INSP - NATIONAL INSTITUTE OF PUBLIC HEALTH OF MEXICO Center for Health Systems Research

1. INSP - NATIONAL INSTITUTE OF PUBLIC HEALTH OF MEXICO Center for Health Systems Research Salud Migrante Developing a Proposal through Binational Health Systems Integration Planning Project

2. Outline • Social protection: progress in Mexico • Social protection & migration • U.S.A. • Mexico • Development capacity for social protection in health • Salud Migrante proposal • Conclusion

3. Family Affiliation to Seguro Popular 14,000 11,500* 12,000 10,000 8,000 Thousands of families 6,000 5,000 4,000 3,000 2,000 295.5 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 * Ley General de Salud projection Source: Ministry of Health of Mexico 2005

4. 80 Col Nay BCS Ags Sin Tamps 70 Son Jal BC QRoo Dgo 60 DF Tab Mich Hgo Camp Ver Tlax 50 Oax Zac Gto NL Yuc SLP Mex Coah Mor 40 Chih Chis Pue Gro 30 Qro .7 .75 .8 .85 .9 Seguro Popular Subscriber Outpatient ServicesState-Level Analysis 2006 according to HDR % HDR r=0.3584 (0.0440) Source: NHS (Ensanut) 2006 & HDR prepared by UNDP

5. Seguro Popularimpact on catastrophic expenditures according to source Not insured Insured with Seguro Popular 12 10 8 % of Catastrophic expenditures 6 4 2 0 NIEHS (ENIGH) NHS (Ensanut) Impact Eval. SP Source: Galarraga O; Sosa-Rubí SG; Salinas A.; Sesma S. Impact of Universal Health Insurance on Catastrophic & Out-of-Pocket Health Expenditures in Mexico. Working Paper. 2008

6. Tendency of the authorized budget from the Ministry of Health of Mexico 90 81.3 80 70 60 Thousands of millions of pesos 49.2 50 35.4 40 30 20 10 0 2000 2001 2002 2003 2004 2005 2006 Year Source: Ministry of Health of Mexico 2005

7. Ministry of Health expenditure - distribution in deciles 2002 1996 2000 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% 1 2 3 4 5 6 7 8 9 10 Decile of expenditure Source: John Scott, CIDE – Center for Economics Research & Education

8. Toward a financial balance in health, 2000-2004 • GDP in health from 5.7% to 6.3% • Annual increase in health expenditure • Public for non-insured: 23% • Out-of-pocket:13% • Reason for federal per capita expenditure according to insurance condition • From 3.0 in 2000 to 2.1 for 2005 Source: Ministry of Health of Mexico 2005

9. Social protection and international migration Situation in the U.S.

10. 11.2 11.2 18.1 18.1 23.0 23.0 24.0 24.0 42.8 42.8 64.4 64.4 U.S. population without medical security, 2004 100% 100% 80% 80% 60% 60% 56.2 56.2 48.1 48.1 75.7 75.7 60.9 60.9 40% 40% 41.4 41.4 23.3 23.3 20% 20% 28.9 28.9 25.7 25.7 13.1 15.7 15.7 12.4 15.0 15.0 12.4 13.1 0% 0% Recent Recent Longer Longer - - stay stay Mexican Mexican U.S. U.S. - - Born Born U.S. U.S. - - Born Born Immigrants Immigrants Mexican Mexican Mexican Mexican American American Whites Whites Non Non - - Whites Whites from other from other immigrants immigrants immigrants immigrants than Mexico than Mexico Private Public Not insured Wallace 2007

11. Dimension of the 11.8 million Mexican migrants in the U.S. • 11% of the Mexican population • 5.8% annual growth • 56% without health insurance • 60% without documents • 21% with U.S. citizen status DIAGNOSIS

12. Migrant contribution to the uninsured population in the U.S. • Migrants (of any nationality) and their U.S.-born children contribute as follows: • 32% of the total population with no health insurance (46 million) • 86% of the growth of the population with no health insurance • Mexican migrants contribute 13% of the total population with no health insurance in the U.S. DIAGNOSIS US

13. Relevance of health insurance for migrants in the U.S. • Health in the U.S., the most expensive in the world, + 14% of the GDP • 5.6% of hospital expenses are not covered • ¿Migrant responsibility? • Represents 0.2% of the GDP DIAGNOSIS US

14. Situation en Mexico

15. Transnational population • 45% of the Mexican migrants are recent • Less than 10 years, 5.38 million of total figure • 85% of the migrants send remittances • to 1.3 million homes in Mexico • 16% of married migrants have wives in Mexico • 27.3% of migrants have at least one child in Mexico • 18% have all of their children in Mexico • Constant migration flow • 700,000 migrate annually • 250,000 return

16. Remittances spent in health services in Mexico, 2002percentage ALL Urban Rural Head of the household Primary healthcare 8.9 9.4 4.9 6.2 8.9 Hospitalization 15.9 20.9 12 8.2 17.5 Pregnancy & birth 4.5 7.6 2.1 0.2 0.5 OTC drugs 2.5 4.2 1.4 1.3 2.7 TOTAL 31.8 42.1 20.4 15.9 29.6 Revision of Amuedo-Dorantes et al 2007, based on NIEHS (ENIGH) 2002

17. Reference population for binational insurance 11.8 million migrants 4.3 million migrant children born in U.S. 5.5 million dependents in Mexico* 21.6 million in transnational communities DIAGNOSIS

18. Development capacity for social protection in health for migrants

19. Willingness to pay for binational health insurance • 57% of migrants are willing to pay • US$75 - $125 per month • Willing to cross the border • Deprived of primary healthcare in the U.S. • Public in Mexico • Cost represents 1/4 to 1/3 of insurance plans in the U.S. • US$ 3,000 & US$ 4,500 per family per annum** • Vs. US$ 12,000 DIAGNOSIS US *Vargas-Bustamante A, Ojeda G, Castañeda X. Willingness to pay for cross-border health insurance between the United States and Mexico. Health Affairs27, no. 1 (2008): 169–178. **Tim Waidmann & Saad Ahmad. Improving Access In a Binational Population. The Potential Role for Binational Health Insurance. Academy Health Research Meeting, Orlando, FL. 2007.

20. U.S. response capacity DIAGNOSIS • Community healthcare centers in the U.S. • 1,200 in total • 6,300 points of service in all states • 17 million persons attended • 147 healthcare centers for migrants • 800,000 clients • Very interested in binational health insurance • Non-profit insurers • Located strategically for providing binational health insurance • Hometown clubs • Broad experience in health • Not always available • Problematic relation with Mexico

21. Mexico response capacity • Ministry of Health services in high- migrant locations • State-level governments very interested in supporting migrants • Seguro Popular Program • Interest & capacity to focus on migrants • Need for new affiliation mechanisms DIAGNOSIS

22. SALUD MIGRANTE PROPOSAL

23. Salud Migrante Components • Doctrine • Policy • Articulating agency • Insurance agencies • Service networks • Community-level support PROPOSAL

24. Salud Migrante doctrine • Migrants are entitled to health protection in the U.S. • Temporary residence abroad should not restrict Mexicans’ constitutional right to health in Mexico. • Constitutional obligation to guarantee migrants access to health services, wherever he may reside temporarily. PROPOSAL

25. Transportation Insurance Departments Decree/Agreement Regulation Salud Migrante Agency Seguro Popular Non-profit insurers Cap. Constr. Concession Affiliation Sale Contract Pay-ment Community agencies Migrants Promotion Providers Mexico Healthcare centers in the U.S. Guarantee Service networks Salud Migrante policy Salud en el Norte Primary healthcare in the U.S. Seguro Popular Affiliation in the U.S. • Diffusion of the Salud Migrante doctrine in Mexico & the U.S. • Capacity building & development: “Servicios de Salud Amigos del Migrante” (“Migrants’ Friends” Health Services) • Insurers & Seguro Popular • Binational health service networks • Civil society organizations • Salud en el Norte insurance • Sale of policies to migrants • Dealer / franchiser for insurance agencies

26. CONCLUSIONS & NEXT STEPS

27. Conclusions • Migration requires far-reaching government policies with a broad vision. • Mexico can lead a binational health insurance program. • Key actors from both countries have the capacity & are interested to collaborate in this regard. • Model can be partially adapted to migrants from other countries.

28. Possible next steps • Development of a model for workers with H2A visas • Promotion of services already guaranteed for migrants in the U.S. • Establishment of the Salud Migrante agency at state level