Mexico's Dual System of Private and Public Healthcare Coverage

Mexico's Dual System of Private and Public Healthcare Coverage

Abstract
Most countries have a system in place to care for the sick and injured. Like the United States, Mexico has dual systems of both private and public healthcare coverage, however, Mexico provides for all of its citizens. While there are similarities in health care facilities in the larger cities in Mexico, the smaller, more economically downtrodden areas, lack many sufficient services. What healthcare costs there are, they have been shown to be significantly less than those in the United States, being funded by federal and state level programs but with out of pocket costs still possible for those not participating in either a public or private health plan. With people living longer and in more concentrated groups, there is a need for a sound public health system in place. The public health system provides the citizens with protection from disease through prevention and care. Working together, public and private health sectors in Mexico can effectively manage a majority of the population’s health problems while working towards preventing future harms.

Introduction
Mexico, like any country has a health care system set up for the people, although having health care set up and it running smoothly are two very different things. Mexico is similar to the United States because they both consist of private and public sectors of health care. However, private hospitals offer very little services and the services they do offer, people are unsatisfied with. Anyone who does not have health insurance has to pay out of pocket costs, which is difficult when 40 million people in Mexico have incomes below the poverty line (Ruelas, 2002). When the citizens living below the poverty line get sick, they have to pay out of pocket costs, these costs accounted for the way 52% of people in Mexico paid for their health care before the reforms (Ruelas, 2002). The major problem with the health care in Mexico and people’s life expectancy is that certain areas of Mexico are extremely poor. It is common to find that in a better off area of Mexico that they will reach the average life expectancy in Mexico which is 76 years, compared with the 79 year life expectancy of the United States (World, 2011). Mortality from any communicable disease in low income areas, the poorest areas of Mexico, is twice as high as the numbers in the better off areas of Mexico (Ruelas, 2002). There are huge gaps in mortality rates between the poorest areas and those that manage to do fairly well. While mortality rates in the different areas of Mexico vary greatly it is important to also notice how Mexico’s mortality rates compare with those of the United States. Overall, Mexico’s mortality rate from non-communicable disease is higher than the United States, and Mexico also has a higher rate of death of children under the age of five (World, 2011).

While Mexico might not be the nation worst off in the scope of the entire world it does face many challenges in the health care system that the country has set up. People living in Mexico do not rate their health care system as excellent due to the many failures in the system. The system is not looking out for the health of the poor people even when the system seems to provide both a private and public sector of health; those two sectors are not doing an adequate job. New policies needed to be put into place in order for Mexico to offer not only a better health care system, but for Mexico to find a better solution to finance that system, in order to protect the public health of its citizens.

Health Care Policies
The people living in Mexico are often left uninsured and when an uninsured individual gets sick the family will have to pay out of pocket costs (Frenk et al., 2009). This means that the poor families in Mexico that can barely afford to keep their family going, also end up having to pay for costly health care. Costly health care that the people of Mexico rate as very poor is the quality of care they are receiving. It is easy to see why many people living in Mexico would refuse to buy health insurance in the first place. Even if they all had health insurance a big problem is the fact that the quality of care is so low. Mexico needed to have new policies that will help to pay for better overall care for the people. However, new ways to care for people, better technology, and better trained and educated individuals do not just come from thin air. All of these things cost money, so new policies in Mexico needed to focus in on providing not only more money but needed to provide more people with better health care. Of course new policies take time and much deliberation between government officials. Finally in 2003, the Mexican Congress approved a reform to the Mexico’s Ley General de Salud, the General Health Law. This reform was called the Sistema de Proteccion Social en Salud (SPSS) which means System of Social Protection in Health. This new policy to health care reform allowed for an increase in public funding, guaranteeing universal health care coverage (Frenk et al., 2009). This ultimately means that the nation’s poor would be able to enroll in Seguro Popular (SP) or the People’s Insurance. This was Mexico’s step to making a new public insurance policy that would assure access to comprehensive health care. The important part to the SPSS policy was that it allowed more poor people to gain health insurance. This meant that 45 million Mexicans, who had no health insurance in the past, now have access to health insurance for the first time (Frenk et al., 2009).

The new health care reform not only helped the poor to finally be insured but it also addressed a lot of the problems with quality of care. With this new reform, resources are being offered in order to better the medical equipment and the medical personnel. Not only are the hospitals getting the resources they always needed, but part of the new reform also mandated that there needed to be protocols in place that will make sure the correct procedures are being performed the right way (Frenk et al., 2009). This greatly increases the quality of care experienced by the patients and makes the medical staff more efficient. Lastly, these new reforms required that all hospitals offering universal health care must be accredited and provide all necessary information to their clients regarding their benefits. By the people knowing exactly what their health insurance offers and by the overall quality of health care being improved in Mexico, these people can live healthier lives. The reform in Mexico in 2003 is similar to the newest policies that could be taking affect in the United States. The United States suffers many of the same problems that Mexico does with their form of health insurance. Today approximately 50.7 million Americans are uninsured and millions more have very poor health insurance which raises the cost Americans are paying out of pocket for health care (Kovner & Knickman, 2011). Many Americas are also unhappy with the way the medical insurance companies seem to rule the health care system. This also makes people unhappy about the quality of care they are receiving. It can be difficult to get an insurance company, such as an HMO company, to pay for a surgery or procedure that a person needs (Kovner & Knickman, 2011).

When President Obama first became the nation’s leader he instantly wanted to do something about the health care problems that many Americans experience. His solution was to create the Affordable Care Act of 2010, commonly known as Obama Care. The goals of this policy are to reduce the number of uninsured, pay for coverage without adding to the nation’s budget deficit, slow the rising cost of health care more generally, and encourage a more efficient and higher value health care delivery system (Kovner & Knickman, 2011). Due to the complexity of this policy it will not fully go into effect until the year 2014. By 2014 the main goal of this policy is to require nearly all Americans to have some form of health insurance or they will have to pay a penalty in their taxes, whether this is constitutional or not is still currently up for debate (Kovner & Knickman, 2011). Mexico and the United States are both trying to fix the current problems in their health care systems. Both countries are going about doing this by health care reform with new policies. Both policies hope to provide more coverage to those who were previously uninsured. Not only will more coverage be obtained but people will have healthier lives because of the extended coverage. Enacting new policies always takes a great number of years and finances, although both of these programs are doing well so far, there are still some issues that will need to be resolved with additional health policies.

Financing Health Care/ Cost of Health Care
During an investigation involving the system of the national health accounts, Mexican officials acknowledge the outcome of the results, which revealed that more than half of the health expenditures were from out of pocket costs. The appalling results of the investigation were connected to the majority of citizens who were uninsured, approximately half of Mexico’s population. These additional out of pocket expenses were causing disastrous financial burden on roughly three to four million Mexican families. Likewise, these expenses are a major concern for many American families. Reported in 2008, a family household could end up spending 6% of their monetary income on healthcare. Consistently each year, there has been a 4% to %5 increase in the out of pocket costs for Americans even though their household income would roughly increase by half this rate (Kovner & Knickman, 2011)
Due to the poor results from the investigation by the system of national health accounts, policy makers from the Ministry of Health (MoH) centered their attention on the healthcare system finances. The results from the MoH analysis lead to the endorsement of a major legislative reform concerning healthcare coverage called the Sistema de Protession Social in Salud (SPSS). Before the SPSS, the Mexican government had set up the social right to health protection two decades before the SPSS policy was formed. However, even two decades ago not all individuals had been equally able to use health care (Frenk et al., 2006).

The financing of the SPSS will be achieved over a seven year period by increasing the gross domestic product by 1% each year (Flenk, Gómez-Dantés & Knaul, 2005). This increase in public funding will allow the policy to help in assisting the 40 million Mexicans who were previously excluded from health care insurance. These individuals ultimately will be given publicly provided health insurance which will be subsidized. In the United States, the Affordable Care Act of 2010 is very similar to what Mexico’s government achieved with SPSS. A difference between the goals of the SPSS and the Affordable Care Act of 2010 is the amount of uninsured citizens who are provided healthcare coverage. Unfortunately, the ACA will not accomplish their goals since the policy will only insure 32 million of the 50.7 million uninsured Americans (Kovner & Knickman, 2011).

Until all sections of the Patient Protection and Affordable Care Act of 2010 are approved, the “safety net provider” will still exist for the millions of American citizens without money and healthcare insurance. These individuals can try to get their medical care provided through free clinics and other health agencies that help the uninsured. In addition, there are state laws that require providers to “give charity care and the insurance system, especially public insurance, gives providers some money to help reimburse them for the charity care they deliver” (Kovner & Knickman, 2011). A significant amount of Mexico’s population was already receiving healthcare through the MoH centers. The finance for the MoH centers came from a combination of federal government, state government and fees paid by the patient at the point of treatment. These citizens were being treated on a welfare basis and their benefits could vary extremely depending on the geographic location of the MoH centers. The main reason for this discrepancy had to do with the fact that the benefit package provided by MoH was not clearly defined for the people. For instance, an individual may have more choices of care in a larger city due to the wealth of the northern states versus the basic set of preventive interventions offer to the poor in the rural south (Flenk, Gómez-Dantés & Knaul, 2005).

Similar to Mexico’s financing of their MoH, in the United States, it is the responsibility of the states and federal government to finance the Medicaid program, which also included welfare up to 1966. Congress decided to separate welfare from Medicaid. The decision was based solely on decreasing the amount of people who would be eligible for Medicaid in each state. Under the new 2010 reform law, Medicaid will be extended to all individual less than 65 years of age. These individuals will have to show an income that is equal to 133% of the federal poverty level (FPL), which is based on their personalized gross income. Though the federal government will continue to fund Medicaid, there are certain specifications on the percentage of funds the states would receive depending on the year. Case in point, states will “…receive 100% federal funding for 2014 through 2016 and 95% federal financing in 2017…” (Kovner & Knickman, 2011, Appendix, p. 366). The SPSS funding is separated into the health related public goods and community health services. The separation of these funds helps to prevent the misuse of the budget. The health related public goods integrate the stewardship functions. The stewardship functions are financed through the Ministry of Health (MoH). The amount allocated remains the same because the finances provided are from the customary budget of the past. The community health services are being funded by a new federal and state government budget. The new resources for the community health services are to be used solely for financing public health activities.

As per personal services funding, an individual would have to deal with the uncertainty of additional insurance claim costs. This led to the creation of the Seguro Popular (SP) also known as the public insurance scheme (PHI). The Serguro Popular is the “insurance instrument devised to finance these services under the reform” (Flenk, Gómez-Dantés & Knaul, 2005). There are two components to this program as a result of the funding; they are the essential package and high-cost tertiary package. The essential package is administered through funds at the state level, while the high-cost tertiary care is financed through the Fund for Protection against Catastrophic Expenditures (FPGC) at a national level. The SP, which was created by the Federal Government, is considered a voluntary family health insurance program for the citizens who are uninsured. The membership process for this program took place from 2004 to 2010, in anticipation that at least “…14.3 percent of the 11 million families that make up the uninsured population will be included each year” (Knaul & Frenk, 2005). SP is primarily being finance by the federal government as a social contribution. Once the spending cap is reached, it is the mutual financial responsibility of the federal and the state government to provide additional financing. Furthermore, the funds are given to each State under certain condition before it is implemented. Ultimately this program was designed to be for those well below the poverty lines as a pledge to those needing healthcare (Homedes & Ugalde, 2009).

There are other requirements such as a family contribution to the SP. These individuals are evaluated according to a sliding scale (Homedes, & Ugalde, 2009). On the other hand, these same costs are being waived for families within the parameter of the two lowest income brackets and for the families who have a child under the age of 5 years. If families are not affiliated by the end of 2010, they are still entitled to receive care through public providers. These families, however, will be required to pay a fee for the time care is delivered. In the United States, there is the Medicaid Children’s Health Insurance Program (CHIP) insurance program which contributes by helping out the lower income Americans. Similar to the program in Mexico, there are requirements by the state and federal government. An individual is denied or accepted into this program according to their income. This program is financed by the state taxation revenues collected and the federal government in returned matches the state’s contributions. Other types of health care insurance in Mexico are the Instituto Mexicano del Seguro Social (IMSS) and the Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE) are both financed by means of collective contributions (Frenk et al., 2009). These two systems use a tripartite analysis for monetary responsibilities and rights. The financial subsidy for these agencies are obtained through “…(i) general taxes, (ii) the employer (with the government being the employer in the case of ISSSTE), and (iii) the employee (in the form of an amount tied to income)” ( Frenk, Gómez-Dantés, & Knaul, 2009).
The Instituto Mexicano del Seguro Social (IMSS) is a medical insurance system that is in place for employed individuals and their dependents. The employers for these individuals also have to equally contribute to the IMSS coverage, along with the federal government. However, the IMSS program excludes the employees who work for the federal, state and local governmental agencies. These individuals are covered under the Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE).

There are two similarities to the tripartite analysis used by Mexico. In the United States, the health care programs run by the federal government are funded by the sum of all the payrolls taxes generated by employees and the employer’s matches the percentage of taxes taken out of the employee’s income. There are certain requirements for an individual to qualify for Medicare. For example, according to Kovner & Knickman (2011) a person qualifies for Medicare if they are a U.S. resident for a certain amount of years, which also includes paying Social Security/ Medicare taxes for ten years. Yet, if a person does not meet these requirements they do have the option of paying a premium towards their insurance. In addition, there are other government financed health care programs available to a specific population in the U.S. For instance, the Defense Department provides care for retirees and their families, allowing these individuals the ability to obtain free healthcare as it is available. There is the Veteran Health Administration (VHA) which is essential in providing care to veterans, their dependents and survivors who are qualified. VHA finances come from general taxation revenues collected. In addition, there are some veterans and/or services that would required a co-payment. Currently there are about 70 million citizens in the United States who are considered eligible for coverage by the VHA. There are roughly 3.3 million American Indians and Alaska Natives in the United States. The Indian Health Service (IHS) provides inclusive health care services to nearly two out of the 3.3 million citizens within the 565 federally approved tribes. According to the U.S. Department of Health and Human Services (2011), “overall, over 50% of the IHS budget authority appropriation is administered by Tribes, primarily through Self-Determination contracts or Self-Governance compacts.”

There is an insurance system called workers compensation for employed individuals. This insurance coverage is in place to protect workers against medical care and loss of income caused by work related accidents and/or illness. Workers compensation programs are individually operated by each state.
The private sector in the U.S. is operated differently from Mexico’s. Privately financed health care in the United States revolves around the employers-based insurance and individual insurance market. There is a tax deduction incentive for employers to provide health care coverage to their employees. Unfortunately, there has been a decline in the percentage of Americans who are receiving employer-based health insurance due to the increase in healthcare costs. The 2010 Reform Act is requiring that employers with greater than 50 employees should offer their employees private insurance or else they will have to pay a penalty. In 2008, there were approximately 16 million out of 160 million individuals who purchase health coverage for themselves and their families, over and above their employer based insurance. The Individual Insurance Market provides coverage’s for those people who are not covered by their employers or are between jobs or are self-employed depends. Regrettably, these individuals are paying a higher premium and the benefits packages are substandard (Kovner & Knickman, 2011). In the United States, there is the Consolidated Omnibus Budget Reconciliation Act (COBRA). This program gives a worker and their families the opportunity to continue with their benefits for a limited period of time, during a life changing events such as divorce, death, transition between jobs, etc. The U.S. Department of Labor (2011) stated that a person who is qualified for COBRA “…may be required to pay the entire premium for coverage up to 102 percent of the cost to the plan.” Even though this may seem like a pretty high cost for health insurance through COBRA, this is still a lower amount when compared to the private insurance market (Kovner & Knickman 2011).

There are many factors that must be considered when comparing two countries health care cost without prejudice. For instance, a country’s population and the cost of living may differ from each other. Each country also has a certain amount of money that is used as the total spending in health care for any given year. The total spending that countries use is a percentage of the country’s gross domestic product (GDP). The population of Mexico for 2009 was 109,610,000, with a gross national income that was $14,340 per person. According to the World Health Organization (2011), the total expenses on health per capita in Mexico in the year 2009 was $836, while the total expenditure was reported as 6.5% of the gross domestic product (GDP). Currently there are indications that the increase in public funding, due to the Sistema de Proteccion Social en Salud policy, will eventually lead to a decrease between the public and private financing of the national health system. However, in 2010, the GDP was reported to be 6.1% by Organization for Economic Cooperation and Development (OECD) statistics, which does not make for much of a decrease.

The finances for healthcare in Mexico are separate into personal health services and clinical health services or health-related public goods. The federal resource funds are divided into four components which are the stewardship role of the Ministry of Health, community health services, non-catastrophic personal health services and lastly, the catastrophic, high-cost personal health services. These financial innovations were implemented to protect the public health interventions against any neglect and abused of financial resources and to distribute the correct amount of finances to meet the demands of health care. According to the OECD (2011) 2009 statistics for health expenditure the finances were split so that 5.1 million dollars went to Ancillary services to health care, 250 million went to Medical goods dispensed to outpatients, 99.1 million to Health administration and health insurance, 879.4 million to total current expenditure, and 918.4 million accounted for total expenditure. In addition, a large portion of the extra public resources were paid to institutions that are providing care to the populations without access to social security, which included the Seguro Popular clients. The budget for MoH increased to 69% in factual terms from 2001 through 2006. The increases in the MoH budgets were used to virtually cover all of the interventions involving the demands of the MoH outpatient units and the general hospitals. Overall there was a 35% increase in the budget for the IMSS and the ISSSTE budget was increased to 45%.

The funding for the SP is separated into federal and state governments. The Funds for Protection against Catastrophic Expenditure (FPGC) are used to cover certain packages of service. These services were chosen for their price, helpfulness and common satisfactoriness criteria. The FPGC funding comes from 8% of the federal social contribution and state solidarity contributions. A second 2% from the sum of social quota, including the federal and state contributions, is used to help built health infrastructures in poorer communities. Lastly, there is a third fund for emergency which is worth 1% of the total is intended to cover unanticipated fluctuations in demand and possible temporary overdue inter-state expenses. So far, there are 18 health interventions by the FPGC which includes neonatal intensive care, management of pediatric cancers, cervical cancer, breast cancer and HIV/AIDS. In addition to the FPGC there are three master plans regarding investing in infrastructure, medical equipment and human resources. The remains of the social allowance and cohesion contributions are allocated to the states. The states use these funds towards the essential packages of health services provided by the PHI. The first plan for infrastructures are use to assist in providing a long-term outline that would increase the availability and capacity for health care. It was noted that there were 1792 new health care building built by the year 2006, which included four high-specialty regional hospitals. The second plan incorporated the National Center for Excellence in Health. They are involved in the creation and execution of new medical equipment. Their plan focuses on “strengthens the maintenance producers for medical equipment and rationalizes the adaption of new technology through evidence-based assessment” (Frenk, et al., 2006). As for the last plan regarding investment in human resources, the objective was to focus on increasing the medical and nursing capabilities needs for the issues going on in the rural areas. These issues were connected to the epidemiological changes occurring and the unemployment rate in the medical labor market. This plan called for an increased amount of doctors and other healthcare workers in state funded institutions (Frenk et al., 2006). After the results from the plans were analyzed, an estimate regarding the amount of supplies needed will be assessed, which would help human resources. Only then will human resources be able formulate a plan of suggestions to help train the institutions and public providers.

In the United States, the total population of people reported was 314,659,000 in the year 2009. The gross national income per person was $ 46,790, which was declared by the World Health Organization (2011). In 2009, it was reported that a person spend $7,410 in total expenses regarding health. According to OECD (2011) the total expenditure on health a people spend in GDP in the year 2009 was 17.2%.
As for PPP per capita in US$ in 2009 (OECD, 2011):
• services for rehabilitative and curative care were $5278.8
• services for long-term nursing care was $446.7
• medical goods dispensed to out-patients was $1069.7
• prevention and public health services were $271.6
• health administration and health insurance were $531.5
• total current expenditure was $7598.3
• capital formation of health care provider institutions was $361.7
• total expenditure was reported to be $7960

In the United States, the federal government funds roughly 50% through 78% of the Medicaid program costs. According to Kovner & Knickman (2011, p. 29) in 2007, “…the various Medicaid programs covered roughly 58 million Americans at an annual cost of just under $339 billion (Kaiser Family Foundation, 2010, p. 29, (1)). There are approximately 47 million elderly and disable American citizens who are covered under the federal health insurance plan called Medicare. It was reported by the Kaiser Family Foundation (2010) that 12% of the federal budget is allocated to Medicare, which was expected to be amount to a total of $509 billion. These funds are used to help pay for hospitals visits, physician visits, prescription’s drugs, acute and post-acute services for the qualified citizens. The VHA received $41 billion to help serve their population. These funds are used to own and operate “153 medical centers, 788 outpatient clinics, and 232 counseling centers (VHA, 2010, (2))” (Kovner & Knickman, 2011, p.39). There are more than 1,500 public general hospitals throughout the United States owned and operated by the local government. The funds for these facilities consist of roughly two thirds of the revenue collected from the state and/or local governments. There is a possibility that it would also include funding from the public insurance coverage. In 2009, the total national cost was expected to be 2.6 trillion dollars. This money was predicted to be distributed, where 84% of it will pay for personal health care services to individuals. The 84% will include services provided by hospital care, physician services, clinical services, assisted home care and prescription drugs. The rest of the funds from 2.6 trillion will be used towards public health services, researches, and administration costs.
The cost of health care in Mexico is reported to be lower when compared to the United States of America. Some south California insurers have developed certain insurance policies that allowed a patient to seek treatments in Mexico (Health Care Financial Management, 2009). These treatments can be done for considerably less in Mexico when compared to the United States, including the cost of travel for the individual. For instance, it would cost $38.72 for a vasectomy procedure in Mexico (Seamans & Harner-Jay, 2007). In the United States, it would cost approximately $713 for a vasectomy according to Trussell, et al., (2009). Another procedure we could compare is the cost of hip fracture. In Mexico it was estimated in 2006 to cost at least US $4,365.50 per case for a hip fracture(Clarke, et al, 2008) versus $33,000 by the Veteran Affairs (National Center for Patient Safety Toolkit, 2008). There were nine hospitals in Mexico that were accredited from 2008 through 2010 by the Joint Commission International (JCI). The San José Tec de Monterrey hospital was the only hospital accredited in 2011by the JCI, until this facility voluntarily withdrew as of January 6th, 2011. In both counties, healthcare access is being evaluated by the policy makers and is considered available for every individual. No one is denied access to care, if they are capable of paying for it through insurance or contribution from governmental agencies, charitable donations, or out of pocket.

Role of Public Health
Public health, regardless of the country, regards the community as its patient. The overall goal of a public health system is to maintain the health of the community in terms of prevention before disease or injury occurs. The mission of the National Institute of Public Health (Instituto Nacional de Salud Publica (INSP)) of Mexico is to make a contribution to social equity by means of improving the health of Mexican citizens and promoting it throughout Latin America through education, training, and innovative health systems. It is the belief of the INSP that public health is the responsibility of each state. Initially, in the 1920s, Mexico’s federal government was charged with the responsibility of public health which included training those involved directly with the health of the public. The School of Public Health tracked epidemiological statistics, prevention, and health promotion programs fell under the school’s jurisdiction. In 1987, the INSP was formed to oversee the states, their health regulation, promotion activities in addition to assuring, and developing a more equitable and efficient health system. Today, the INSP is broken up into the following major departments, Center for Infectious Disease Research, Center for Health Systems Research, Center for Population Health Research, Center for Nutrition and Health Research, Center for Assessment and Surveys Research, Regional Center for Public Health, and the Research Center for Information on Public Health Decisions.

The roles of the public health system are quite similar to those found here in the United States. This is due in part because both countries follow the basic program outlines set up by the International Association of National Public Health Institutes (IANPHI). Though both the United States and Mexico came into the realm of public health through different avenues, both countries are members of the IANPHI thus the goals of the INSP and the U.S. Department of Health and Human Services as well as Mexico’s Ministry of Health are essentially the same: to prevent disease and promote health while making services accessible to as many as possible (Mexico 1b, 2011).

Despite the United States not currently having a widespread socialized health program (though some would argue the Medicare and Medicaid fall under the heading of socialized medicine), Mexico’s socialized medicine is run by the Secretariat of Health. This individual is a member of the Executive Cabinet and is appointed by the President. Otherwise all other health responsibilities are transferred to the individual states. Similarly, the United States has a comparable breakdown; at the federal level there is the U.S. Department of Health and Human services from which other offices, such as the CDC branch off from. Public health clinics are the responsibility of the state or even the county level. The American equivalent of the Secretariat is a hybrid between the Surgeon General and the Secretary of the Department of Health and Human Services. Both the Surgeon General and the Secretary of the Department of Health and Human Services is appointed by the President although the Surgeon General tends to have the final word on public health in the U.S.

Like the United States, Mexico has a similar break down to regional public health services through Instituto Mexicano de Seguro Social (IMSS). There is a tiered system that everyone must go through seeking medical care, who is covered by the national system: the first tier is the family care clinics, the gateway to the rest of the health system in the non-emergency sector. There are no standards as to the technology so the amount of services (labs, x-ray, etc.) varies greatly. However, all of the clinics have a pharmacy on site. Each clinic is assigned to a regional hospital, the second tier in the system, where patients are sent to see specialists. Patients are encouraged to stay within their assigned regional hospital, but there are exceptions made for emergencies. As with clinics in the United States, they are not equipped to handle emergencies. Public health is something that is guaranteed to citizens in their constitution which was modified in 2003 to include health care for those who are unable to afford private health insurance which were those who didn’t fall under the traditional umbrella of Mexican public medicine. Passed by a large majority of Congress in Mexico, the government will increase public funding by a full percentage point of gross domestic product (GDP) over a period of seven years to provide universal health insurance, which will benefit the 50 million Mexicans who have been excluded until now from formal social insurance because they are self-employed, are unemployed, or work in the informal sector of the economy (manual labor, service industries, etc.) (Frenk & Gómez-Dantés, 2009). This echoes the roughly 58 million people in the United States who, until the passing of the Affordable Care Act of 2010, were also without coverage, relying solely on free clinics and Emergency Rooms for care (Kovner & Knickman, 2011).Some of the largest steps in public health prevention lie in the smoking realm. On 26 February 2008 Mexico’s congress passed the largest smoking law to date, banning smoking in public places which includes restaurants, public buildings, schools, bars, offices, and night clubs. Despite these places still needing to provide smoking areas, this is a prime example of INSP working to prevent diseases associated with smoking and people being exposed to the secondhand smoke. Similarly, in September of 1999, a lawsuit was filed by the United States against the major cigarette manufacturers and two industry affiliated organizations (Litigation against Tobacco Companies, n.d.). This lawsuit was the byproduct of public health pushing for more and more tobacco free work and public places, though technically it was a lawsuit to prove wrongful death, injury, and medical expenses as a result of tobacco use (United States Department of Justice, n.d.). It would not have been possible to prove this without the tracking of public health entities such as the CDC.

One of the greatest recent successes in the Mexican public health system, in respect to both prevention and treatment, was evident with the onset of the influenza A (H1N1) outbreak. In 2003, a National Preparedness and Response Plan for an Influenza Pandemic was developed, focusing on risk communication, health promotion, healthcare, epidemiological surveillance, strategic stockpile of medications and vaccinations, research and development was put into law (Córdova-Villalobos, Sarti, Arzoz-Padrés, Manuell-Lee, Méndez & Kuri-Morales, 2009). The plan was structured around the lessons learned from an influenza pandemic that occurred in 1918-19 during which time 40 to 100 million people died (20-30% of the world population at that time). During the H1N1 outbreak, the regional clinics and their related hospitals noted a sudden spike in upper respiratory infections; this in turn triggered an epidemiologic alert which included public service announcements such as “sneeze etiquette” and reminders for citizens to wash their hands as well as to take other precautions. Under the World Health Organization’s International Health Treaty of 2005 (Fiedler & Baker, 2006), samples of the virus were sent to the Centers for Disease Control as well as to the Winnipeg lab in Canada (Córdova-Villalobos, Sarti, Arzoz-Padrés, Manuell-Lee, Méndez & Kuri-Morales, 2009). This was Mexico’s public health community and system reaching out to the world to inform about the pandemic setting up for the perfect storm. Thanks to the monitoring of the population in Mexico, the Secretariat of Health was able to turn what had the possibility of causing widespread disease throughout not only Mexico, but the Americas, to a managed epidemic. The United States public health systems responded in a similar way, making vaccinations first available to those at high risk, namely first responders and healthcare workers, and each state dispersing the vaccine as they were able and saw fit. Like Mexico, the media played a key role in reminding people of the above mentioned sneeze etiquette and other preventative measures.

Conclusion
Mexico has had its share of growing pains in relation to the development of a healthcare system that covers all Mexicans. Like the United States, those without insurance will have to pay for services out of their own pockets. Mexico made a large leap forward to cover her citizens with the 2003 law change providing those who were not covered by private or public insurance to have that coverage. Our neighbors to the south may be ahead of us in terms of citizen coverage, but the 2010 Affordable Care Act is a step in the direction to have our citizens protected from enormous healthcare bills. Public health is something that has proven to be an important aspect in both countries. Without a stable public health system in place within both Mexico and the United States, since we share a border there would be a stronger chance for epidemics to turn into pandemics causing both nations to have their healthcare systems stressed, if not running the risk of collapse. Though many people may discount Mexico as a second world country with shoddy healthcare, the exact opposite is the case considering Mexico shows more concern for the health and personal finances for its citizens. Healthcare isn’t a commodity in Mexico as it is in the United States; Mexico has been reminded that healing is an art.

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