image by: Los Muertos Crew
Thinking about going to Mexico to get your health care? Definitely, a lot of Canadians and Americans do. But make sure you know the players and the rules
Medical tourism is growing in leaps and bounds. And Mexico has established itself as one of the most sought after destinations. But what is the Mexico system really like? Having a special interest in health care, it’s delivery and financing, I met a lot of people and did research about health care in Mexico. Here's what I learned to help make your experience a healthy one.
Our adventure started in central Mexico, the real Mexico, the Mexico where children would stare at me because I was the first and only gringo they had ever seen in person. We were driving down the main thoroughfare of a beautiful city called Queretaro, in the state of Queretaro—famous for it’s great climate, recent economic growth, and the execution of Maximillian in the late 1860s.
As we turn into a shopping center near downtown, I notice several older men, all dressed in white shirts and wearing blue baseball caps, shuffling around the parking lot. Studying them further, I notice they seem to be directing cars in and out of parking spots. All the while blowing whistles in some sort of code, giving all sorts of hand signals to the drivers.
Esmeralda is with me in the car. She and I have driven to this, her home town, to get a hysterectomy. She gets the hysterectomy, I do the driving. I asked her “Who are these old guys in the white shirts? What are they doing?” She responded “They’re directing cars in and out of the parking spots.”
Just then one of the directed cars slammed into the rear quarter panel of its neighbor. The man in the white shirt motioned for it to go forward, turn its wheels, then try again. On the second try they made it out safely and the demolition derby was over. The driver gave the conductor some coins.
This was how I first suspected there may be no government sponsored social security or universally accessible healthcare, in Mexico. I learned these older gentlemen supported themselves with tips from the shoppers they allege to safely conduct in and out of slots, among other things. Inside the store: Older women bagging groceries. Their sole income also tips.
Mexico has a population of almost 100 million people. Half have no or inadequate protection from medical disaster. The U.S. has just over 300 million people. About half have no or inadequate insurance or other means of protecting their assets in case of serious illness or accident. The most common cause of bankruptcy in the U.S. is still medical debt.
Mexico currently spends 5% of it’s GDP on healthcare, or $350 per person per year, or $50 billion. The U.S. 16% and $7600 per person per year or a total of about $2.3 trillion. We’re always at the top of the expenditures per citizen per year. North Korea, in case you were wondering, spends thirty five cents per person per year and is always at the bottom.
Mexico’s land area is about the size of two Texas-sized states or three quarter of a million square miles whereas the U.S. is about 3.79 million square miles. Both countries have sectored, some would say fragmented, health care supply markets with multi-tiered equity—different levels of care and benefits for different groups.
The Providers and Their Plans
Instituto Mexican Seguro Social (IMSS)
IMSS or Seguro Social was founded in 1943 to help meet the provisions of the Mexican constitution to make workplaces safe, and provide healthcare. It was a very socialistic time in Mexico and the plan also provided pension plans to those who were covered.
In actuality, Seguro Social is neither social or secure. It is available only to employed people and it mandates employers to pay the entire cost of health benefits and pensions. You lose your job, you lose your benefits. There is a distinct disincentive for employers to hire anybody over 35 years and there is no effective proscription against age discrimination in hiring.
Individuals can also apply for IMSS and pay the fee of about $350 per year. This has become a very popular option for Americans, Canadians and other emigrees. You can be turned down for pre-existing conditions and there is a phase-in or vestment of benefits. But it is basically an HMO with defined benefits funded by premiums, or cuotas paid by business for the employees and private enrollees. And it covers about 40 million people. It is the largest, by far, plan in Mexico.
It is often criticized for its less than optimal quality and wait times. But many retirees, citizen and émigré, on fixed income like the idea of limited risk and full coverage for most conditions after the three year phase in.
It has its own delivery system of outpatient clinics and hospitals. So some enrollees will see their doctor in their private offices, then get their procedures and more expensive tests done in the IMSS framework by the same doctor. All doctors are required to put in so many hours a year of service to the lower paying government sponsored plans. You want your license to practice, you pay the price.
IMSS is generally considered to have more modern equipment, but inadequate capacity and long waits. Recently, there was a rash of patient complaints to a Mexican version of “Action News” and the IMSS was embarrassed with the reporting of long waits, rude staff, and medical errors.
So Seguro Social, as it’s called, isn’t secure and there’s nothing social about it at all because it doesn’t address the needs of the poor or unemployed. And once enrolled you can’t change plans.
Instituto Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE)
ISSSTE is the government funded benefit for state government workers that began in 1943 also and was extended in 1959. As with IMSS, eligible employees have to enroll in ISSTE, it is not optional, and you cannot enroll in any of the other plans, including Seguro Popular. Cuotas or premiums are deducted from the employees check each month. Employees contribute 100% of the premium.
This plan also has its own delivery system of clinics and hospitals. It includes a generous pension plan that pays more than the base salary at retirement. It, too, is criticized for poor quality and long wait times. It’s generally considered to have older, sometimes outdated equiment .
The largest subgroup within ISSTE is the teachers. Benefits vary by state, each of which administers federal funds and adds some of its own. Teachers, as one could assume, have a powerful union in Mexico and were able to get their benefits sectored out of the rest of the population.
Secretariat Salud de Assistencia Federal (SSA) – ‘Hospitals Civil’
SSA is a system of state sponsored hospitals and clinics similar to our county hospitals. Patients pay according to their ability and these “Hospitals Civil” cater to the poor.
One of my interviewed people told me “Many people go to the civil hospitals and clinics because it’s so inexpensive. And it’s the same doctors and nurses as Seguro Popular.” Patients may pay the equivalent of $5 US for single visit as opposed to a yearly cuota of up to $1000 US for Seguro Popular, whose main benefit is protection against catastrophic illness or accident.
It’s the hope for the half of the country with total or substantial risk exposure to devastating medical debt. To most observers it is clearly the result of the long-needed change in political parties from the PRI to the more socially conscious party of Vicente Fox, the PAN or Partido de Accion Nacional. The mandate of the Mexican constitution for the government to provide healthcare was finally put into practice soon after the turn of the century.
It is an insurance plan and does not add to the capacity of hospital beds or clinics. It is similar to our Medicaid plan in that it provides insurance for most conditions and enrollees are on an ability to pay sliding scale, with premiums costing from zero to about $1000 per year. It does not cover many high cost illnesses, like renal failure requiring dialysis.
Financing is about half federal, one quarter state, and one quarter cuotas, or premiums. Financing is made equitable by varying the cuotas and varying the amount of state contributions based on their populations’ median income. Some states determine cuotas by neighborhood, other’s by declared income and expenses.
It has enrolled more than 20 million people so far and within that group there has been a 50% reduction in household financial disasters secondary to catastrophic illness. It uses the civil clinics and hospitals of the SSA to deliver its care. The civil hospitals are staffed by attending certified physicians and interns and residents. Much like our teaching hospitals. If certain tests or procedures are not available immediately, Popular patients are referred to the private sector and are still covered.
It’s praised for using an implementation strategy of “Piggy-backing” into deployment using existing social programs like Oportunidades and others. These latter plans were very successful in implementing community wide strategies to treat pneumonia, give vaccinations, standardized treatment for diarrhea and others. Their unique strategy was to pay people to bring themselves and their children to medical clinics and hospitals. With this they could compete with the Curaderas, or lay healers, pharmacies which sold medical treatment advice and a lot of medicine, and home remedies in general.
Seguro Popular is receiving good reviews by most observers. And you have to be a Mexican citizen to participate. Yet, it is often criticized for being too expensive to operate but the World Bank was so impressed with both the plan’s success and need that it loaned $1.5 billion to help keep it going.
Military and Private
About 7 percent of Mexico’s insured lives are covered by the military and private industry sponsored plans given as benefits to active and retired military personnel and the larger corporations like Pemex, the semi-private oil monopoly. These are also completely independent plans in that they have their own clinics and hospitals.
There are many short and long term private insurance plans with usually significant deductibles and most of them are third parties: You pay the providers then submit a claim to the insurance company. Premiums can range from $200 to $3000 per year.
I interviewed several patients and some doctors from each plan. Virtually all told me their first choice for their own care would be the private sector if they could afford it.
IMSS is considered to be well equipped but understaffed with long waits. A major hindrance for IMSS operations is that it gets a global budget for the entire year and usually runs out of money two or three months ahead of time.
It does not have the option of outsourcing, as does Seguro Popular, so patients, even seriously ill ones will go to county or private hospitals or wait. Whereas ISSTE is viewed by most as having older equipment and being understaffed with triage by waiting.
So to bring our story full circle, the older men and women from the beginning of this report, working for tips at the neighborhood grocery store, would no doubt go to the civil-county hospitals for their care because there really is no social security in the true sense of the term.
The Bottom Line
Esmeralda could have enrolled in IMSS and waited for six to twelve months, or enrolled in Seguro Popular, a three year wait, or she could have gone to the civil hospital in town. After brief consideration and interviewing, we went to a private doctor and began Part two of our adventure in Mexico.
J. Linder Jones MD MHA practiced emergency medicine for over two decades in Southern California and now writes as a senior correspondent for HealthWorldNet.
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