Improving Access In a Binational Population

The Potential Role for Binational Health InsuranceTim 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 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?

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  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

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

Legal* Mexican

Immigrants Citizen Citizen rewtd

Potential Change for

Legal Mexican

Immigrants

ESI as employee 20.4% 47.4% 32.2% 345,905 ESI as dependent 10.8% 20.3% 16.8% 178,714 Public 13.4% 9.2% 15.5% 62,490 Private non-group 1.8% 6.0% 7.2% 157,616 Uninsured 53.6% 17.1% 28.3% (744,725)

*Legal status imputed from other characteristics.

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?

Average Medical Spending, 2001-2003

TotalOffice

Visit

Out-patient

ServicesHospital

ERHospital Inpatient Dental Rx Drug

Other (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$ 50$ 162$ 62$

Recent Immigrant (<10 yrs)

Privately Insured, Hispanic 1,412$ 328$ 69$ 112$ 567$ 148$ 94$ 95$

Uninsured, Hispanic 927$ 148$ 45$ 44$ 560$ 40$ 80$ 9$

Long-term Immigrant (>10 yrs)

Privately Insured, Hispanic 1,405$ 399$ 138$ 113$ 353$ 112$ 235$ 55$

Uninsured, Hispanic 859$ 237$ 55$ 44$ 311$ 42$ 148$ 24$

MEPS spending estimates