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Table 2: Characteristics of health insurance and health plan companies in Brazil from the s to Owners of pioneering health plan companies provided consultancy on drafting the legislation for the privatization of social-security medical care Cordeiro H. Specific policies for skilled workers, considered an asset to be stabilized The pioneering companies based their organization on self-financing and physicians' quotas and expanded their clientele through fixed per capita transfers from Social Security. They were created by physician-proprietors based on physical outpatient care structures or hospitals the latter by the s

Discurso de posse no Congresso Nacional. Criticism of the inefficiency of public services Anderson P. Argentina: Consejo Latinoamericano de Ciencias Sociales; The Brazilian health system: history, advances, and challenges. Lancet ; During the so-called lost decades Bielschowsky R. Buenos Aires: Siglo Veintiuno Editores; The growth and diversification of activities of health plan companies attracted domestic investors and investments and some international insurance companies.

Still, the predominance of domestic capital was preserved. Rosemburg C. Exame ; The legislation stimulated the expansion of private health plans and insurance. With regard to demand incentives, the direct transfer of public funds to companies characteristic of the first cycle was replaced by indirect subsidies and payment of plans for government employees. That is, the mobilization of fiscal policies combined with administrative provisions and the inclusion of spending on private plans in the government budgets.

On the supply side, the main rulings focused on the reduction of tax rates or tax exemptions on the Services Tax ISS Supremo Tribunal Federal. The adoption of long-term loans from state-owned banks for charitable and private hospitals Braga IF.

In the late s, various health plan companies began to congregate corporate groups, and the insurance companies not only entered the health care market, but also presented themselves in it as relevant interlocutors in the formulation of regulatory policies in the process of debates and approval of Law 9.

Scheffer M. The changes in the scale of operations of health plan companies enabled them to mediate the relations between the demand and health service providers in different conditions from those prevailing in the accumulation regime based on self-financing.

Brazilian corporate groups in the finance-dominated accumulation regime: the example of Amil The early 21st century witnessed renewed hopes for the recovery of growth and new linkage between social and economic policies for an inclusive development model.

There was evidence that that the basic macroeconomic conditions for sustained expansion had been reestablished. The increase in formal employment and improved income distribution signaled the recovery of Brazil's industrial capacity and prospects for generating endogenous technical progress Quadros WJ. However, the systemic crisis that struck in the late s imposed fiscal requirements and pushed away the functions of energizing effective demand and productive profits, while economic policies became essential vectors for the macroeconomic reproduction of financial wealth Braga C.

Estud Av ; Therefore, gains in access to and use of health care provided by the SUS were not limited to the growth of the private sector, a process that included competition for public human and financial resources Policies for the expansion of consumption energized not only the low-income credit segment, but also the marketing of health plans to income classes C and D, the so-called "new middle class" Meirelles R.

Villela F. And in , according to polls conducted by Meireles Meireles R. The history of Amil from until its sale to the American corporation UnitedHealth suggests that its adherence to capitalization via acquisitions was a strategy that both preceded and remained in force after it launched part of its capital on the Stock Exchange Table 3.

Despite the shareholding changes, family control of Amil was maintained. The change in the company's accumulation regime, including launching part of its capital on the market and the acquisitions, increased the company's worth. However, its capital expansion was considerably superior to the increase in the number of policies.

Table 4 shows the values involved in the acquisition of Amil by UnitedHealth, evidencing the rapid appreciation of the Brazilian group's capital, as measured both by the increase in the nominal share value and especially in the multiplication of the company's capital both in Brazilian currency and U.

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Table 4: download and sale values for Amil's shares and Amil Group's capital. Amil is now a company with foreign capital.

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Its former owner still heads the health business in Brazil. Contrary to the history of other health plan corporate groups, including some acquired by Amil itself, changes in the company's formal shareholding structure did not include the removal of the former owners from action in its health business.

Its main leader and founder's influence even appears to have expanded, as witnessed by his presence in the meeting of the so-called "Brazilian GDP" group with the Minister of Finance Although assessments on the success or failure of financialization are beyond the scope of this paper, it appears plausible that the company's capital appreciation has opened select political channels to the corporate group.

Discussion The concentration and recent internationalization of health plan companies, as evidenced by the Amil story, allows different interpretations. In the more conventional sense, the health plan and insurance industry is highly concentrated.

In July , Amil operated 7. From a regional perspective, Ranking third, the industry can be seen as regressive or concentrated from the angle of the clients' income. There is a positive association between family income and private health policy coverage. In , only 2. Internationalization of Brazilian health plan companies actually preceded authorization by Law 9, of Likewise, the investment by domestic and international funds in hospital and diagnostic laboratory networks preceded the legislation that allowed participation by foreign capital in health care activities, under Law 13, of Still, operations of the size involved in the acquisition of Amil required backing by the legislation and approval by the Federal Attorney General's Office, suggesting that the legal provisions and their interpretations were relevant for ensuring reliability in the eyes of foreign investors.

The mismatch between corporate internationalization practices and the legislation suggests complacency by public authorities in the face of strategies that anticipated changes in the capitalization rules.

The finance-dominated accumulation regime of health plan companies in Brazil differs from that in the United States. Pegoraro, F. Gomes, F. Lumertz, R. Lopes, F. Oliveira and R.

Souza, J. Garcia-Frias and R. Ribeiro, R. Romano, C. Power Delivery, pp. Freitas JR. Cavalcanti and R.

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