Health Care System Complementarity

The Future of Mexico-U.S. Health Policy Integration

by Julio Frenk & Octavio Gómez-Dantés

Introduction

In the early 1990s, as part of the negotiation of the North American Free Trade Agreement (NAFTA), Mexico’s National Academy of Medicine analyzed the potential impact this agreement could have on the healthcare systems of each of the three countries involved.[i], [ii] At the time, there was a consensus that NAFTA offered both opportunities and challenges. A few years later, experts from the U.S. Institute of Medicine (IOM) and scholars from several Canadian universities joined the conversation.[iii]

Two events – the collapse of the Twin Towers in 2001 and the influenza A H1N1 pandemic in 2009 – have further highlighted the need to strengthen cooperation between Mexico and the United States on public health matters that could potentially affect both countries, such as natural disasters, epidemics, and bio-terrorist attacks.[iv]

The purpose of this essay is to examine the cooperation in public health and the exchange of health services that has occurred between the United States and Mexico in recent years, and to explore whether or not both countries will eventually achieve expected levels of integration in terms of health policy. The first section discusses the possibility of expanding cooperation regarding public health and the second deals with opportunities to integrate personal health services.

Cooperation In Terms of Public Health in North America

Mexico and the United States can be viewed as a single entity when it comes to public health, given that they share a 1,951-mile border that is crossed by 350 million people each year. It has even been said these two countries are inevitably linked in their struggle for homeland security through the implementation of a blend of binational economic, military, political, diplomatic, environmental, and health measures.

There is a long history of binational cooperation in terms of public health.  During the 1990s, binational public health efforts focused mostly on measures to control the transborder dissemination of infectious diseases such as tuberculosis and HIV/AIDS. The cooperation in this field was expanded with the creation in 2000 of the U.S.-Mexico Border Health Commission.[v] Its goals were to spur binational conversations regarding several public health issues along the U.S.-Mexico border. The SARS epidemic, several outbreaks of bird flu, and above all, terrorist acts and the influenza A H1N1 pandemic, highlighted the need to strengthen and expand cooperation in health between both nations.

2010 Targets for the Border Region as Outlined by the Healthy Border Program

Following the tragic events of 9/11, many feared that the U.S.-Mexico border would become an easy pathway for terrorists to conduct bio-terrorist attacks. This led to an increase in binational security cooperation, evidenced, among other things, by the creation of the Global Health Security Action Group (GHSAG), a discussion forum for G7 health ministers that also includes Mexico.

Among the GHSAG’s first actions were the creation of diverse working groups that consolidated relationships among health ministries of all the countries involved, and the creation of strategic reserves of vaccines and antibiotics.[vi] The relationship between Mexico and the United States, in particular, was significantly strengthened after formalizing daily communication between the U.S. Center for Disease Control (CDC) and Mexico’s National Center of Epidemiological Surveillance and Disease Control (CENAVECE). U.S. government assistance in strengthening Mexico’s network of laboratories along the border also helped to strengthen binational communication. These developments improved surveillance and epidemiological response capabilities not only for bio-terrorist attacks but for binational public health more generally.

In the past decade, the U.S. government spent approximately three trillion dollars to fortify its national security. A portion of these resources was used to improve the Strategic National Stockpile of medicines and medical supplies for public health emergencies and the CDC’s Information Exchange System, with its network of more than 150 laboratories that already serve as reference centers for Mexico.[vii] Even though this surveillance and response system displayed some flaws during Hurricane Katrina, it responded well to the SARS outbreak in 2003, and especially well during the H1N1 influenza pandemic in 2009.

U.S.-Mexico cooperation on public health, as mentioned above, has also expanded to other areas. The U.S.-Mexico Health Border Commission’s constitution, for instance, includes actions to prevent and manage diabetes and breast cancer and expand vaccination rates, among other things. One of the most innovative tools that has emerged from this international cooperation is the so-called Binational Health Weeks. During these events, state and federal government agencies, civil society organizations, and volunteers meet during the month of October in several cities throughout Mexico and the United States to conduct health promotion workshops, vaccination campaigns, medical screenings, and more.

The process of trade liberalization and the epidemiological and bio-terrorist crises that took place over the past decade have thus helped consolidate U.S.-Mexico cooperation in the area of public health.

The Exchange of Personal Health Services Between Mexico and the United States

Another important area for potential integration between Mexico and the United States is in health services. There are four basic types of international exchange of personal health services in North America: transborder exchange of services, commercial presence, movement of suppliers, and movement of consumers, and all four have strengthened in recent years. However, challenges remain and must be addressed to guarantee universal access to comprehensive health services in this region.

Transborder exchange of services refers to the movement of diagnostic procedures and therapeutic plans across borders. This type of exchange of services has undergone explosive growth as a result of telemedicine, the use of new communication and information technologies to provide personal health services at a distance. In 2011, the global telemedicine market reached 11.6 billion dollars, and it is expected to surpass 27 billion dollars in 2016.[ix] The most important hospitals in the United States, such as Massachusetts General Hospital, Mayo Clinic and Cleveland Clinic, export telemedicine services to different parts of the world, including Mexico.

Survey of American Retirees in Mexico Who Return to the U.S. for Health Care Services

Commercial presence, the establishment of healthcare units or providing health insurance services in other countries, is also growing in North America as a result of both trade liberalization and the increased transborder mobility of health care consumers. International Hospital Corporation owns five hospitals in Mexico, CHRISTUS Group owns eight, and CIMA owns four. Several of these hospitals have already been certified by the Joint International Commission. Although these units are designed for Mexican patients, they are also preparing for an increase in patients from other countries.[viii] Indeed, 30% of the patients treated at CHRISTUS Hospital in the Mexican city of Reynosa in 2011 were U.S. residents.[x]

Recent years have also witnessed the development of health insurance policies whose benefits can be accessed in countries other than the insured’s country of residence. Southern California’s Blue Cross Blue Shield currently offers health insurance packages with considerably lower-than-average premiums to customers who are willing to receive some services in Mexican hospitals. In fact, California is the only American state authorized to provide health insurance in collaboration with Mexican service providers. A 1998 amendment to the Knox-Keen Act allows California employers to buy health insurance for their employees living in Mexico or for those who prefer utilizing health services there.[xi] These services are provided by suppliers located in Baja California – all of which must abide by the regulatory standards established by the state of California.

The movement of suppliers (doctors and nurses) across borders has also become a common event. In the United States, foreign doctors often join the American healthcare system through clinical specialty programs. Nurses, on the other hand, respond more directly to labor market needs. The huge deficit of nurses in the United States, particularly in states with large Hispanic populations, is increasing the demand for Mexican nurses. An example of this is the Autonomous University of Tamaulipas’ Nursing School where, of the approximately 120 nurses graduating annually from the program, ten to fifteen migrate to Laredo, Texas, where hospitals offer much better wages than in Mexico and provide a chance to obtain U.S. residency.[xii] This process is facilitated by the existence of special work visas for qualified Mexican nurses offered by the U.S. government.

The advantages of such transborder movements are obvious. It offers Mexican doctors and nurses better professional opportunities, while providing Mexico an additional source of foreign exchange in the form of remittances. The United States benefits by attenuating its deficit of nurses and by gaining culturally appropriate personnel to address the health needs of its growing Hispanic population. Nevertheless, there are risks. This migrant flow of nurses could become a disincentive to strengthen nursing school programs in the United States, while promoting an exodus of qualified nurses from Mexico.[xiii]

Survey of Retired Americans’ Health Care Plans – Source: International Community Foundation, 2009

Finally, the cross-border movement of consumers of health services has also intensified throughout North America. High-income Mexicans use American health services with increasing frequency. Residents of border towns in the United States, in turn, often cross into Mexico in search of either culturally compatible health services, in the case of residents of Mexican origin, or cheaper services, particularly opthalmological and dental care that is not often covered by their health insurance policies.[xiv] Many uninsured Americans travel to Mexico to receive services that would be much more expensive back home. While a hip replacement in the United States might cost between 40,000 and 60,000 dollars, in Mexico, it is only 12,000 dollars.[xv] Open heart surgery costs between 100,000 and 150,000 dollars at Los Cabos’ Amerimed Hospital, and between 350,000 and 500,000 dollars at a similar hospital in the United States.[xvi] Americans also often travel to Mexico in search of plastic surgeries, which in addition to being a lot less expensive than back home are sometimes unavailable in the United States due to regulatory standards.

The most interesting niche related to the transborder movement of health services consumers is that of retired American citizens. It is estimated that one million retired Americans currently reside in Mexico, and this number could grow fivefold by 2025.[xvii] The majority of this population is covered by Medicare, but this health insurance does not cover the medical expenses its recipients may incur outside the United States.

Various surveys indicate that retired Americans would be willing to use health services in Mexico if Medicare would pay for them. There is, however, a powerful resistance to the expansion of Medicare to Mexico led by the American Medical Association and the American Hospital Association, who think such a measure would signal the beginning of expansion of coverage to places like China and Eastern Europe, where medical costs are extremely low.[xvii] In response to this resistance, organizations such as Americans for Medicare in Mexico and the Association of American Residents Overseas have been pressuring the U.S. Congress to expand Medicare‘s coverage abroad.

But perhaps the greatest health care challenge of all in terms of consumer mobility is the six million undocumented Mexicans living in the United States with limited access to health services.[xviii] One alternative for their families in Mexico is to join the Seguro Popular, a publicly-provided and voluntary form of medical insurance that covers health care costs for those without a job or for those who work independently and thus not part of IMSS or ISSSTE. For the immigrants themselves, one option could be the creation of a binational health insurance – with services in the United States supplied by private non-profit organizations, and services in Mexico supplied through the Seguro Popular. This option has been discusses in various forums.[xiv][xx]

Conclusions and Policy Recommendations

The processes of regional and global integration have forced national governments to cooperate with other countries to better confront health challenges that have no respect for borders. The increasing international mobility of people and goods at the turn of the 21st century, as well as rapid climate change, have all contributed to a rise in environmental, epidemiological and terrorist contingencies.

North America has not been an exception. The increasing flow of people, goods and services associated with NAFTA and with globalization more generally has intensified the danger of man-made natural disasters and infectious disease outbreaks. Two excellent recent examples are the terrorist attacks of 9/11 and the H1N1 influenza pandemic.

Fortunately, both the Mexican and U.S. governments have been quick to respond to these challenges. Surveillance and response systems designed for epidemiological contingencies and other disasters have been strengthened on both sides of the border, and the regular exchange of information at every level has been enhanced. A medium term task is to consolidate this process of cooperation with the goal of creating a true regional public health system capable of anticipating, preventing and controlling any health threat that may affect the people of North America. The most important measure in this regard is the creation of a regional public health system.

At the same time, the exchange of personal health services can generate huge economic and health benefits for both Mexico and the United States, but to achieve this it is necessary to consider how healthcare in the region can be improved in terms of coverage and quality.[xxi]

Exporting U.S. services to Mexico can expand access to specialized services and thus improve access to and quality of healthcare. Here the biggest challenge is regulation, through certificate of need, of the supply of non-cost-effective services, including those which require the use of expensive medical technologies.

Hospitals in Mexico financed with U.S. capital have produced an inflow of foreign exchange, more jobs, and widespread access to state of the art technology which will ultimately strengthen the Mexican health industry’s infrastructure. At the same time, this commercial presence comes with the risk of increased healthcare costs in Mexico and the for potential overuse of imported technology such as CT and MRI scanners.

Transborder mobility of healthcare personnel can also expand access to high quality health services and facilitate the exchange of information and clinical procedures. The problem, however, is that this also encourages an exodus of qualified Mexican workers to the United States, a problem faced by most developing countries which has been extremely difficult to confront. A portion of the income that these nurses and doctors earn in the United States does return to Mexico in the form of remittances, but Mexico suffers the loss of its talent and is unable to fully capitalize on the investment it made to train these individuals.

Finally, the transborder mobility of consumers can also increase access to cheaper and/or culturally adequate health services for certain sectors of the U.S. population. This type of service exchange, however, has not seen a great deal of expansion mostly due to the low portability of public and private health insurance in North America.

A particularly attractive option would be for Medicare to cover the expenses of U.S. citizens who choose to retire in Mexico. In fact, former Mexican President Felipe Calderon discussed this proposal with President Obama during an April 2012 visit to Washington.[xxii] This possibility would benefit both countries as it represents an important source of revenue for Mexico and a significant savings niche for Medicare given the huge difference in healthcare costs between the two countries.

But U.S. retirees are not the only potential market for Mexican healthcare providers. There are currently 45 million uninsured, and many more under-insured, people in the United States and many others that require procedures not covered by their insurance policies. This population is becoming increasingly willing to seek health services in countries with similar quality and standards as the United States, but where the cost is much lower.

Another major challenge for the exchange of health services is to design strategies to offer healthcare services to undocumented Mexican migrants in the United States. There is ample evidence that shows that undocumented Mexican workers benefit the American economy as a hard-working labor force, consumers of goods and services, and taxpayers, and should have legal access to comprehensive healthcare. The concern around these issues has increased since President Obama’s healthcare law may reduce federal support for hospitals that treat undocumented immigrants in their emergency rooms.[xxiii] The argument for withdrawing such support revolves around the idea that the uninsured population will be greatly reduced once the law comes into effect. The problem, however, is that undocumented immigrants have been excluded from the benefits of this expansion of health insurance coverage in the United States.

Mexico and the United States face the challenge of increasing their level of integration in the field of health. Common epidemiological challenges and security threats demand the consolidation of a regional public health system, which should include both a solid surveillance apparatus and agile response mechanisms.  In terms of personal health services, these two countries should strive to create the conditions to expand the exchange of personal health services in order to increase access to healthcare in the region, especially for Mexican migrants; improve the quality of services offered by Mexican providers; and help contain the costs of healthcare in the United States.

Julio Frenk, MC, PhD is the Dean of the Faculty at the Harvard School of Public Health and served as Mexico’s Minister of Health from 2000-2006. Octavio Gómez-Dantés, MC, MSP is Senior Researcher at the National Institute of Public Health of Mexico and from 2001-2006 served as Director General for Performance Evaluation at the Mexican Ministry of Health of Mexico. 


i. Academia Nacional de Medicina. El Tratado de Libre Comercio y los servicios médicos. México, D.F.: Academia Nacional de Medicina, 1994.

ii. Frenk J, Gómez-Dantés O, Cruz C, Chacón F, Hernández P, Freeman P. Consequences of the North American Free Trade Agreement for Health Services: A perspective from Mexico. Am J Public Health 1994;84(10):1591-1597

iii. Freeman P, Gómez-Dantés O, Frenk J, editores. Los sistemas de salud ante la globalización: Retos y oportunidades para América del Norte. México, D.F.: Academia Nacional de Medicina, Institute of Medicine, 1995.

iv. Frenk J, Gómez-Dantés O. Saldos de la influenza mexicana. Letras Libres 2009;XI(126):20-23.

v. Guidotti TL, Conway JB. Cooperation in health affairs between adjacent international communities: a successful model. Am J Prev Med 1987;3(5):287-292.

vi. Ortiz M. Camino y destino. Una visión personal de las políticas públicas de salud. México, D.F.: Cuadernos de Quirón, 2009:294.

vii. Garrett L. I heard the sirens scream: How Americans responded to the 9/11 and anthrax attacks. Seattle: Amazon, 2011 (e-book).

viii. Smith RD, Chanda R, Tangcharoensathien V. Trade in health-related services. Lancet 2009;373:593-601.

ix. Healthcare Information Week. Global Telemedicine Market Headed for $27 billion. Accessed July 24, 2012.

x. The Daily Beast. Crossing to Mexico for Hospitals and Healthcare. Accessed July 24, 2012.

xi. Vargas-Bustamante A, Ojeda G, Castañeda X. Willingness to pay for cross-border health insurance between the United States and Mexico. Health Affairs 2008;27(1):169-178.

xii. Rubios News. Enfermeras mexicanas emigran a los Estados Unidos. Disponible en: http://www.rubiosnews.com/nuevo-laredo/enfermeras-mexicanas-emigran-a-los-estados-unidos. Accessed July 24, 2012.

xiii. Reséndez G. Enfermeras que emigran, riesgo para México. Accessed July 24, 2012.

xiv. Chanda R. Trade in health services. Ginebra: Commission on Macroeconomics and Health, WHO, CMH Working Paper No. 4, 2001.

xv. Hylton H. Medicare savings: Is the answer in Mexico? Disponible en: http://www.time.com/time/nation/article/0,8599,1931559,00.html.  Accessed July 24, 2012.

xvi. Kiy R, McEnany A. Health care and Americans Retiring in Mexico. Accessed July 25, 2012.

xvii. Van Ostrand M. How Mexico will attract 5 million U.S. retirees. Accessed July 25, 2012.

xviii. Consejo Nacional de Población. Mexico-United States Migration. Health Issues. Mexico, D.F.: CONAPO, 2005.

xix. Cedillo-Nolasco T. Un seguro binacional de salud para migrantes beneficiaría a México y EUA. Accessed July 26, 2012..

xx. El Universal. Crearán seguro de salud para migrantes en EU. Accessed July 26, 2012.

xxi. Frenk J, Gómez-Dantés O. Intercambio de servicios de salud. México y Estados Unidos a 10 años del TLCAN. Foreign Affairs en español, 2004;4(1):51-59.

xxii. Bookman J. Someday, U.S. May Catch Up to Mexico on Health Care. Accessed July 25, 2012.

xxiii. Bernstein N. Hospital Fear Cut in Aid For Care to Illegal Immigrants. Accessed July 27, 2012.

ABOUT THIS PROJECT

The U.S.-Mexico Network’s Imagining 2024 project is designed to provide readers a quick overview of key issues in US-Mexico relations – the background of the issue, its current state, where we ought to be by 2024, and how to get there.

 

Each short essay is coupled with suggested background readings for those interested in a more detailed understanding of the issue at hand.  And as an electronic publication, both the essays and their associated resource pages are updated as needed to keep the information and analysis fresh.
 

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