso do Sul, Mato Grosso, Goiás and the Federal District. Figure 1 shows the proportions of possession of health plans for Brazil, by Brazilian Region and by State, based on the data from the PNS and from the Beneficiaries Information System of the ANS.

Table 2 shows the other indicators researched, by gender of interviewee. There was a significant difference in possession of a health as primary owner: the proportion was greater for men (54.5% CI 95%: 53.5-55.5) than for women (41.8% CI 95%: 40.6-43.0). However, differences by gender were also found for: People whose health plan is paid by the nominal holder through work – greater in men (35.6% – CI 95%: 34.2-37.0); and People whose health plan is paid directly by the nominal holder, greater among women (27.7% – CI 95%: 26.5-28.8). The other indicators did not show significant differences.

Table 3 shows the indicators by interviewee age group. The proportion of people having an exclusively dental health plan was greater in the age group 30-39 (7.3% – CI 95%: 6.6-7.9) than in the others. For people with a government workers’ institutional health plan, higher proportions were found in the 40-49 age group (8.0% – CI 95%: 7.4-8.6) and 60 or over (8.7% – CI 95%: 7.9-9.4). These age groups were also those with the highest proportions of holders of a health plan for more than one year without interruption. The proportion of people whose health plan was paid directly by the owner was highest in people aged 60 or over (43.5% – CI 95%: 41.1-45.8).

Table 4 shows the indicators by interviewee's level of schooling. In this comparison, several categories showed significant differences. The proportions were highest for those with complete higher education for the following categories: People holding a health plan in the status of primary holder (67.4% – CI 95%: 66.0-68.8); people with more than one health plan (8.5% – CI 95%: 7.6-9.4); people who have an exclusively dental plan (12.6% – CI 95%: 11.6-13.6); people with a government workers’ institutional health plan (17.8% – CI 95%: 16.7-19.0); and people who have had a health plan for more than one year without interruption (63.4% – CI 95%: 61.7-65.1). There was a gradual increase in the proportions with the increase in level of schooling. Thus, the lowest proportions of holding of plans, mostly, were found in the category of people without schooling and/or without having completed primary education (Table 4).

Discussion

The proportion of people with health plans in Brazil has increased in the last five years, to 27.9%, or approximately 56 million Brazilians, in 2013. The proportion of plans is higher after the age of 30, and for those who are in the labor market, followed by retirees and the elderly. Further, it is higher among people with higher levels of schooling, and indeed is as much as four times higher among those with completed higher education; and slightly more frequent among women. The populations of the Southeastern and Northern regions have, respectively, the highest and the lowest proportions of health plan coverage. In urban regions health plans are four times more frequent than in rural areas.

The PNS showed an increase in the number of beneficiaries of health plans in Brazil, which may be explained by various components of the population, especially people with formal employment and companies, being led to acquire health plans as a result of the increase in the number of people employed, economic growth, and/or greater availability of money¹⁰10. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional por Amostra de Domicílios. Um panorama da saúde no Brasil. Acesso e utilização de serviços, condições de saúde e fatores de risco e proteção à saúde 2008. Rio de Janeiro: IBGE; 2010.

11. Santos IS, Ugá MAD, Porto SM. O mix público-privado no Sistema de Saúde Brasileiro: financiamento, oferta e utilização de serviços de saúde. Cien Saude Colet 2008; 13(5):1431-1440^-1212. Santos FP, Malta DC, Merhy EE. A regulação na saúde suplementar: uma análise dos principais resultados alcançados. Cien Saude Colet 2008; 13(5):1463-1475..

This increase coincides with the registration data of the ANS, identified by the Beneficiaries Information System. These data indicate that the number of beneficiaries in the year 2008 was approximately 40 million, increasing to 50 million in 2013, that is to say an increase of 25% in five years. However, it is emphasized that the data of the ANS refer to the number of health plans, and that one individual may have more than one. Also, the number of plans does not include plans for government workers, which are not under the regulation of the ANS¹⁵15. Agência Nacional de Saúde Suplementar (ANS). Caderno de Informações. [acessado 2015 mar 13]. Disponível em: http://www.ans.gov.br/portal/site/
http://www.ans.gov.br/portal/site/... .

Another item of data that is worth highlighting is that the majority of beneficiaries of health plans are affiliated to the collective plans¹⁵15. Agência Nacional de Saúde Suplementar (ANS). Caderno de Informações. [acessado 2015 mar 13]. Disponível em: http://www.ans.gov.br/portal/site/
http://www.ans.gov.br/portal/site/... . This was already indicated by the 2008 PNAD¹⁰10. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional por Amostra de Domicílios. Um panorama da saúde no Brasil. Acesso e utilização de serviços, condições de saúde e fatores de risco e proteção à saúde 2008. Rio de Janeiro: IBGE; 2010., and also by the administrative information of the ANS, which indicates growth in corporate collective plans from 23.4 million in 2008 to 33.7 million in 2014, and collective plans by subscription totaling 6.7 million, resulting in a total for 2013 of approximately 40 million collective plans, or approximately 75% of the market¹⁶16. Malta DC, Moura EC, Oliveira M, Santos FP. Usuários de planos de saúde: morbidade referida e uso de exames preventivos, por inquérito telefônico, Brasil, 2008. Cad Saude Publica 2011; 27(1):57-66.. Some plans that are contracted collectively are sponsored by companies, and thus relate to the population involved in the labor market, that is to say, the population of working age¹⁴14. Instituto Brasileira de Geografia e Estatística (IBGE). Acesso e Utilização dos Serviços de Saúde, Acidentes e Violências. Rio de Janeiro: IBGE; 2015.^,1616. Malta DC, Moura EC, Oliveira M, Santos FP. Usuários de planos de saúde: morbidade referida e uso de exames preventivos, por inquérito telefônico, Brasil, 2008. Cad Saude Publica 2011; 27(1):57-66..

Also, the increase in the supply of collective plans can be attributed to the legislation governing the sector, which sets measures such as maximum increases in rates for individual plans – while this is not the case for collective plans, for which it was supposed that the market would be able to regulate increases of prices. Thus, the collective plans became more competitive and attractive, as well as offering a large number of benefits, for the great majority of the population involved in the market – of productive age, younger and with a lower risk of becoming ill. These movements have the effect of increasing the cost of individual plans, leading to reduction of demand and supply¹²12. Santos FP, Malta DC, Merhy EE. A regulação na saúde suplementar: uma análise dos principais resultados alcançados. Cien Saude Colet 2008; 13(5):1463-1475..

Although the proportion of plans has increased, the regional variations have persisted. The differences between urban and rural populations were significant, as were also the differences between the Brazilian Regions and States. Data from previous PNADs showed a difference between figures in Brazil's Southern and Southeastern Regions and in its other regions. That difference persisted in this survey, which could be due to the higher concentration of wealth, jobs, and also the greater proportion of the total population in these regions¹⁰10. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional por Amostra de Domicílios. Um panorama da saúde no Brasil. Acesso e utilização de serviços, condições de saúde e fatores de risco e proteção à saúde 2008. Rio de Janeiro: IBGE; 2010.^,1717. Instituto Brasileiro de Geografia e Estatística (IBGE). Censo Demográfico 2010. Características gerais da população, religião e pessoas com deficiência. Rio de Janeiro: IBGE; 2012.. The greatest growth in percentages of coverage, however, was in the Center-West Region: from 24.5% in 2008 to 30.4% in 2013 – an increase of 24%¹⁴14. Instituto Brasileira de Geografia e Estatística (IBGE). Acesso e Utilização dos Serviços de Saúde, Acidentes e Violências. Rio de Janeiro: IBGE; 2015..

Another differential was the larger proportion of plans among people with higher levels of schooling. Schooling is regarded as a proxy for income, and has been indicated as a determining factor in access to health services²2. Malta DC, Cecílio LCO, Merhy EE, Jorge AO, Franco T, Costa MA. Perspectivas da regulação na saúde suplementar diante dos modelos assistenciais. Cien Saude Colet 2004; 9(2):433-444.^,1818. Brasil. Rede Interagencial de Informação em Saúde. Indicadores Básicos para a Saúde no Brasil: conceitos e aplicações. Brasília: Organização Pan Americana de Saúde; 2008.^,1919. Malta DC, Jorge AO. O mercado de saúde suplementar e análise dos dados das operadoras selecionadas. In: Agência Nacional de Saúde Suplementar, organizador. Duas faces da mesma moeda: microrregulação e modelos assistenciais na saúde suplementar. Rio de Janeiro: Agência Nacional de Saúde Suplementar; 2005. p. 37-60.. Other studies also indicate that schooling is strongly associated with possession of a health plan⁷7. Malta DC, Jorge AO. Modelos assistenciais na saúde suplementar: o caso de uma operadora de autogestão. Cien Saude Colet 2008; 13(5):1535-1542.^,2020. Lima-Costa MF. Estilos de vida e uso de serviços preventivos de saúde entre adultos filiados ou não a plano privado de saúde (inquérito de saúde de Belo Horizonte). Cien Saude Colet 2004; 9(4):857-864.^,2121. Bahia L, Costa AJ, Fernandes C, Luiz RR, Cavalcanti ML. Segmentação da demanda dos planos e seguros privados de saúde: uma análise das informações da PNAD/98. Cien Saude Colet 2002; 7(4):671-686..

The PNS shows a segment that is not covered by the administrative data of the ANS – the healthcare plans for state, municipal or military government workers. These are approximately 6.1% of the population, or approximately 12 million people, with the highest proportions in the Federal District, Goiás, Mato Grosso do Sul and Rio Grande do Sul, and also among people over the age of 40 and with higher levels of schooling. Thus, only data of the population base can be used to monitor the distribution of these plans¹⁴14. Instituto Brasileira de Geografia e Estatística (IBGE). Acesso e Utilização dos Serviços de Saúde, Acidentes e Violências. Rio de Janeiro: IBGE; 2015.. This difference in the registration base of the ANS also explains the difference found in the related data of the PNS.

The PNS indicated that children and young people have lower percentages of coverage by health plans, which could be explained on the basis that they are healthier populations – so that families delay inclusion of their youngest in health plans. Also, the current legislation has created ten age groups and six bands for increases of health plan charges, requiring the costs of plans to be distributed between all groups and not concentrated among the oldest – this is referred to as the principle of inter-generation solidarity. Under this arrangement, charges are increased for the earlier age groups: populations up to the age of 59 pay higher monthly charges than the risk for their age, while the elderly pay lower monthly charges than the risk associated with their age range²²22. Cechin J, Badia BD, Martins CB. Pacto intergeracional, seleção adversa e Financiamento dos planos de saúde. Saude em Debate 2009; 33(82):214-221.^,2323. Agência Nacional de Saúde (ANS). Resolução Normativa n° 63, de 22 de dezembro de 2003. Define os limites a serem observados para adoção de variação de preço por faixa etária nos planos privados de assistência à saúde contratados a partir de 1° de janeiro de 2004. Diário Oficial da União 2003; 23 dez.. This mechanism also stimulated entry into health plans of people already in the labor market, in productive age groups – more usually enrolling in collective plans.

The PNS indicated a high participation of the elderly in health plans, which can be understood in terms of this age group's greater health needs, due to their higher probability of becoming ill. As age increases the demand for plans tends to increase, as people seek greater access to care¹⁵15. Agência Nacional de Saúde Suplementar (ANS). Caderno de Informações. [acessado 2015 mar 13]. Disponível em: http://www.ans.gov.br/portal/site/
http://www.ans.gov.br/portal/site/... ^,1919. Malta DC, Jorge AO. O mercado de saúde suplementar e análise dos dados das operadoras selecionadas. In: Agência Nacional de Saúde Suplementar, organizador. Duas faces da mesma moeda: microrregulação e modelos assistenciais na saúde suplementar. Rio de Janeiro: Agência Nacional de Saúde Suplementar; 2005. p. 37-60.. Studies in Japan show that per capita expenditure on health for people over the age of 75 is 7.5 times the level for young people between age 15 and 19²⁴24. Fukui T, Wamoto Y. Policy options for financing the future health and long-term care costs in Japan. In: Ito T, Rose A, editors. Fiscal Policy and Management in East Asia. Chicago: University of Chicago Press; 2007. p. 415-442.. European studies also indicate that spending increases with age, to as much as a factor of 10 for people older than 70 compared to the expenditure for the age groups between 5 and 19²⁵25. Westerhout E, Pelikaan F. Alternative scenarios for health, life expectancy and social expenditure: the influence of living longer in better health on health care and pension expenditures and government finances in the EU. ENEPRI Research Report 2005; 8.. This shows the importance of establishing inter-generation solidarity for coverage of common costs for the elderly²³23. Agência Nacional de Saúde (ANS). Resolução Normativa n° 63, de 22 de dezembro de 2003. Define os limites a serem observados para adoção de variação de preço por faixa etária nos planos privados de assistência à saúde contratados a partir de 1° de janeiro de 2004. Diário Oficial da União 2003; 23 dez..

In other countries, factors such as white skin, schooling level, income, older age groups and people being in the labor market are also associated with possession of a plan, and also lower levels of coverage among young people²⁶26. Ahluwalia JB, Bolen J, Garvin B. Health insurance coverage and use of selected preventive services by working age women, BRFSS 2006. J Women's Health 2007; 16(7):935-940.

27. Nelson KM, Chapko MK, Reiber G, Boylo EJ. The association between health insurance coverage and diabetes care: data from the 2000 behavior risk factor surveillance system. Health Serv Res 2005; 40(2):361-372.^-2828. Hagdrup NA, Simoes EJ, Browson RC. Health care coverage: traditional and preventive measures and associations with chronic disease risk factor. J Community Health 1997; 22:387-399.. This pattern is repeated in Brazilian studies¹¹11. Santos IS, Ugá MAD, Porto SM. O mix público-privado no Sistema de Saúde Brasileiro: financiamento, oferta e utilização de serviços de saúde. Cien Saude Colet 2008; 13(5):1431-1440^,2929. Malta DC, Bernal RTI. Comparação dos fatores de risco e proteção de doenças crônicas na população com e sem planos de saúde nas capitais brasileiras, 2011. Rev Bras Epidemiol 2014; 17(Supl. 1):241-255.^,3030. Lima-Costa MF, Guerra HL, Firmo JO, Vidigal PG, Uchoa E, Barreto SM. The Bambuí Health and Aging Study (BHAS):private health plan and medical care utilization by older adults. Cad Saude Publica 2002; 18(1):177-186..

Self-evaluation of state of health is an indicator used internationally as an objective measure of potential for illness and use of services, and a powerful predictor of mortality. Thus it would seem to be an indication of greater use of services, and higher spending³¹31. Barros MBA, Zanchetta LM, Moura EC, Malta DC. Auto-avaliação da saúde e fatores associados, Brasil, 2006. Rev Saude Publica 2009; 43(Supl. 2):27-37.. There was a greater possession of plans among people who assess their own state of health as good, possibly reflecting the greater concentration of plans among adults of productive age, due to their being in the labor market and having access to collective plans. These populations are healthier and have lower risk of becoming ill. Further, populations with plans have higher levels of schooling and income and, in general, have better access to health services, healthcare and health-promoting practices, and thus make a better self-assessment of their own health¹²12. Santos FP, Malta DC, Merhy EE. A regulação na saúde suplementar: uma análise dos principais resultados alcançados. Cien Saude Colet 2008; 13(5):1463-1475.^,2929. Malta DC, Bernal RTI. Comparação dos fatores de risco e proteção de doenças crônicas na população com e sem planos de saúde nas capitais brasileiras, 2011. Rev Bras Epidemiol 2014; 17(Supl. 1):241-255.^,3030. Lima-Costa MF, Guerra HL, Firmo JO, Vidigal PG, Uchoa E, Barreto SM. The Bambuí Health and Aging Study (BHAS):private health plan and medical care utilization by older adults. Cad Saude Publica 2002; 18(1):177-186.. The concentration among those that have a better state of health also reflects the growth of collective plans, with people who are younger and have lower risk of becoming ill. The high cost of individual plans, and the rule relating to pre-existing illness¹³13. Szwarcwald CL, Malta DC, Pereira CA, Vieira MLFP, Conde WL, Souza Júnior PRB, Damacena GN, Azevedo LO, Azevedo e Silva G, Theme Filha MM, Lopes CS, Romero DE, Almeida WS, Monteiro CA. Pesquisa Nacional de Saúde no Brasil: concepção e metodologia de aplicação. Cien Saude Colet 2014; 19(2):333-342., both constitute difficulties for entry of people who are already ill.

Conclusion

The increase of the percentage of the Brazilian population who have health plans reflects the improvement in the supply of jobs and the growth of Brazil's economy.

Population-based data information presents a great challenge in showing the characteristics of the sector, such as the regional and social-demographic distribution of possession of health plans, and distribution by factors including age group, level of schooling, and income – and supports the public policies for regulation of the sector.

These data can support health policies, and indeed orient policies for regulation of the sector.

References

Publication Dates

History