Andrew Nelson IAFS 45005/3/2014

Final PaperHealth System Analysis: Mexico and the United States

Given Mexico’s proximity to the United States and strong relationship with regards to

trade and foreign investment, one could assume that Mexico’s economic development would

be similar to that of the United States, however, Mexico remains a relatively poor country

characterized by huge disparities in wealth and large sectors of the population living in poverty.

Economic differences between the United States and Mexico can be attributed to the very

different political and economic institutions that exist in the two countries. While the political

and economic challenges facing each country are inherently different, they share a similar

challenge of dealing with a population who continues to pack on the pounds with each

successive generation. According to the UN’s Food and Agriculture Organization (FAO), Mexico

is now the most obese heavily populated country in the world, surpassing the United States.

While some may attribute these respective obesity epidemics to separate factors in each

country, there is no denying the interconnectedness of these epidemics, given the large

number of Mexican immigrants living in the United States, and the high consumption rate of

US-based fast food in Mexico. Given the intersected nature of these obesity epidemics it is

important to understand the similarities and differences in how each country’s health system

combats obesity. Internalized stereotypes on the part of US citizens characterize Mexico as

corrupt, dangerous, unsanitary, impoverished, and medically outdated. However, as one begins

to delve deeper into the facts, it is clear that the respective health systems in each country

share many similarities. The purpose of this paper is to compare and contrast the US health

system with that of Mexico, specifically focusing on the opportunities and challenges facing

each country with regards to controlling obesity. This paper will analyze and evaluate the health

systems of each country, and will conclude with my own recommendations on how Mexico and

the United States can learn from each other’s experiences, and improve their individual health

systems with regards to controlling obesity. Engaging in a comprehensive cross-cultural analysis

such as this requires an accurate representation of the present health systems on both sides of

the US-Mexico border, and relevant perspectives from those who have experienced both health

systems first hand.

In recent years, the number of people along the US-Mexico border seeking cross-border

medical care has increased significantly. Contrary to popular perceptions, this cross-border

medical care movement is not flowing north from Mexico into the United States, but rather,

South from the US into Mexicoi. Mexico is marketed to many seasonal tourists and border

residents as a practical solution to the growing costs of medical care and limited access to

insurance in the United States, while offering shorter waiting times, international accreditation,

and unique office amenities, such as massaging chairsii. Although the Mexican medical system

offers unique advantages that are not available in the United States, the general American

perception of Mexican society, as unable to provide modern services to its citizens, is also

applied to their medical system. In order to overcome these perceptions, the Mexican medical

system has made a concerted effort to replicate certain aspects of the US medical system that

American patients perceive as suggestive of a high quality medical experience, such as

international accreditation, using the English language, and modern technologyiii. According to a

2010 study titled, US-Mexico: Imports and Exports Health services, an estimated 19.9% of US-

Mexico border residents have sought medical care in Mexico, and 29.4% have purchased

pharmaceuticals in Mexico, with an annual expenditure between 194 and 388 million dollars iv.

These statistics clearly show an American demand for Mexican health services, but now the

question becomes: What are the factors influencing this large scale cross-border medical care

movement?

In 1983, under duress from the International Monetary Fund and the World Bank,

Mexico’s healthcare system began implementing decentralization and privatization efforts,

resulting in an underfunded and understaffed public healthcare system, while the private

healthcare system benefitted from proper funding, better doctors, newer facilities, and a higher

concentration of US patients who generally paid more than Mexican patientsv. This shift to a

more decentralized and privatized healthcare system in Mexico has promoted the

establishment of medical border towns, which according to Alex Oberle and Daniel Arreola, can

be defined as an area that facilitates access to and profits from foreign consumption of its

medical services. These medical border towns provide cheap, easy access to health services,

and cater to the specific needs of their predominantly American clientele. This means providing

a blend of good care and good services, which equates to modern biomedical care that is not

altered by local cultural valuesvi. Often times US patients who cross the Mexican border in

search of medical care associate high quality institutions with those that are similar to the

healthcare institutions that are found in the United States. Thus, by incorporating aspects

similar to US medical providers into their practices, Mexican practitioners reassure US patients

that the medical experience they are receiving is similar to what they will find on the other side

of the border. The article titled, Shadowing Modernity: The Art of Providing Mexican

Healthcare for Americans, offers several firsthand accounts of US medical patients seeking

medical care in Mexico. Bud and Paula, a retired couple from Iowa prefer to travel to Mexico

for many of their healthcare needs because according to them, “the healthcare is less

expensive and the same as is the US.” Upon receiving treatment for fibromyalgia at a Mexican

medical facility, Paula, a retired nurse stated that, “the doctor who treated her was trained in

Europe, published in journals, and spoke good English”, all of which encouraged her to claim

that the care she received was similar to what she would have received in the US for half of the

pricevii. This passage shows that the increasing demand for Mexican healthcare services by US

patients is undeniable, begging the question: what is it about the US health system that makes

people want to travel to Mexico in order to receive medical care? In order to answer this

question one must have a better understanding of the US health system as a whole.

Healthcare in the United States can be defined as an intricate mixture of private and

public care, in which the government runs military and veteran healthcare systems, the Indian

health service, and several programs for vulnerable populations, such as Medicare and

Medicaidviii. Medicaid covers the impoverished population, while Medicare covers the elderly

and certain disabled low-income populationsix. With regards to private healthcare, private

insurance is usually provided by an employer or purchased by individualsx. While healthcare in

the United States is wide-ranging, it is also extremely expensive, exemplified by the fact that in

2008, according to the Organization for Economic Co-operation and Development (OECD), 16%

of the US’s GDP was spent on healthcare, compared to the OECD average of about 9%xi.

However, according to the World Health Organization, in comparison to other industrialized

countries the US ranks 37th with regards to health outcomesxii. While the US government spends

a great deal of money each year on healthcare, the healthcare system continues to suffer from

unequal access, overcrowded medical facilities, and relatively high deductibles, premiums, and

co-paysxiii. In the United States, health insurance is treated as a market good and, thus, its

quality is connected to its price, leading to various levels of access and carexiv. But what happens

to those people who do not fall under the various federal programs such as Medicare and

Medicaid, or do not have access to health insurance because they cannot afford it, or it is not

provided by the company they work for? Are they simply left to die in the streets?

There exists a number of social safety nets in the United States for those lacking

individual insurance, work-related insurance, or do not adhere to the specific categories that

are required to gain access to federal programs. For example, hospitals, clinics, and private

practitioners can be compensated for treating those lacking health insurance if these people

are citizens or long-term residents and fall under certain categories such as, being disabled,

very old, very young, or very poorxv. A number of states and counties around the US have

expanded these social safety nets to include programs that do not require proof of citizenship

or a legal permanent address in order to receive carexvi. Those who utilize these expanded social

safety nets often receive care that is variable in quality and often find themselves being treated

and released in a quick manor. While emergency rooms are legally obligated to provide care to

those in need, the bills and charges associated with these services can be financially disastrous,

especially to poor patients, leading many people to avoid these services even when they are in

desperate need of carexvii. Although the network of clinics that deliver care to those who are

uninsured provide basic medical services, some assistance with chronic conditions, and

programs centered on preventing the spread of infectious diseases, such as AIDS, patients in

need of long-term intensive care, such as diabetics, face extreme barriers and long waiting

periods, in which the fate of their health is largely left up to chancexviii. According to an estimate

by the Urban Institute, about 27,000 preventable deaths occur each year in the United States

due to lack of health insurance (as cited in Krugman, 2008). This statistic is staggering

considering the relatively large amount of money the United States spends on healthcare each

year, however, the Patient Protection and Affordable Care Act seeks to address the underlying

problems contributing to the large number of preventable deaths due to lack of health

insurance in the United States.

On March 23rd, 2010, President Barack Obama signed into law the Patient Protection

and Affordable Care Act, commonly referred to as Obamacare, in an effort to ensure better

access to health care for many Americans through expanded public and private insurance

coverage, which includes basic preventative care, minimum standards for health insurance

policies, health insurance exchanges, and the establishment of a same rate offer regardless of

pre-existing conditions or sexxix. The Affordable Care Act requires most Americans to secure a

private insurance policy that meets federal standards or pay a penalty, which is known as the

“Shared Responsibility Payment”, and in 2016 the penalty will be greater than 2.5% of

household income, or $2,085 for a family, which is still less than the insurance paymentxx. While

the Affordable Care Act seeks to reduce the costs associated with healthcare for individuals and

the government, and expand both public and private insurance coverage, increased access to

health insurance does not guarantee better health outcomes, especially considering the fact

that more than 85 cents of every dollar spent on health in the US are spent on the treatment

and management of chronic diseases, such as those caused by preventable conditions related

to tobacco use and obesityxxi. Although health spending on the treatment of chronic diseases

associated with preventable conditions such as obesity is extremely high in the United States,

there exists a great deal of confusion as to who is responsible for controlling obesity, and how

these obesity control mechanisms relate to the US health system. According to J.M. McGinnis,

more than 60% of a person’s health is determined by lifestyle, behavior, and environmental and

social factors, and not by what happens in the healthcare provider’s officexxii. Primary

prevention techniques, or policy and system changes that reduce exposure and risk factors, are

extremely effective at keeping disease and injury from happening in the first place and lead to

reductions in healthcare and social costs of treating and managing disease and injury after they

occur (as cited in Frieden, 2010)xxiii. One of the most important impacts of the Affordable Care

Act is that it opens the door to transform the US health system to ensure that primary

prevention is implanted within the health system, benefitting patients, providers, and

communitiesxxiv.

Currently, the primary obesity control mechanism that is incorporated into the United

States health system is the use of the Healthcare Effectiveness Data and Information Set

(HEDIS). HEDIS is a widely used set of performance measures that are intended to reduce the

costs of healthcare and improve the overall quality of care. HEDIS measures health plan

performances regarding the measurement of body mass index for adolescents, children, and

adults, and also for the nutrition and physical activity counseling of children and adolescentsxxv.

In medicine, “what gets measured gets done”, thus, the new obesity-related measures are

intended to improve healthcare providers’ attention to obesity care, treatment, and

preventionxxvi. In July 2004, the Centers for Medicare and Medicaid revised obesity’s status as

not being considered a disease in order to permit Medicare to consider covering payments for

obesity-related treatments (as cited in CMS, 2004)xxvii. Although Medicaid is managed at the

state level, the Medicare ruling enabled some states to broaden their Medicaid programs,

increasing the coverage of services for the prevention and treatment of obesity, for example,

West Virginia and Tennessee offer both partial and full reimbursement for participation in

Weight Watchers programs (as cited in Unicare, 2007, and Tenncare, 2005)xxviii. By mid-2008 it

was estimated that 11 states exhibited strong evidence that they provided reimbursement for

behavioral and nutritional therapy to overweight and obese children in Medicaid programs,

while in 8 states, Medicaid programs covered 3 types of obesity treatment: drug therapy,

bariatric surgery, and assessment and consultationxxix. Although the US health system

incentivizes obesity prevention and control mechanisms, these mechanisms are not widely

incorporated and are largely determined and implemented to varying degrees on a state to

state basis. Thus, there exists a great opportunity to increase the use of obesity prevention and

control mechanisms in the US health system because the practice of healthcare is licensed and

regulated, whereas the weight loss industry is notxxx.

So far, this paper has outlined the US health system and has shown the underdeveloped

status of obesity prevention and control mechanisms within this system. The focus of this paper

now transitions to the Mexican health system and the various obesity prevention and control

mechanisms that exist within this system.

Healthcare in Mexico is predominantly public with some unregulated private institutions

that operate on the ability of patients to pay for these services. Social security organizations in

Mexico are funded by the government, the employer, and the employee, and cover many

workers, whereas the Ministry of Health, the State Health Services, and the IMSS-

Oportunidades Program provide care to those without insurancexxxi. The Mexican healthcare

system is considered to be highly fragmented because there exists a number of disconnected

social insurance providers for employees in the salaried labor market, whereas those who are

not covered under the social security system are left with few optionsxxxii. Access to social

security institutions in Mexico continues to be based on employment status, and although

these institutions are framed as social insurance, each one functions as a miniature health

service, in which there is no guaranteed package of services, and affiliates must go to clinics

operated by their insurance fund, suggesting that there is very little competition among

providersxxxiii. The Ministry of Health, which is responsible for providing healthcare services to

the population uninsured by social security, has decentralized the supply of care for these

groups, in which states now operate individual health service systems of public hospitals and

clinics that vary in quality and the amount of expendable resources they have. According to the

Lancet article titled, Assessing the effect of the 2001-06 Mexican health reform, in 2001, nearly

half of the total Mexican population was uninsured. In response to this problem the Mexican

government created the Seguro popular, a voluntary health insurance program that is funded

through financial resources contributed by the federal and state governments for each newly

affiliated family, who pay a small premium each yearxxxiv. The Seguro Popular expands health

insurance coverage for a package of essential interventions to uninsured people, increases

public spending on health, and creates a fund to protect families from catastrophic health

expendituresxxxv. One of the most interesting aspects of the Mexican healthcare reforms and the

Seguro Popular is that resources flow to the State Ministries of Health as a function of

affiliation, in which the State Ministries of Health must insure that affiliates are satisfied with

service delivery in order re-affiliate each yearxxxvi. This system provides incentives, in the form of

securing annual affiliations, for states to provide high quality care and increased coverage.

According to the Lancet article titled, Assessing the effect of the 2001-06 Mexican health

reform, Mexican healthcare reforms and the Seguro Popular have had a positive effect on

Mexico’s health system in that healthcare inequalities have been reduced, effective coverage is

increasing, and catastrophic spending has fallen. Although the Mexican healthcare reforms and

the Seguro Popular have had a positive effect on the Mexican health system, the effectiveness

of these reforms have been inhibited by structural inefficiencies and premium payment issues.

Currently, the Mexican health system is characterized by weak infrastructure and insufficient

human resources which continues to limit the ability of the Seguro Popular to provide

guaranteed servicesxxxvii. Another problem that Mexican authorities are currently dealing with is

the fact that many individuals are not willing to pay for this insurance program. In an effort to

meet affiliation targets, states purposefully misclassified those whose incomes were high

enough to afford the premium as poor, enabling them to receive care without paying for itxxxviii.

Although the Mexican government has classified 93-97% of Seguro Popular affiliates as poor

since the program began in 2004, independent analysts have found that only 46% of affiliates

were properly classified as poor (as cited in Scott 2006)xxxix. This premium payment issue is

particularly important to the financial sustainability of the Seguro Popular because this program

requires contributions from the non-poor in order to function properly, which so far, has not

materialized. While universal health coverage has been achieved in Mexico, it remains to be

seen as to whether or not the Mexican health system will be able to sustain itself in the future.

The financial instability of the Mexican health system is particularly unsettling given the

fact that the main causes of healthcare utilization in Mexico stem from diabetes and

cardiovascular disease, accounting for 9.5% of care for the uninsured and 13.5% among the

insured (as cited in Arredondo, 2005)xl. According to the Mexican Secretary of Health, in 2008,

the direct costs associated with treating weight-related NCDs was about $ US 3.2 million,

representing 33.2% of the total healthcare expenditurexli. These non-communicable diseases

are directly associated with preventable risk factors such as physical inactivity, improper diet,

and obesity. Although the growth in the prevalence of obesity and weight-related NCDs costs

the Mexican health system millions of dollars each year, the Mexican government has done

very little to promote obesity prevention programs. With the prevalence of obesity, weight-

related diseases, and the associated economic burden in Mexico expected to drastically

increase in the coming years, the question remains: What is the Mexican health system doing in

order to prevent and control obesity?

In Mexico, about 73.5% of the current heath budget is going towards treatment, with

about 2.7% of this budget going towards prevention and public healthxlii. Given this information,

it is clear that the Mexican health system should reallocate its budget to invest more in obesity

prevention. In 2001, the Mexican Social Security Institute (IMSS) created a preventative care

program (PrevenIMSS) that provides health education, nutritional information, disease

prevention techniques, and screening for weight-related diseases, including type 2 diabetes and

hypertensionxliii. PrevenMISS also provides support groups with the aim of improving lifestyle

practices through education about exercise and diet to people who are overweight or obesexliv.

This program was able to spread its message of the importance of preventative care to the

Mexican population through a significant investment in media advertisements, including both

television and radio adsxlv. Although the PrevenMISS program achieved wide reaching

recognition from the Mexican population, investing in a unified national campaign that included

the three main health systems would have produced more noticeable and sustainable resultsxlvi.

In response to the increased consumption of sugary beverages among the Mexican population,

in 2008, the Ministry of Health established an expert panel to develop recommendations on

beverage intake for a healthy life, developing a graphic representation known as the “healthy

beverage pitcher” which outlines the recommended consumption levels of certain beveragesxlvii.

This graphic representation was widely distributed through social networks and media outlets,

eventually becoming part of the curriculum of the national primary education system in which

this graphic is displayed within multiple textbooksxlviii. After years of collecting data and

reviewing experiences, the Mexican Ministry of Health, with help from international experts

and stakeholders, developed the National Agreement for Healthy Nutrition (ANSA) which

identified ten objectives for a national policy aimed at preventing obesity and weight-related

diseasesxlix. The agreement was signed by 15 government agencies from the fields of health,

education, economics, agriculture, labor, social welfare, social development, along with NGOS,

and the food and beverage industry, which agreed to work together to implement this national

strategyl. Many of these obesity control objectives are based on the modification of

environments and the transformation of individual habits outside of the health system and thus

require harmonization between industry interests and public health objectives, which has

proved to be particularly challenging in Mexicoli.

So far, this paper has outlined both the US health system and the Mexican Health

system, and has identified the challenges and opportunities that each country faces with

regards to obesity control and prevention. Although both Mexico and the United States have

exhibited a concerted effort to combat obesity, it is clear that there is room for improvement,

especially within their respective health systems.

The primary focus of most obesity control and prevention strategies is the management

of the risk environment, which is critical for any country’s approach to reducing the incidence of

obesity and weight-related NCDs. However, this paper does not focus specifically on the obesity

control and prevention mechanisms within the risk environment, but rather, obesity control

and prevention mechanisms within the health system. Although in order to run a successful

obesity prevention campaign, overlap between these two realms is certainly necessary, the

next paragraph will focus specifically on recommendations for improving both the US and the

Mexican health systems with regards to preventing and controlling obesity.

Leading health experts overwhelmingly agree that prevention is more effective than

treatment alone in reducing obesity and should be addressed as a priority in the public health

sectorlii. Health systems in Mexico and the United States must identify the determining factors

for obesity and use these factors to develop a large scale, long-term strategy to combat obesity.

In Mexico, the preventative care program known as PrevenMISS must be expanded to include

all of the health systems rather than just the Mexican Social Security Institute. The expansion of

this program will include a mandatory consultation for every Mexican citizen on proper exercise

and diet practices upon receiving their annual checkup, with the continuation of these

consultations with each successive visit to a medical facility. The Mexican Health system should

also utilize the US strategy of incentivizing participation in weight loss programs, such as weight

watchers, by having healthcare providers compensate all citizens who participate in these

programs. In compensating those who participate in weight loss programs, Mexican healthcare

providers will spend less money on treating weight-related NCDs, and will also receive

increased funding from the Mexican government based on the number of people who

participate in weight loss programs. Currently, the primary challenge facing the Mexican health

system with regards to preventing obesity is the fact that behavioral and lifestyle changes are

largely left up to the individual to initiate outside of the health system, requiring the

harmonization between industry interests and public health objectives. In order to circumvent

these harmonization efforts the Mexican Health system should implement a universal payment

premium reduction strategy, in which individuals who lose weight will incur a reduced premium

payment according to the amount of weight that they lose. Another aspect of the US health

system that can be incorporated into the Mexican health system with regards to obesity control

is the use of the Healthcare Effectiveness Data and Information Set (HEDIS). By incorporating

the HEDIS into their health system Mexican healthcare providers will be able to improve

performances regarding the measurement of body mass index for adolescents, children, and

adults, as well as for the nutrition and physical activity counseling of children and adolescents.

These enhanced measurements will allow Mexican healthcare providers to better identify areas

of improvement regarding obesity prevention and control. The primary challenge facing the

United States with regards to implementing obesity prevention and control mechanisms, is that

these mechanisms are not widely incorporated and are largely determined and implemented to

varying degrees on a state to state basis. Thus, the US health system should implement a large

scale strategy across all 50 states to increase coverage for obesity related treatments, and

reimburse individuals who participate in behavioral and nutritional therapy programs. The US

health system should also incorporate the Mexican strategy of implementing preventative care

programs similar to PrevenMISS. These programs will include the identification of overweight

and obese individuals through proper measurements and will provide free mandatory exercise

and diet consultations upon each visit to a medical facility. Another strategy that the US health

system can borrow from Mexico is the development of healthy food and beverage consumption

graphics similar to the “healthy beverage pitcher”. These graphic representations should be

expanded to include both food and beverage intake recommendations that are specific to

individuals body composition and lifestyle practices. For example, upon each yearly checkup an

individual’s doctor will create a graphic representation of the healthy food and beverage

consumption levels specific to the individual’s lifestyle and body composition. Through these

practices, patient and doctor relationships will be strengthened which will allow for a more

personal medical experience, similar to what is experienced by the many US health tourists who

cross the border into Mexico in order to receive medical care.

While these recommendations are quite broad, it is important to recognize the need for

such large-scale interventions regarding the prevention and control of obesity given the highly

fragmented implementation status of obesity prevention and control mechanisms in Mexico

and the United States. In order to continue to prevent and control obesity, Mexico and the

United States must identify the multiple settings in which obesity prevention and control

mechanisms can be implemented, and should promote a combined strategy that seeks to

influence both the risk environment and the health system with regards to preventing and

controlling obesity.

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