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I recently wrote an article for L.A. Progressive entitled, “One Reason America Doesn’t Have Universal Healthcare.” I agreed with other writers that racism was a strong although hidden component of our political system’s failure to establish universal healthcare. I think our history of segregation and Jim Crow laws has created a roadblock against programs that assist the poor, since the black population represents a significant part of that poor population. But let’s look at the situation in Brazil.

brazilian healthcare system

Brazil was the last country in the Western Hemisphere to abolish slavery. While the U.S. fought a bitter and divisive civil war to end slavery in 1865, Brazil ended slavery in 1888 without any sort of violence or rebellion. However, “[w]hen Brazil's slaves were finally set free in 1888, they faced economic catastrophe rather than experiencing the officially proclaimed jubilation of freedom. They were simply left to their individual fates — without land, without money and without an education. And that is largely where their descendants still stand today.”

In the United States, there was a period between 1861 and 1877 when the Union Army occupied part or all of the former Confederate States. “The military occupation of the South that began in 1861 had profound consequences, some short-lived, others long-lasting. The suffering and destruction were enormous, but the suffering abated with the war's end and the destruction was soon repaired. The liberation of the slaves, however, changed the nation in ways that continue to affect every American deeply, while the memory of those years of invasion and occupation helped shape a distinctive Southern mentality that endures to this day.” The freed slaves were given some assistance through the Freedmen’s Bureau, which lasted from 1865 until Congress (under pressure from the Southern states) dismantled it in 1872. “A lack of funding, coupled with the politics of race and Reconstruction, meant that the bureau was not able to carry out all of its initiatives, and it failed to provide long-term protection for blacks or ensure any real measure of racial equality.” The Reconstruction era lasted until 1877.

In the South before the Civil War there were “slave codes” (controlling slaves) and “black codes” (controlling blacks who had gained freedom). The latter continued after the war. “Black Codes restricted black people's right to own property, conduct business, buy and lease land, and move freely through public spaces. A central element of the Black Codes were vagrancy laws. States criminalized men who were out of work, or who were not working at a job whites recognized. Failure to pay a certain tax, or to comply with other laws, could also be construed as vagrancy.

“Nine southern states updated their vagrancy laws in 1865–1866. Of these, eight allowed convict leasing (a system in which state prison hired out convicts for labor) and five allowed prisoner labor for public works projects. This created a system that established incentives to arrest black men, as convicts were supplied to local governments and planters as workers. The planters or other supervisors were responsible for their board and food, and black convicts were kept in miserable conditions. As Douglas Blackmon wrote, it was "slavery by another name". Because of their reliance on convict leasing, Southern states did not build any prisons until the late 19th century.”

Although the Brazilian healthcare system seems much fairer than the American one, the former has faced difficult financial issues, forcing patients to go to private facilities or not obtain healthcare.

Although Reconstruction ended, segregation laws, Jim Crow laws, and other anti-black legislation went on for years. “The U.S. Supreme Court upheld the constitutionality of segregation in Plessy v. Ferguson (1897), so long as "separate but equal" facilities were provided, a requirement that was rarely met in practice.

On July 26, 1948, President Harry S. Truman signed Executive Order 9981, ending segregation in the United States Armed Forces. The “separate but equal” doctrine in education was overturned in Brown v. Board of Education (1954).”

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Finally, the Civil Rights Act of 1964 outlawed segregation and banned employment discrimination on account of race, religion, and other grounds. There was also the start of government-sponsored healthcare in 1965 with the enactment of Medicare for elders.

The situation in Brazil was quite different. There never was a Freedmen’s Bureau, Reconstruction, legislated segregation laws, or Jim Crow laws. This is not to say that there wasn’t discrimination against blacks, because there was, and it still exists. However, racism was legislated into illegality in the 1950s, when a black dancer was barred from a white hotel. Moreover, “health care is a right for every citizen and a duty for the government, as established in Brazil's 1988 Federal Constitution.”

Here’s an example. “[I]n 2012, the Brazilian government announced that it would bear the costs for replacing defective silicone breast implants from French company PIP and Dutch company Rofil. These brands—now banned in Brazil—had a high rate of rupture because of the inferior quality of their materials. The Brazilian Ministry of Health identified this as a public health issue. It declared it would fully cover implant replacement costs, including for implants originally made for aesthetic reasons and carried out under the private health system, as long as rupture in the silicone was detected. Along the same lines, the government provides free weight-loss surgery for obese citizens over 16 years old and as of 1996, free medicine for HIV patients.”

Along with these specific issues, “[p]rimary healthcare remains the responsibility of the federal government, elements of which (such as the operation of hospitals) are overseen by individual states. Public healthcare is provided to all Brazilian permanent residents and foreigners in Brazilian territory through the National Healthcare System, known as the Unified Health System (Portuguese: Sistema Único de Saúde, SUS). The SUS is universal and free for everyone.”

Historically, the African-Brazilian population was much larger than the white population. Then between 1890 and 1940, there was a large migration from Europe, which made the white population larger. That has changed over time, so that by 2013 the African-Brazilian population has again become larger.

Although the Brazilian healthcare system seems much fairer than the American one, the former has faced difficult financial issues, forcing patients to go to private facilities or not obtain healthcare. And there have been reports of discrimination against blacks in the public system, despite anti-discrimination laws. Yet similar issues have been cited in connection with the U.S. system.

The fix for the Brazilian system is basically an easy one conceptually. Why does the healthcare system face financial difficulties? “Although the level of total health expenditure is comparable to other countries in Latin America, public expenditure is low for a universal healthcare system and burdens individuals with large out-of-pocket costs.” The only real answer for this is to increase the public expenditures. Another possibility would be to force the private doctors and hospitals into the public system, eliminating the “escape hatch” for the wealthy. So far as discrimination goes, there should be an ombudsman or other person who is open to reports of discrimination and who has the power to do something about it.

It is interesting to understand that Brazil, with a much high number of blacks proportionally in its population, has not really encountered racism in its establishment of universal healthcare. The U.S., on the other hand, has been hung up on the concept for years. During the last attempt (by President Obama, legislation passed in 2010) the concept of universal coverage was again rejected. And Rush Limbaugh branded the law an attempt to get a “Civil Rights Bill” and “reparations”.  This was yet another attempt to connect healthcare reform to the fight for racial equality, even when the reform had nothing to do with race. Except Limbaugh tried to make it so, in order to block it with calls for discrimination.

michael hertz

Michael T. Hertz