Ever since 1988, the Brazilian constitution has promised free public healthcare to every citizen. “‘Health is a private right and a duty of the state,’” said Alexandre Chiavegatto Filho, a health policy professor at the University of Sao Paulo, quoting the statute. “People do love that phrase. It would be crazy and impossible for any government to change that.”

By a lot of measures, Brazil’s Sistema Único de Saúde—or SUS—has led to huge health gains. The country now has an infant mortality rate of about 13 per 1,000 live births, down from about 27 in 2000. Maternal mortality has also been cut in half since 1990. The average Brazilian only lived to about 66 in 1990; today, life expectancy is at a respectable 74.

But take a closer look, and the system seems more like “a safety net with holes,” as one Brazilian doctor put it to me. There are only about two hospital beds for every 1,000 people. It can take months to get an X-ray in Sao Paulo. A quarter of Brazilians are able to afford private doctors, paying with American-style insurance they get through work. But a sizable chunk of the population is still poor, living in remote jungles and farms or in ghettoized favelas, and relies on the publicly funded SUS. The health outcomes of the two groups are just as strikingly different as their life circumstances. In a 2013 poll, 48 percent of respondents said they thought healthcare was Brazil’s biggest problem, ranking the issue well above education, corruption, violence, and unemployment.

In other words, universal healthcare looks very different in Brazil than it does in, say, Scandinavia. Finland, for example, provides free healthcare to all its citizens, but the country is smaller and more homogeneous than the state of Minnesota. Brazil, meanwhile, has 200 million people. And it has roughly the same landmass of the continental U.S., if you shaved off the entire West Coast and some of Florida. Brazil was also one of the last countries in the Western world to abolish slavery, and it has the lasting racial issues to show for it.