Improving Access In a
Binational Population
The Potential Role
for Binational Health
Insurance
Tim Waidmann &
Saad Ahmad
The Urban Institute
Background on BHI
Insurance product with care options
on both sides of US/Mexico border
 Address issue of “binational” families
 Take advantage of lower-cost,
culturally competent providers
 Build on existing private models
 Aligned interests of US providers,
Mexican economy (and immigrants)

Factors Influencing Demand
What’s in it for potential enrollees?
Can predictable access to providers
be improved?
 How important is border-crossing
care?
 Potential improvements for family
members in Mexico?

Could BHI fill gaps?




5.4 Million uninsured Mexican immigrants
in the U.S.
2/3 are undocumented, so border
crossing to see a doctor is unrealistic.
Up to half a million legal immigrants live
outside of the 4 border states.
Bottom line: About 25% of uninsured
Mexican immigrants might reasonably
expect to benefit from BHI (1.3 million)
Measuring Affordability/
Willingness to Pay
No established market to do
econometric estimates
 Survey evidence
 Income-based affordability (fixed
relative expenditure on health)
 Current total binational expenditure
estimates

Out of Pocket Expenditures
Uninsured recent Latino immigrants
spend an average $200/year in US.
(MEPS)
 Remittances to family: (Mexico
received $20Bn in 2006)


At the margin, 20% of additional
remittances are spent on health care
Other considerations
Private insurance is unfamiliar
 Some surveys indicate no perceived
problems in current access to care

Supply side:What could be
offered & at what price?

Care in US: MEPS data suggest half the
cost. $1000/mo becomes $500.



Exclude hospitalization (about half of cost).
$500 becomes $250.
Care in Mexico: Full IMSS for $40/mo
($80 if cover parents). SP could be half
that.
Existing BHI plans: $350/mo. (group,
family), $75 (non-group, individual)
Coverage alternatives, cost
Primary &
ER
Full USbased
plan
New
Migrant
plan +
IMSS
$12,000
$ 3,000
New
Migrant
Plan +
Seguro
Popular
$ 3,000
cvd
$
519
$
180
Hospital
Border
HMO
MexiPlan
$ 4,080
$ 1,800
cvd
cvd
Out of
Pocket
$
200
$
200
$
200
$
200
$
800
Remittances
$
450
$
450
$
225
$
450
$
450
Total
$12,650
$ 4,169
$ 3,330
$ 4,430
$ 3,050
Price is right?
$3,000 to $4,500/year for low-cost
alternatives. (Best case)
 Using the 10% rule:

at $3,000, roughly 20% of uninsured
Mexican immigrants could afford
coverage.
 At $4,500, 5-8%
 Full freight, $12,000, <1%

A little help?
Employers
 US federal/state governments
 Mexican government
 Hometown Associations

Best case?

Reweighting exercise
Choose a comparison population that
represents an attainable standard, i.e.,
without altering fundamental
socioeconomic characteristics
 Match on age, sex, education, income,
geography, employment and family
structure

Adults, simulated coverage
ESI as employee
ESI as dependent
Public
Private non-group
Uninsured
Legal*
Mexican
Immigrants
Citizen
Citizen rewtd
20.4%
10.8%
13.4%
1.8%
53.6%
47.4%
20.3%
9.2%
6.0%
17.1%
32.2%
16.8%
15.5%
7.2%
28.3%
*Legal status imputed from other characteristics.
Potential
Change for
Legal
Mexican
Immigrants
345,905
178,714
62,490
157,616
(744,725)
Implementation issues
Potential opposition
 Legislative/regulatory changes
 Plan management challenges



Quality control
Past enrollment experience with this
population
Summary







Adults are most challenging target
Low utilization among recent immigrants
creates opportunity for lower cost
products
Geographic concentration makes BHI
feasible
Mexican public sector most likely partner
Immigration reform important
Legislative changes at state level
necessary
Outreach would be key
Research Questions





Immigration Reform. Many possible
outcomes. (Too many?)
Modeling takeup. Estimation challenges in
new population.
Utilization under cross-border plans.
Accessibility of providers for families of
potential enrollees.
What about expanding public program
eligibility?
Concluding thoughts
Is insurance necessary?
 Is comprehensive plan necessary?
 Is integrated product necessary?
 Equity issues

Non-citizens?
 Mexican citizens only?
 Non-border populations?

MEPS spending estimates
Average Medical Spending, 2001-2003
Total
OutOffice
patient
Visit Services
Hospital Hospital
ER Inpatient
Dental
Other
Rx Drug (inc LTC)
Native-born US
Privately Insured, Non-Hispanic
$ 3,088
$ 713
$ 387
$ 103
$ 911
$ 254
$ 624
$
95
Privately Insured, Hispanic
$ 1,793
$ 490
$ 188
$
87
$ 459
$ 175
$ 316
$
76
Uninsured, Non-Hispanic
$ 1,809
$ 442
$ 182
$ 104
$ 536
$ 105
$ 379
$
61
Uninsured, Hispanic
$ 1,197
$ 227
$
60
$
86
$ 549
$
$ 162
$
62
Privately Insured, Hispanic
$ 1,412
$ 328
$
69
$ 112
$ 567
$ 148
$
94
$
95
Uninsured, Hispanic
$
927
$ 148
$
45
$
44
$ 560
$
$
80
$
9
Privately Insured, Hispanic
$ 1,405
$ 399
$ 138
$ 113
$ 353
$ 112
$ 235
$
55
Uninsured, Hispanic
$
$ 237
$
$
$ 311
$
$ 148
$
24
50
Recent Immigrant (<10 yrs)
40
Long-term Immigrant (>10 yrs)
859
55
44
42