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 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?

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. 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 $ 4,080$ 1,800 Hospital cvd$ 519$ 180 cvd Out of Pocket $ 200 $ 800 Remittances$ 450 $ 225$ 450 Total$12,650$ 4,169$ 3,330$ 4,430$ 3,050

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