INVESTIGACIÓN ORIGINAL ORIGINAL RESEARCH
Utilización transfronteriza de los servicios de salud por residentes en los Estados Unidos que viven cerca de la frontera con México
Theresa L. ByrdI; Jon G. LawII
IUniversity of Texas-Houston, School of Public Health, El Paso, Texas, United States of America. Send correspondence to: Theresa L. Byrd, UTSPH, 1100 North Stanton, Suite 110, El Paso, Texas, 79902, United States of America; fax: +01-915-747-8512; email: Theresa.L.Byrd@uth.tmc.edu
IIPaso del Norte Health Foundation, El Paso, Texas, United States of America
OBJECTIVES: To determine what proportion of El Paso (Texas, United States of America) residents access health care services in Mexico, which services they use, and why they cross for care.
METHODS: A cross-sectional, telephone survey of El Paso County residents was conducted from October-November 2007 to determine use of health care services in Mexico. At total of 2560 telephone interviews were completed. Descriptive statistics and Chi-square analysis were used to determine the proportion crossing the US-Mexico border for care and identify correlates of crossing.
RESULTS: The proportion of El Paso residents that had crossed into Mexico for some type of health care service during the two years prior to the survey interview was 32.5%. Of border crossers, 27.1% used health services; 63.2%, dental services; 82.0%, pharmacy; and 9.8%, traditional healers. Reasons given were cost, lack of health insurance, language barriers, and convenience. Hispanic ethnicity, having lived in Ciudad Juárez, being uninsured, and younger age were associated with crossing. The majority were satisfied with the health services received.
CONCLUSIONS: Crossing the border to access health care services in Mexico is not uncommon for US residents living in El Paso County, Texas. Given the high rate of uninsured in the United States and the increasingly stringent security requirements, health policies may be needed that allow for cross-border care, making use of this alternative health care system easier and safer.
Key words: Health policies; health care surveys; border areas; Mexico; United States.
OBJETIVOS: Determinar la proporción de habitantes de El Paso (Texas, Estados Unidos de América) que acceden a los servicios de salud de México, los servicios utilizados y las razones para buscar atención del otro lado de la frontera.
MÉTODOS: Se realizó un estudio transversal mediante encuesta telefónica a personas residentes en el condado de El Paso. La encuesta se aplicó a 2560 personas entre octubre y noviembre de 2007 para determinar el uso de servicios de salud en México. Se utilizaron métodos de estadística descriptiva y la prueba de la c2 para determinar la proporción de personas que cruza la frontera de los Estados Unidos hacia México en busca de atención sanitaria e identificar los factores relacionados con ello.
RESULTADOS: La proporción de habitantes de El Paso que han cruzado a México en busca de algún tipo de atención sanitaria en los 2 años previos al estudio fue de 32,5%. De los que cruzaron la frontera, 27,1% utilizaron servicios médicos; 63,2% servicios estomatológicos; 82,0% farmacéuticos y 9,8% curanderos. Las razones ofrecidas fueron: el costo, no tener seguro de salud, las barreras idiomáticas y la conveniencia. Los factores asociados con el cruce de la frontera fueron ser hispano, haber vivido en Ciudad Juárez, no tener seguro y una menor edad. La mayoría se manifestó satisfecha con los servicios de salud recibidos.
CONCLUSIONES: Entre los residentes del condado de El Paso, Texas, es frecuente el cruce de la frontera para acceder a los servicios de salud de México. Dada la elevada proporción de personas sin seguro médico en los Estados Unidos y los requisitos cada vez más rigurosos para obtener un seguro, se necesitarían políticas de salud que permitan la atención sanitaria transfronteriza, con el uso de un sistema alternativo de salud más fácil y seguro.
Palabras clave: Política de salud; encuestas de atención de la salud; áreas fronterizas; México; Estados Unidos.
Disparities in access to and utilization of health care services in the United States of America (US) have been a topic of discussion and debate among policymakers for many years. Many would consider the utilization of health care to be an individual choice; however, public health practitioners recognize that individual behavior is enmeshed in social, environmental, political, and cultural contexts. Bastida and colleagues have referred to this ecological model regarding the use of health care services in Mexico by US residents (1). Clearly the decision to seek health care and where to seek care is not simply personal preference; cost, insurance coverage, availability of services, and public policies that allow or prohibit access to services are influential factors.
The United States Department of Transportation has estimated that in 2006, approximately 225.5 million individuals crossed into the US from Mexico in either a personal vehicle or as a pedestrian (2). Several studies have shown that individuals crossing the border northbound are US residents who live near the border area and are returning from medical treatment and/or purchasing medications at a pharmacy in Mexico (3-10). Possible reasons why US residents utilize medical services in Mexico are: affordability, different prescription requirements, and cultural preference (3-5, 7-9). A high proportion of residents in US border counties lack any kind of health insurance coverage. It has been estimated that in Texas border-counties, 40.7% of all residents over age 18, and 46.1% of Hispanic residents, had no health insurance whatsoever (11). Not having insurance may be an important correlate of cross border care utilization (5).
This phenomenon has multiple implications. Individuals accessing treatment in Mexico may be receiving concurrent treatment by a provider in the United States, potentially leading to duplication of diagnostic tests and/or counteractive effects between medications prescribed by the different providers (4). As policy actions to improve health care access are being considered, US residents of the US-Mexico border area have the benefit of proximal access to a second health care system. To the extent that US residents are comfortable utilizing that system, policies may be developed that make using more than one health care system more affordable, easier, and safer.
The literature on cross-border utilization of health care services is emerging. Multiple studies have gathered data using purposive sampling methods (3, 4, 7, 9). The relevant studies using probability sampling methods are embedded within broader studies. The small number of survey items included in these studies limits the scope of their analyses (5-6). There are some studies looking at the purchase of pharmaceuticals in Mexico, but there are few that also explore the use of other health care treatment, such as medical or dental services.
The purpose of this study was to determine the proportion of El Paso residents accessing health care services in Mexico, what services they are utilizing, and why these individuals choose to cross the border for those services. El Paso County is a valuable sample population to study this phenomenon because of its contiguousness with Mexico, a high proportion of uninsured individuals, and the absence of a Texas state law, such as California's Knox-Keane Act, that allows health insurance to cover medical treatment in Mexico.
MATERIALS AND METHODS
A cross-sectional, telephone survey of El Paso residents was employed to determine use of health care services in Mexico. The 40-item survey was developed by the authors using both existing and new items (12). The survey was conducted in October-November 2007. The process used a list-assisted, random-digit dialed sample of telephone-equipped households in El Paso County, Texas. Eligible participants were defined as adults (18 years of age or older) residing in El Paso County. The Centers for Disease Control and Prevention (CDC) telephone data collection and quality assurance procedures were followed. Respondents were interviewed in the language of their choice (English/Spanish).
A total of 2 560 interviews were completed. Two measures of response rate recognized by the CDC for random-digit dialed surveys were utilized. These are the Behavioral Risk Factor Surveillance System Survey Questionnaire (BRFSS) and the BRFSS Overall response rates (13). These rates were 41.8% (BRFSS) and 22.6% (Overall). These numbers are consistent with CDC recommendations for surveys with similar call and selection protocols (13). Each respondent was asked early in the interview about use of health care services in Mexico. If the response was that they had not used services in Mexico in the last two years, the interview was ended. If the response was affirmative, the interviewer obtained data regarding what services were used, why the respondent chose to cross the border for these services, and what the level of satisfaction was. Demographics were also collected (age, ethnicity, gender, educational level, and health insurance status).
Two datasets were entered into a statistical program; an unweighted dataset and a weighted dataset. The unweighted data were analyzed using descriptive statistics (means and proportions) and Chi-square analysis to determine the percent of the sample crossing the border for health care and to assess correlates of border crossing. Weighted data were used only to estimate the percentage of the El Paso adult population crossing the border for health care services. Preliminary weights were constructed to correct for differential probabilities of selection of both households and members within households. After preliminary weighting, post-stratification weights were also applied based upon ethnicity (Hispanic/non-Hispanic), gender, and age data for El Paso from the 2006 American Community Survey.
Description of sample
The sample was predominantly female, Hispanic, and United States citizens by birth (Table 1). The age of the participants' ranged from 18-99 years, with a mean age of 67 years. Almost one-third (30.5%) of the sample reported speaking only Spanish or mostly Spanish; 40.5%, speaking only English or mostly English; and 29.0%, speaking both languages equally well. The majority were born (61.6%) and educated (74.0%) in the United States. Most had some type of health care coverage, though 32.6% reported no coverage. Of those educated in the United States, 3.0% reported having 8 years of schooling or fewer; 34.8%, some high school; 33.4%, some college; 18.4%, a bachelor's degree; and 10.5%, some graduate study. Of those educated in Mexico, 4.0% reported no schooling; 22.0%, 9 years or fewer; 36.0%, 10-12 years; 16.0%, 13 years; and 22.0%, 14-17 years of schooling. Slightly more than one-third (33.7%) of the respondents reported earning US$ 20 000 or less per year. Thirty percent of participants had lived in Ciudad Juárez, El Paso's bordering Mexican city, at some time, and 37.1% reported having family currently living there.
Crossing the border for care
When asked about crossing into Mexico for any type of health care service (provider visits, hospital visits, dental visits, or pharmacy) during the last two years, 27.1% of the sample indicated having done so, although the majority (88%) also reported mostly using health care in the United States. Of those visiting a medical provider (27.3% of those crossing for any kind of service), the majority (62.2%) reported visiting a private doctor, 30.6% reported visiting a medical clinic, and only 8.9% reported using hospital services. Sixty-three percent said they had visited a dentist in Mexico, 82.0% a pharmacy, 7.9% a sobador (massage therapist), and 1.9% a curandero (traditional healer).
Of those who reported crossing the border for health care, 53.4% reported that they also had a health care provider in the United States. Of those, 46.2% reported that the US-based provider knew about the use of services in Mexico, while only 6.6% said that the US-based provider encouraged use of those services.
Participants were asked a series of questions related to their motivations for seeing a medical practitioner in Mexico; the instrument allowed participants to identify multiple reasons. The most common reason given for visiting a medical provider in Mexico was lower cost (91.9%), followed by ease of getting an appointment (84.5%). Eighty percent said that the reason was that the "doctors speak Spanish in Mexico." Sixty percent reported they had always seen the same doctor in Mexico. Fewer reported that they felt the providers were better (46.4%), that the care was better (40.9%), or that "the medicine is stronger" (58.4%) in Mexico. When asked about their satisfaction with medical care in Mexico, 89.4% reported being "very satisfied" or "satisfied" with the care.
Reasons given for visiting a dentist in Mexico were similar to those for visiting a medical provider. Most common was lower cost (94.6%), ease of getting an appointment (82.5%), the dentist speaks Spanish (79.6%), and convenience (77.0%). Sixty-seven percent reported they had always seen the same dentist in Mexico. Fewer reported that the dentists are better in Mexico (36.7%), that care is better (44.9%), or that "medicine is stronger" (40.4%). Of those receiving dental care in Mexico, 89.2% reported that they were "very satisfied" or "satisfied" with the care they received.
The most commonly used cross-border health care service was the pharmacy. The medications most often purchased by the study participants were antibiotics (79.1%) and "pain pills" (57.8%). Table 2 lists other drugs purchased. The most common reasons given for purchasing medications in Mexico were lower cost (86.5%), more convenient (77.1%), a Mexican physician prescribed the drugs (69.0%), no need for a prescription (55.4%), and "the medicine is stronger" in Mexico (51.8%). Fewer reported that the medicine is better quality (42.5%), a pharmacist in Mexico recommended the drug (45.0%), they had always used the same pharmacist (41.8%), or the medicine of choice was not available in the United States (30.2%).
The weighted dataset was used to determine the estimated proportion of the El Paso population crossing the border for any kind of health care service dur-ing the two years prior to the interview. Table 3 shows the sample percentages and the population percentages for the weighting variables (gender, ethnicity, and age group). According to these data, 32.5% of El Paso residents had crossed into Mexico for some type of health care service in the two years prior to October- November 2007.
The correlates ethnicity, history of having lived in Ciudad Juárez, and health care coverage yielded statistically significant differences when compared to medical and pharmaceutical services, but not in the case of dental services (Table 4). Those who reported Hispanic ethnicity, having ever lived in Ciudad Juárez, or lacking health care coverage were more likely to have crossed into Mexico to use both medical and pharmacy services.
Age was also related to use of services in Mexico, with older respondents being less likely to report crossing the border for any kind of health service (Table 4). This difference was true for both medical and pharmacy services, but not for dental services.
Income was related to use of medical services in that the middle income group-those earning US$10000-25000-were somewhat more likely to use physician services in Mexico than either those in the lowest or the highest income groups. Income was not, however, associated with use of dental or pharmacy services.
A total of 27% of the study participants reported having crossed into Mexico for some kind of health care service in the two years prior to the interview. The majority of these indicated that they were satisfied with the care they had received. According to the weighted data, approximately 33% of the El Paso population had been to Mexico for some kind of health care service in the two years prior to October/November 2007.
As was expected, most reported crossing the border for pharmacy services with cost being a major reason for doing so. Participants in other studies have reported that medications are less expensive in Mexico (3, 4, 9). A minority staff report produced for the United States House of Representatives found that, on average, prices of the top five drugs used by the elderly in the state of Maryland were 95% less expensive in Mexico (14). Danzon (15) also found similar differences in the cost of medication between the United States and Mexico. As an example, a price comparison done in the year 2000 showed that Amoxicillin, a common antibiotic, was US$ 55.51 for 30 tablets in the United States versus US$ 35.00 in Mexico; and Claritin, an allergy medication, was US$ 179.63 for 100 tablets in the United States versus US$ 67.00 in Mexico (16).
Consistent with previous research (17), antibiotics were mentioned most often as a drug purchased in Mexico. Antibiotics are available without a prescription at pharmacies in Mexico. Some pharmacists in the United States have expressed concern that overuse and improper use of these drugs might lead to medical complications and drug-resistance. Casner and Guerra (4), practitioners at a clinic in El Paso, documented severe allergic reactions among individuals taking antibiotics without a prescription. Respondents without health insurance coverage were more likely to report using a pharmacy in Mexico. For people without prescription drug coverage, filling a prescription in Mexico, written by either a US or Mexican physician, might be the only way of getting the medicine they need.
It is interesting that "pain pills" were the second most commonly mentioned drug purchased in Mexican pharmacies. Unfortunately, the survey instrument did not request specifics on the type of pain medication, so data are not available on whether the pain medications were over-the-counter (OTC), such as Ibuprophen and aspirin, or by prescription, such as narcotics. A previous study conducted in 1996 (8) found that of medications declared at the border by persons crossing from Mexico to the United States, the top five were anxiety drugs (Diazepam and Alprazolam), sedatives (Flunitrazepam), stimulants used for weight control (Diethylpropion), and narcotic pain medication (Oxycodone). Although things may have changed since 1996, it is reasonable to expect that at least some of the "pain pills" coming across the border are narcotics. If they are being obtained without a prescription, which would be illegal in Mexico, patients may not be using the proper dosage or may misuse the drugs, but for those in need and without insurance, the availability of low cost drugs may be critical.
The most common reason for seeking a health care practitioner in Mexico was cost. Those most likely to seek pharmacy services in Mexico were those without insurance coverage, of Hispanic ethnicity, and/or former residents of Mexico. It is interesting to note that with regard to seeking care from a physician in Mexico, income was a factor. Those in the middle income bracket, rather than those in the lowest, were somewhat more likely to get medical care in Mexico. This may be because Medicaid, the United States' medical assistance program, is available to the lowest income group, but not to the middle group. In addition to, and consistent with another study (6), older respondents were less likely to cross for care, perhaps because government insurance coverage increases with age (18).
Language was also an important reason for using care in Mexico. Eighty percent of respondents reported that being able to speak to the doctor in Spanish was a reason for getting care in Mexico; and of those, 28% said that they could speak English and Spanish equally well. It may be that when it comes to health care, people feel most comfortable in their primary language, even if they speak and understand other languages. Because having lived in Mexico was also associated with use of care in Mexico, it is probable that familiarity with the culture of the health care setting also influences choices. Given that 44% of Texas border residents are uninsured, and that over 80% are of Hispanic ethnicity, the availability of low-cost health care from Spanish-speaking physicians in Mexico may be beneficial. On the other hand, crossing into Mexico and returning to the United States has become more difficult and time-consuming in the post-September 11th era. Therefore, it is still important to work towards an equitable system of health care coverage for all United States residents.
The low use of hospital services in Mexico by El Paso residents is consistent with the findings of Bastida et al. (1), i.e., US residents are unlikely to access services in Mexico for major health emergencies or specialized health care services. Bustamante et al. (19) found that, among the population surveyed, individuals were willing to pay a monthly premium for comprehensive care in Mexico, particularly if offered through public hospitals. Currently, through the Knox-Keene Act of 1998, California is the only state in which health insurance can cover health care in Mexico. Similar bills have been introduced in the Texas legislature, but have not been made law (20). A Texas-version of Knox-Keene could improve the affordability of specialized treatment for Texas border residents and could require Mexico-based providers to comply with regulatory standards. This study affirms the assertions of Bustamante et al. (19): cross-border insurance options will be particularly important in all US states if immigration reform avails any form of regularization (i.e., guest-worker status, conditional amnesty) to the estimated 12 million undocumented residents in the United States.
Use of dentistry services in Mexico was not correlated with ethnicity, income, insurance coverage, age, or ever having lived in Mexico. There are possible explanations for this. Nationwide, more people lack dental insurance than medical insurance (20). According to the Kaiser Family Foundation, only 45 % of US residents have dental insurance (21). More recently, in a study of older adults, Manski and associates (22) found that dental insurance coverage decreases as age increases. In their study, 51% of respondents 55-64 years of age had coverage, while only 28% of those 65-74 years had coverage. In addition, dental services in Mexico are advertised online, and dental clinics in Ciudad Juárez have made efforts to attract customers from the United States. They even provide transportation from El Paso to the clinic for ease of use, and most of the clinics offer services in English.
There were several limitations to this research that should be considered. First, the survey was completed by telephone. This may have caused a bias towards those who have telephones, if they are different from those who do not. In addition, many people now use cell phones exclusively rather than land lines, and may have been missed in the sample selection. In a past BRFSS study conducted in the New Mexico border area, face-to-face interviews were conducted in areas with low rates of telephone coverage, and the results did not differ significantly from those of the telephone interviews (23). This cannot be assumed to be true in the case of this research. Second, the analysis included only standard variables for weighting the data. In the future, other variables could be included, such as country of birth and insurance coverage. In this study, those variables were treated as correlates of using health care in Mexico. Finally, data on the providers being used in Mexico, such as distance from the border or specialty, were not collected. This would be an interesting addition to future research. In addition, as with any survey research, it is important to remember that errors in self-reported data are always a possibility.
Use of medical, pharmacy, and dental services in Mexico is not uncommon near the United States-Mexico border. Recent changes in border crossing and customs regulations, such as the need for a US passport to re-enter the United States, and unpredictable wait times at ports of entry, may make using health care services in Mexico more difficult in the future. Given the high rate of uninsured in the United States, especially among those of Hispanic origin, increased border security protocols may compromise access to health services.
After this research was completed, violence associated with drug cartels erupted in Ciudad Juárez and the military was deployed to the city in the summer of 2008. The increased violence may influence the use of services in Mexico and may prevent those in need from getting care across the border.
In order to ensure that all US residents receive necessary health care, policies around the use of and insurance payment for services in Mexico may be needed for cross-border use, making more than one health care system easier and safer. For example, increasing communication between practitioners across borders and encouraging patients to carry copies of medical records to their providers could help decrease problems of over-treatment and contraindications. In addition, public education programs need to address the dangers of using medications without assessment or management by a practitioner, and the need to report to all health care providers what medications, as well as herbal remedies, one is using. These policy and public education changes are needed to address the social, political, and individual factors that influence health care utilization and the disparities that exist in the United States.
Acknowledgments. We are grateful to the Paso del Norte Health Foundation, El Paso, Texas, United States of America, for supporting this research.
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Manuscript received on 22 July 2008.
Revised version accepted for publication on 21 January 2009.