Improving Access In a Binational Population

1. Improving Access In a Binational Population The Potential Role for Binational Health Insurance Tim Waidmann & Saad Ahmad The Urban Institute

2. 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)

3. Factors Influencing DemandWhat’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?

4. 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)

5. 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

6. 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

7. Other considerations • Private insurance is unfamiliar • Some surveys indicate no perceived problems in current access to care

8. 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)

9. Full US-based plan New Migrant plan + IMSS New Migrant Plan + Seguro Popular Border HMO Mexi-Plan Primary & ER $12,000 $ 3,000 $ 3,000 $ 4,080 $ 1,800 Hospital cvd $ 519 $ 180 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 Coverage alternatives, cost

10. 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%

11. A little help? • Employers • US federal/state governments • Mexican government • Hometown Associations

12. 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

13. Adults, simulated coverage *Legal status imputed from other characteristics.

14. Implementation issues • Potential opposition • Legislative/regulatory changes • Plan management challenges • Quality control • Past enrollment experience with this population

15. 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

16. 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?

17. Concluding thoughts • Is insurance necessary? • Is comprehensive plan necessary? • Is integrated product necessary? • Equity issues • Non-citizens? • Mexican citizens only? • Non-border populations?

18. MEPS spending estimates