Almost one-half million Mexican immigrant adults living in California were estimated to have travelled to Mexican for medical care, dental care, or prescription drugs, half of whom travelled over 120 miles to do so. Consistent predictors of seeking cross-border care included living near the border (i.e., availability of care in Mexico), having no health insurance (accessibility barriers in the U.S.) and acceptability issues. These findings suggest health-related services in Mexico serve as an important safely valve for significant numbers of Mexican immigrants in California who face accessibility and acceptability barriers.
Health status needs, including self-reported health, is strongly associated with physician and other medical care use in the U.S. among Mexican immigrants (35
). But in this analysis, self-reported poor health modestly reduced
the likelihood of seeking medical care and prescription medications in Mexico, while chronic conditions increased it. One explanation is that immigrants with the worst self-reported health may have been too sick to travel to Mexico. Immigrants with common chronic conditions often need on-going medical attention where the interpersonal quality of care in Mexico may have been more important and they may have been healthy enough to travel for care (36
). Gender was not associated with medical or prescription drugs in Mexico, despite higher needs by women of reproductive ages. California’s Medicaid coverage for all low-income pregnant women, regardless of immigration status lowers accessibility barriers, and immigrant women’s desires to deliver their babies in the U.S. for citizenship purposes adds an incentive to remain in California (37
While distance to the border, indicating availability of care in Mexico, was associated with use of services in Mexico, many Mexican immigrants hundreds of miles from the border reported seeking cross-border care. They may have made opportunistic or emergency use of health services during vacations and other trips back to Mexico. In other words, some Mexican immigrants may have crossed the border for reasons other than seeking services such that service use was incidental to the initial purpose of their visit. An early study of health care among Mexican immigrants in San Diego found that about half of care received in Mexico was in the nearby border town of Tijuana and half in the immigrants’ other hometowns and elsewhere (38
). The interaction effects with distance indicated that Mexican immigrants who lived farther from the border had a greater odds of seeking medical care in Mexico if they had no usual source of care, suggesting that some long-distance travel to Mexico that included medical care was motivated in part by health care needs.
Accessibility barriers to U.S. health care decreases Mexican immigrants’ U.S. health care use (1
). Our findings suggest that the uninsured displaced some care to Mexico where it was cheaper, although the effect was weaker for medical care among short-stay immigrants. Poverty’s lack of effect on medical or prescriptions may have been due to the costs of travel to Mexico offsetting the financial savings of that travel. Delay in seeking care, marital status, and noncitizen had the predicted effects. When including the interaction effects, no usual source of care also increases the use of medical care in Mexico, but the effect may be larger away from the border if some who are close to the border consider care in Mexico as their usual source.
The acceptability of available U.S. care also influenced seeking cross-border care. LEP significantly predicted use of services that involved extensive interpersonal contact (medical and dental), but not more retail-style purchases (prescriptions). This can be due to simple communications barriers with U.S. providers or by a deeper cultural congruence with providers in Mexico. Use of nonphysician providers may be a function of respondents seeking out alternatives to allopathic medical care due to culture, or it could be another indicator of need.
We found that short-stay Mexican immigrants were less likely than long-stay immigrants to seek services south of the border in the descriptive data. After controlling for covariates, however, short-stay immigrants had two to four times greater odds of using services in Mexico, which may be driven by a greater familiarity with services in Mexico and a lack of awareness of options for low cost care in California. In fact, short- and long-stay immigrants differed in several predictors of seeking care in Mexico which suggests that short-stay is also another proxy for undocumented status. LEP probably increased the odds of going to Mexico services only for long-stay immigrants because those immigrants were more likely to have immigration papers which made it easier to obtain linguistically matched care. Non
-LEP increased the odds for prescription drugs only for short-stayers; recent immigrants with good English abilities may be more likely to have immigration documents. Similarly, the lower odds of travel to Mexico for short-stay immigrants who are uninsured for medical care, live further from the border for dental care, and delay seeking prescriptions are all consistent with an immigration barrier explanation. The cost and/or risk of detection is high for undocumented immigrants attempting to return to California after visiting Mexico; a disproportionate number of recent immigrants do not have immigration documents that would allow them easier passage across the border (40
). Thus, immigration status for short-stay immigrants may be a greater barrier for obtaining medical services in Mexico than in the U.S. where the perceived risk of detection is less given the availability of storefront and other private providers in Mexican immigrant communities (41
At the time of this survey, it is likely that few respondents had insurance coverage for the care they received in Mexico because cross-border health insurance in California had just begun. The significant numbers of immigrants crossing the border for services, and the barriers they faced in accessing services in the U.S., suggest that cross border health insurance might improve the ability of some Mexican immigrants to access care in Mexico. The accessibility and acceptability features of existing cross-border plans – lower cost, access to Spanish-language and Mexican culturally consistent care (21
) – are consistent with the factors associated with seeking care in this study. Cross-border plans have had only a modest success when marketed to employers at the border (23
). However, a recent study found that Mexican immigrants had a high willingness to pay out-of-pocket for lower-cost family insurance that used public sector (versus private) facilities in Mexico (42
). For binational insurance to expand it will likely need: (a) to change from the more expensive private sector to less expensive public sector providers in Mexico, (b) be subsidized to make it more affordable, or (c) be offered through an employer mandate. The last two approaches are consistent with efforts to expand coverage in California (43
There are several factors that have likely affected the dynamics of border crossing for health care since the 2001 data reported here was collected. The introduction of binational private health insurance, noted above, will have promoted border crossing. In addition, Mexico initiated a new health insurance program that is fully-subsidized for low-income Mexicans, Seguro Popular (44
). Immigrants from Baja Mexico who retain that coverage after migrating to California would have an increased incentive to return for care in Mexico. The significant tightening of the U.S.-Mexico border after 2001, however, would have made it significantly more difficult and expensive for undocumented immigrants to seek care in Mexico (45
). The net effect has probably increased the ability of documented Mexican immigrants to seek care in Mexico and decreased the ability of undocumented immigrants to seek care south of the border.
The limitations of this study include its cross-sectional design, telephone administration, and limited variables on the health care services sought in Mexico. The cross-sectional design makes it impossible to identify causation. The telephone design, while weighted to account for homes without telephones, is likely to under represent migrant farm workers who might seek services in Mexico (46
). However, farm labor is a relatively small part of the total Mexican immigrant labor force in California (47
), creating a slightly conservative bias in our analysis. Some of our variables are proxies. For example, we did not have data on immigration status and used citizenship status as a proxy. Since a substantial number of Mexican noncitizens are undocumented and we expect the effect of citizenship was driven largely by the undocumented (1
). Nevertheless, our results likely underestimated the effect of undocumented status.
Similarly, language is a commonly used yet widely critiqued proxy for acculturation (48
), in addition to being an indicator of communication barriers. With better measures, we would expect to find stronger effects, making our current findings conservative. The most significant limitation is that we only have data on whether the respondent received any care in Mexico. It would been useful to know the purpose of the health care visit(s), and the frequency, location, and payment method of the visit(s). Additional data would allow us to understand care-seeking behaviors for chronic versus acute conditions and the broader set of issues important for the Mexican immigrant population in accessing U.S. health care services.