No outside funding or assistance of any kind was used for this research or in manuscript preparation. Schafer and Galante are employed by Precision for Value, a payer ad marketing agency that works exclusively with life science companies. Shafrin is employed by Precision Health Economics, a consulting company to insurance and life science industries. Shafer, along with Galante and Shafrin, contributed to study design, data collection, and manuscript preparation. The authors contributed equally to data analysis and interpretation and manuscript revision.

T he Brazilian Unified Health System (SUS) is one of the largest and most complex public health systems in the world and ensures comprehensive, universal access, and free health care for the entire population of Brazil. SUS provides universal access to the public health system without discrimination. Comprehensive health care has become a right for all Brazilians from pregnancy to the end of life, focusing on health with quality of life and aiming at prevention and health promotion. However, the SUS is not the only health care coverage option in Brazil. The private sector in Brazil currently covers 22.5% of the Brazilian population, yet this sector accounts for 57% of all health care spending in Brazil, including out-of-pocket expenses. Private health care is accessed either through employers or as supplemental insurance purchased by individuals.Private health plans are regulated by Agencia Nacional de Saude (ANS), a government agency, and are classified into several types, which comprise different forms of operation, such as health maintenance organizations, health insurers, selfinsured companies, philanthropies, and medical cooperatives. In November 2018, according to data from ANS, Brazil had 746 health plans, with 47.38 million beneficiaries. 1,2 The total health care expense in Brazil is approximately 8.2% of the gross domestic product: 4.4% is from private expenses, and 3.8% is

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