Brazil's Supreme Federal Court (STF) voted 9 to 1 on Tuesday to review a 2021 decision that denied a general repercussion ruling on payment rates the Unified Health System (SUS) pays to private and philanthropic hospitals. The case centers on whether SUS reimbursement tables should match the higher rates used by the National Supplementary Health Agency (ANS) for private health insurance reimbursements to the public system.
The Health Ministry estimates that aligning SUS rates with ANS tables would cost approximately R$24 billion (roughly USD 4.8 billion at recent rates, approximate conversion) annually, a figure that would pressure the federal budget and potentially crowd out other public health initiatives.
What the review entails
The STF will now examine lawsuits filed by philanthropic hospitals — notably Santas Casas — seeking payment parity with ANS tables. These hospitals argue current SUS rates do not cover actual costs. The 2021 ruling had classified the matter as infraconstitutional, meaning it did not require a binding nationwide precedent. The Court has now reversed that classification, agreeing to rule on the constitutional dimensions and set a binding standard for all pending cases.
Justice Gilmar Mendes, the rapporteur, defended the review on social media platform X. He wrote that a financial commitment of this magnitude "cannot be decided case by case, at the whim of the court where the action was filed." Mendes highlighted that 65 percent of the 343 cases awaiting a definition from the Superior Court of Justice (STJ) are concentrated in the Federal Regional Court of the 1st Region (TRF1) in Brasília, which has jurisprudence favorable to hospitals. Other regional courts have ruled in the opposite direction.
Concerns over forum shopping and precatório markets
Mendes warned that the concentration of cases in TRF1 raises questions about forum shopping — litigants filing in jurisdictions with favorable precedents. He also flagged the role of the precatório market, where creditors sell the right to receive court-ordered government payments at a discount due to long delays in federal payouts.
The Federal Justice Council recently suspended payment of nine precatórios totaling R$775 million (roughly USD 155 million) pending verification of credit regularity. In one case cited by the federal government, 70 percent of a precatório's principal was assigned to an agribusiness company and 30 percent to the law firm handling the suit, with no provision for repayment to the hospital that originally provided the services.
Fiscal and institutional stakes
The outcome will affect the financial sustainability of SUS and the division of health costs among the Union, states, and municipalities. Mendes emphasized that the discussion "surpasses the interest of the parties and reaches the financing of public health." No date has been set for the merit hearing.