Objectives. To assess health coverage among Mexicans with US migration experience, before and after the implementation of Mexico’s universal health care program, Seguro Popular

Wassink, Joshua T.

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PubMed

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Implications of Mexican Health Care Reform onthe Health Coverage of Nonmigrants andReturning MigrantsObjectives. To assess health cov-erage among Mexicans with USmigration experience, beforeand after the implementationof Mexico’s universal health careprogram, Seguro Popular.Methods. I used data fromthe 2000 and 2010 MexicanCensuses to generate nation-ally representative estimatesof health coverage amongworking-age Mexicans by mi-grant status.Results. In 2000, before theimplementation of Seguro Pop-ular,56%ofMexicansaged15to60 years with no recent US mi-grations were uninsured com-pared with 80% of recentlyreturned migrants. By 2010,the proportion uninsured de-clined from 56% to 35% (–38%)among nonmigrants and from80% to 54% (–33%) amongreturn migrants.Conclusions. Seguro Popularhas increased health cover-age among Mexican returnmigrants, but they remainsubstantially underinsured.A creative and multifacetedapproach likely will be neededto address Mexican immigrants’health care needs. (Am J PublicHealth. 2016;106:848–850. doi:10.2105/AJPH.2016.303094)Joshua T. Wassink, MAMexican migrants to theUnited States are a largeand vulnerable population. Inrecent years, the mass immigra-tion of Mexicans to the UnitedStates has been mirrored by highlevels of return migration (bothvoluntary and forced).1 Between2005 and 2010, nearly 1.5millionMexicans returned home fromthe United States, many of themmotivated by a declining USeconomy and increasing de-portations.1 Mexican returnmigrants are at elevated risk forobesity, smoking, posttraumaticstress disorder, and depressionrelative to nonmigrants, which isespecially noteworthy givenevidence that better health inMexico prior to migration is as-sociated with higher odds ofemigration to the United States.2Despite the health challengesfaced by Mexican return mi-grants, little is known about theassociation between US migra-tion and health coverage inMexico.In 2003, the Mexican gov-ernment implemented SeguroPopular, a universal health in-surance program intended toinsure the tens of millions ofinformally employed Mexicanswithout access to Mexico’semployment-based social secu-rity program, Instituto Mexicanodel Seguro Social (IMSS).3Seguro Popular has dramaticallyreduced uninsurance, and re-search suggests that SeguroPopular enrollees have higherhospital use than the uninsured.4Yet, no studies (tomyknowledge)have considered Seguro Popular’seffect on Mexican migrants.Given that Seguro Popular tar-geted rural, lower socioeconomicstatus communities, from whichmost Mexican migrants havehistorically originated,5 I exam-ined Seguro Popular’s effect onaccess to health care for returningmigrants.I used data from the 2000 and2010 Mexican Censuses toidentify changes in health in-surance coverage during the firstdecade of the 21st century amongrecently returned working-ageMexican migrants comparedwith nonmigrants. This analysismakes 2 contributions to thestudy of migration and health.First, it provides a national-levelassessment of the association be-tween a recent migration expe-rience and health insurancecoverage among contemporaryreturn migrants. Second, itindicates whether Seguro Popu-lar has successfully reached returnmigrants. Mexican return mi-grants’ health coverage is relevantto US policy because un-documented Mexican immi-grants frequently return toMexico for medical treatment.6METHODSData came from the 2000 and2010 Mexican Population andHousing Censuses (PHC). ThePHC is a nationally representa-tive decennial survey adminis-tered to a 10% stratified randomsample of Mexican households.At both years, PHC respondentswere asked: “What state of theRepublic or what country didyou live in 5 years ago?”I defined migrants as thosewho lived in the United States 5years prior to the PHC (1995 and2005, respectively). Respondentsalso reported their health in-surance coverage, if any. TableA (available as a supplement tothe online version of this articleat http://www.ajph.org) pres-ents the health insurance op-tions that were listed in the 2000and 2010 PHCs. Because 80%of the Mexican migrants between1995 and 2009 were workingage (15–60 years), I omitted allother ages.7 The analytic samplecontained 12164 346 observa-tions. I used survey weights togenerate nationally representativeestimates. Unfortunately, thePHC did not solicit informationon length of migration or causeof return.ABOUT THE AUTHORJoshua T. Wassink is with the Department of Sociology, University of North Carolina atChapel Hill, and the Carolina Population Center, University of North Carolina at ChapelHill.Correspondence should be sent to Joshua T. Wassink, MA, Department of Sociology, 155Hamilton Hall CB #3210, UNC-CH, Chapel Hill, NC 27599-3210 (e-mail: wassink@live.unc.edu). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.This brief was accepted January 22, 2016.doi: 10.2105/AJPH.2016.303094848 Public Health Policy Peer Reviewed Wassink AJPH May 2016, Vol 106, No. 5AJPH POLICYRESULTSFigure 1 presents health cov-erage in 2000 and 2010 amongnonmigrants and former USmigrants in Mexico. (Table Acontains a list and description ofthe alternative health insuranceprograms.) In 2000, before theimplementation of Seguro Pop-ular, more than half of Mexicansaged 15 to 60 years with no re-cent US migrations (56%) wereuninsured. Most of the insuredwere covered through IMSS(35%). By contrast, fully 80% ofrecently returned migrants wereuninsured in 2000, with almostall of the insured covered throughIMSS (18%).The proportion of uninsureddecreased substantially by 2010because nonmigrants and thoserecently returned from theUnited States enrolled in SeguroPopular (21% and 26%, re-spectively). Enrollment in pre-existing programs remainedrelatively stable among returnmigrants and nonmigrants, sug-gesting, as expected, that SeguroPopular largely accounted for thereduction in uninsurance amongworking-age Mexicans.Although the absolute declinein the percentage uninsured wasslightly greater among recentlyreturned migrants relative tononmigrants, the proportionalodds of transitioning from un-insured to insured were greateramong nonmigrants. In otherwords, the greater percentagedecline in uninsurance amongreturnmigrantswas driven to someextent by the greater proportion ofat-risk (uninsured) returnees in2000. Among nonmigrants, theproportion uninsured decreasedfrom 56% to 35% between 2000and 2010—a 38% reduction in therate of uninsurance. By contrast,the proportion uninsured amongrecently returned migrants de-creased from 80% to 54%—onlya 33% decline. Analyses (notshown) found that the negativeassociation between migration andhealth coverage was strongeramong women than among menand that following adjustment forpotential demographic and socio-economic confounders, the nega-tive association between USmigration and the odds of beinginsured remained robust.DISCUSSIONPerhaps as a result of their ab-sence during major enrollmentperiods, limited social networks,and persistent overrepresentationin the informal occupations,working-age Mexicans who re-cently returned from the UnitedStates remain substantially un-derinsured relative to nonmigrants.Despite the 26% reduction inuninsurance among returnees, therelative decline has been slowerthan among nonmigrants. Futureresearch might explore targetedprograms specifically intended toprotect internationalmigrants. ThePhilippines, for example, providespremigration training and in-surance to workers living abroadthrough their Overseas WorkersWelfare Administration. Ofcourse, any binational programwould face the challenge of in-corporating millions of un-documented migrants who, forobvious reasons, often prefer toremain “off the books.”This study has implicationsfor US policy and the well-beingof Mexicans in the United States.The underinsurance identifiedamong recently returned mi-grants and the fact that theAffordable Care Act does notaddress access to care amongundocumented Mexican immi-grants indicate a need for policiesthat directly address the healthcare needs of current and formerundocumented Mexican mi-grants. Given the US Congress’sinability to pass comprehensiveimmigration reform or approvea binational health care agree-ment between the United Statesand Mexico, which was draftedin 2004, and the current climateof hostility toward Mexican im-migrants, a creative and multi-faceted approach will likely beneeded to address Mexican im-migrants’ health careneeds.ACKNOWLEDGMENTSI would like to thank the Carolina Pop-ulation Center for training support (T32–21%***–3%***1%***–1%*21%***3%***0Insurance Program Insurance Program102030405060708090–26%***–1%*23***4%***0.0PercentagePercentage10.020.030.040.050.060.070.080.090.0UninsuredIMSSISSSTESegPopOtherPEMEXUninsuredIMSSISSSTESegPopOtherPEMEXa b20102000 20102000Note.Thesefigures represent theproportions ofMexicans affiliatedwith each insurance program in 2000 and2010, bymigrantstatus (n = 12 037836nonmigrants andn = 126520 returnmigrants). Data labels indicate the size anddirectionof the change inpercentage affiliated with each program. Significance levels refer to the differences between 2000 and 2010 insurancecoveragebyprogram. Fewer than1%of the respondentswho reportedmultiple types of insurance (e.g., InstitutoMexicanodelSeguro Social [IMSS] and other or Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado [ISSSTE] and SeguroPopular [SegPop]) were omitted. Return migrants are those who resided in the United States 5 years before the census’sadministration. Less than 0.5% of the return migrants reported affiliation with Petróleos Mexicanos [PEMEX] in either census;their participation was rounded to 0%. The proportions were weighted to yield nationally representative estimates of healthcoverage enrollment for the working-age (15–60 years) Mexican population in 2000 and 2010.*P < .05. **P < .01. ***P < .001.FIGURE 1—Health Insurance Coverage Among Working-Age Mexicans in 2000 and 2010, by (a)Nonmigrants and (b) Return Migrants: Mexican Population and Housing Censuses 2000 and 2010AJPH POLICYMay 2016, Vol 106, No. 5 AJPH Wassink Peer Reviewed Public Health Policy 849HD007168) and for general support (R24HD050924) of this research.Data for this project were made avail-able via theMinnesota PopulationCenter,Integrated Public Use Microdata Series,International: Version 6.3 [machine-readable database]. Minneapolis: Univer-sity ofMinnesota. Thedatawere originallycollected by the National Institute ofStatistics, Geography, and Informatics,Mexico.I would also like to thank JacquelineHagan, Robert Hummer, and KristaPerreira for their thoughtful comments onearlier drafts.HUMAN PARTICIPANTPROTECTIONThis study was reviewed and approved bythe University of North Carolina in-stitutional review board.REFERENCES1. Passell J, Cohn D, Gonzalez-Barrera A.NetMigration FromMexico Falls to Zero–andPerhaps Less. Washington, DC: PewResearch Center; 2012.2. Ullmann SH, Goldman N, Massey DS.Healthier before they migrate, lesshealthy when they return? The healthof returned migrants in Mexico. Soc SciMed. 2011;73(3):421–428 .3. Knaul FM, Frenk J. Health insurance inMexico: achieving universal coveragethrough structural reform. Health Aff(Millwood). 2005;24(6):1467–1476.4. Knaul FM, González-Pier E, Gómez-Dantés O, et al. The quest for universalhealth coverage: achieving social pro-tection for all in Mexico. Lancet. 2012;380(9849):1259–1279.5. Fussell E. Sources of Mexico’s migra-tion stream: rural, urban, and bordermigrants to the United States. Soc Forces.2004;82(3):937–967.6. González-Block MA, Sierra-de la VegaLA. Hospital utilization by Mexicanmigrants returning to Mexico due tohealth needs.BMCPublic Health. 2011;11:241–248.7. Instituto Nacional de Estadística yGeografía. Encuesta Nacional de la DinámicaDemográfica 2009: Panorama Socio-demografíco de México Principales Resultados.Aguascalientes City, Mexico: InstitutoNacional de Estadística y Geografía; 2011.AJPH POLICY850 Public Health Policy Peer Reviewed Wassink AJPH May 2016, Vol 106, No. 5

Implications of Mexican Health Care Reform on the Health Coverage of Nonmigrants and Returning Migrants

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Implications of Mexican Health Care Reform on the Health Coverage of Nonmigrants and Returning Migrants

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