1. INSP CHSR 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. INSP CHSR 2/27 Outline 1.Social protection: progress in Mexico 2.Social protection & migration  U.S.A.  Mexico  Development capacity for social protection in health 3.Salud Migrante proposal 4.Conclusion

3. INSP CHSR 3/27 Family Affiliation to Seguro Popular * Ley General de Salud projection 295.5 3,000 11,500* 0 2,000 4,000 6,000 8,000 10,000 12,000 14,000 200220032004200520062007200820092010 Thousands of families 5,000 Source: Ministry of Health of Mexico 2005

4. INSP CHSR 4/27 Seguro Popular Subscriber Outpatient Services State-Level Analysis 2006 according to HDR r=0.3584 (0.0440) Source: NHS (Ensanut) 2006 & HDR prepared by UNDP Ags BC BCS Camp Coah Col Chis Chih DF Dgo Gto Gro Hgo Jal Mex Mich Mor Nay NL Oax Pue Qro QRoo SLP Sin Son Tab Tamps Tlax Ver Yuc Zac 30 40 50 60 70 80.7.75.8.85.9 HDR %

5. INSP CHSR 5/27 Seguro Popular impact on catastrophic expenditures according to source 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 0 2 4 6 8 10 12 % of Catastrophic expenditures NIEHS (ENIGH)NHS (Ensanut)Impact Eval. SP Not insured Insured with Seguro Popular

6. INSP CHSR 6/27 Tendency of the authorized budget from the Ministry of Health of Mexico Year Thousands of millions of pesos 0 10 20 30 40 50 60 70 80 90 2000200120022003200420052006 Source: Ministry of Health of Mexico 2005 81.3 49.2 35.4

7. INSP CHSR 7/27 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 12345678910 1996 2002 Ministry of Health expenditure - distribution in deciles 2000 Decile of expenditure Source: John Scott, CIDE – Center for Economics Research & Education

8. INSP CHSR 8/27 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. INSP CHSR 9/27 Social protection and international migration Situation in the U.S.

10. INSP CHSR 10/27 U.S. population without medical security, 2004 12.4 15.7 28.9 13.1 25.7 15.0 23.3 41.4 48.1 75.7 56.2 60.9 0% 20% 40% 60% 80% 100% Recent Mexican immigrants Longer-stay Mexican immigrants Mexican American U.S.-Born Whites U.S.-Born Non-Whites Immigrants from other than Mexico 12.4 15.7 28.9 13.1 25.7 15.0 23.3 41.4 48.1 75.7 56.2 60.9 11.2 18.1 24.0 64.4 42.8 23.0 0% 20% 40% 60% 80% 100% Recent Mexican immigrants Longer-stay Mexican immigrants Mexican American U.S.-Born Whites U.S.-Born Non-Whites Immigrants from other than Mexico Public Not insured Wallace 2007 Private

11. INSP CHSR 11/27 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 DIAGNOSISDIAGNOSIS

12. INSP CHSR 12/27 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. DIAGNOSISUSDIAGNOSISUS

13. INSP CHSR 13/27  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 Relevance of health insurance for migrants in the U.S. DIAGNOSISUSDIAGNOSISUS

14. INSP CHSR 14/27 Situation en Mexico

15. INSP CHSR 15/27 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. INSP CHSR 16/27 Remittances spent in health services in Mexico, 2002 percentage Revision of Amuedo-Dorantes et al 2007, based on NIEHS (ENIGH) 2002 Head of the household 29.615.920.442.131.8TOTAL 2.71.31.44.22.5OTC drugs 0.50.22.17.64.5Pregnancy & birth 17.58.21220.915.9 Hospitalization 8.96.24.99.48.9Primary healthcare RuralUrban ALL

17. INSP CHSR 17/27 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 DIAGNOSISDIAGNOSIS

18. INSP CHSR 18/27 Development capacity for social protection in health for migrants

19. INSP CHSR 19/27 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 *Vargas-Bustamante A, Ojeda G, Castañeda X. Willingness to pay for cross-border health insurance between the United States and Mexico. Health Affairs 27, 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. DIAGNOSISUSDIAGNOSISUS

20. INSP CHSR 20/27 U.S. response capacity DIAGNOSISDIAGNOSIS  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. INSP CHSR 21/27 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 DIAGNOSISDIAGNOSIS

22. INSP CHSR 22/27 SALUD MIGRANTE PROPOSAL

23. INSP CHSR 23/27 Salud Migrante Components  Doctrine  Policy  Articulating agency  Insurance agencies  Service networks  Community-level support PROPOSALPROPOSAL

24. INSP CHSR 24/27 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. PROPOSALPROPOSAL

25. INSP CHSR 25/27 Healthcare centers in the U.S. Contract Providers Mexico Pay- ment Salud en el Norte Primary healthcare in the U.S. Seguro Popular Affiliation in the U.S. Salud Migrante policy Insurance Departments Regulation Sale Salud Migrante Agency Decree/Agreement Migrants Affiliation Service networks Guarantee Community agencies Promotion Transportation Seguro Popular Cap. Constr. Non-profit insurers Concession  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. INSP CHSR 26/27 CONCLUSIONS & NEXT STEPS

27. INSP CHSR 27/27 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. INSP CHSR 28/27 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