Mecanismos de Compartilhamento de Custos em Saúde – Parte II: experiências internacionais e o caso brasileiro

This paper, the second in a series on health care cost-sharing mechanisms, examines their use across different health systems and discusses the Brazilian case, with particular emphasis on regulatory design. The analysis covers nine countries—Australia, Chile, China, France, Germany, Italy, Japan, South Korea, and the United States—representing different arrangements of health financing, coverage, and private-sector participation. The international comparison shows that copayments, coinsurance, deductibles, and other cost-sharing mechanisms are generally combined with out-of-pocket limits, exemptions, and differentiated rules according to the type of service and patient characteristics. These mechanisms are also used to influence care pathways by encouraging the use of specific providers or levels of care. In Brazil, cost-sharing mechanisms are widely used in private health plans, although the current regulatory framework still has important gaps regarding the intensity of charges, cumulative financial exposure, and the protection of vulnerable groups. The evidence across countries indicates that the effects of cost sharing depend on both its design and the institutional context in which it operates. In the Brazilian case, the regulatory challenge is to combine utilization management, financial protection, and care organization while taking into account the coexistence of private coverage and a universal public health system.