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Journal of Health Care for the Poor and Underserved, Volume 26, Number
3, August 2015, pp. 990-1004 (Article)
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ORIGINAL PAPER

Mexican Immigrant Health: Health Insurance

Coverage Implications
Henry Shelton Brown, III PhD
Kimberly J. Wilson, MPIA, DrPH(c)
Jacqueline L. Angel, PhD
Abstract: A key facet of the Patient Protection and Affordable Care Act (PPACA) is the
expansion of health insurance coverage. However, even with the PPACA, an estimated 11.2
million undocumented immigrants will remain uncovered. The majority of the remaining
uncovered immigrant population is of Mexican origin. We assess the long-term benefits
and short-term costs of providing coverage to male migrants from Mexico, employing data
from the 20072011 Mexican Migration Project (MMP) and the 2009 Medical Expenditures
Panel (MEPS) survey. Our results show that health status prior to migration, age at time
of interview, emigrating from Central Mexico, and use of health services in the U.S. all
predict declines in health at a significant level. We also find that having spent more than
10 cumulative years in the U.S. has borderline significance in predicting health decline
(p=.052). Estimated coverage costs for health insurance for largely undocumented immigrants increase over time, but remain lower than those of comparable U.S.-born individuals.
We conclude with several policy implications.
Key words: Health, immigrants, insurance, Mexican, Hispanic.

key facet of the Patient Protection and Affordable Care Act of 2010 (PPACA) is the
expansion of health insurance coverage. Hispanics are the largest ethnic minority group in the U.S. and are most likely to lack coverage and could therefore benefit
from increased health care access afforded by coverage.1,2 Despite this, health insurance
coverage under PPACA excludes undocumented immigrants, who were estimated to
number 11.5 million in 2011 (or 3.7% of the population and 5.2% of the workforce);
of these, 6.8 million (59%) are from Mexico.3 If having insurance is associated with
positive health outcomes in the long-term, it is possible that withholding insurance
from undocumented immigrants in PPACA will prove expensive in the long-term.
However, we know little about the short- and long-term potential costs and benefits of
extending coverage to this group or about the short-term cost of covering this group.
Currently, Mexican-origin migrant adults who are neither citizens nor legal permaDR. BROWN is Associate Professor of Health Economics and KIMBERLY WILSON is a Dell Health
Scholar and graduate assistant at the University of Texas School of Public Health in Austin, TX.
DR.ANGEL is Professor of Public Affairs and Sociology in the LBJ School of Public Affairs, University
of Texas at Austin. Address correspondence to Dr. Brown at the Michael & Susan Dell Center for
Healthy Living, Austin Regional Campus, 1616 Guadalupe Street, Suite 6.330, Austin, TX 78701; phone:
(512) 433-9873; fax: (512) 391-2521; email: h.shelton.brown@uth.tmc.edu.
Meharry Medical College

Journal of Health Care for the Poor and Underserved 26 (2015): 9901004.

Brown, Wilson, and Angel

991

nent residents are the people least likely to have insurance coverage in the U.S.47 This
population is also less likely than the native-born population to have access to a regular
health care provider due in part to the high cost of such care and partly due to the
lack of continuous coverage.5,8 Given that studies have shown that having continuous
coverage is associated with favorable mental and physical health outcomes,911 the effect
that a lack of insurance may have on migrant health is an important subject of inquiry.
Having health insurance may improve health care access and, hence, health. It is also
true, however, that those with good health are less likely to acquire health insurance
due to adverse selection and migrant workers tend to be young and healthy.12 Thus,
the silver lining is that covering relatively healthy, but uninsured, migrant workers may
be inexpensive in the short-run. Lower costs in the short-run would only add to the
cost-benefit calculus of providing health insurance to improve health in the long-run.
If undocumented immigrants in our sample have the same health advantage relative
to natives as they have had in other samples,12 providing insurance through PPACA
exchanges may lower health premiums for everyone else.13 Whenever an uninsured
healthy person or group, relative to those insured, joins a pool of insured persons,
the average health of the insured pool improves with their addition, thereby lowering average costs. Thus, enrolling immigrants in the exchanges under PPACA could
result in existing enrollees paying lower health premiums than they otherwise would.
So, expansion could be motivated by enlightened self-interest for the insured as well
as by an interest in social justice.
As of this writing, many individual states had yet to accept the Medicaid expansion
dollars they are entitled to under the PPACA. While the five-year wait period created
by the Personal Responsibility and Work Opportunity Reconciliation Act of 1996
(PRWORA) will still apply, legal non-citizen residents will be able to buy insurance
through the exchanges created by PPACA and may qualify to receive tax credits based
on their income relative to FPL.14 Even so, federal and state policy excludes 6.8 million
undocumented immigrants from Mexico alone.3
This paper sheds new light on the short-run costs and benefits of extending coverage
to these groups.13 Toward that end, we first examine whether having health insurance
while in the U.S. is protective of health for these migrants in the long-run, and then
project the near-term cost of providing coverage to this population. Based on our findings, we also offer policy implications for expanding health insurance options.
The demography of Mexican migrants. Most immigrants from Mexico come to
the U.S. for work.15 This population has significantly lower levels of educational attainment than non-Mexican immigrants and non-immigrant Hispanics.16 The differences
in attainment are more attenuated for Mexican-origin population.17 Compared with
native-born Americans, Mexican migrants are more likely to be male and young.18,19
Immigration, health and health behaviors. There are two compelling explanations for the initial immigrant health advantage relative to natives and its subsequent
decline. On one hand, the healthy migrant hypothesis maintains that because migrating
to a new country, where one might have little social and economic support, is risky
and arduous, one needs to be relatively healthy to even endeavor to make to journey.
Accordingly, those who are not sufficiently healthy remain home in Mexico.12 On the
other hand, the acculturation hypothesis states that individuals migrating from Mexico

992

Mexican immigrants insurance

bring better health habits (e.g., better nutrition, lower rates of smoking, less alcohol
consumption) with them, and that these positive health habits erode with time spent in
the U.S.2028 We should note, however, that some questions about the healthy migrant
hypothesis remain viable.29,30
Insurance, health and health care utilization. Multiple studies have shown that
having health insurance coverage reduces morbidity and mortality by reducing barriers
to health care access.3032 However, this evidence is mixed, with some studies showing
that coverage leads to moral hazard that may lead to overutilization of care without
improving health.9,33 Adverse selection makes it appear that insurance harms health,
because the less healthy are selecting in.9,31,3436

Methods
We employ data from two sources. First, we use the Mexican Migration Project (MMP)
to characterize the Mexican migrant population and to examine the long-run health
benefits of insurance. Second, we use the 2009 Medical Expenditure Panel Survey
(MEPS) to estimate the cost of covering Mexican migrants relative to those who will
be covered under the exchanges in PPACA.
The MMP data have been collected annually since 1987, and are available through
2011. Sampling is based on a random selection of communities in Mexico from which
households are sampled for structured interviews on an annual basis. The dataset
includes 19 of 31 states in Mexico, and communities selected are both urban and rural
and are not necessarily known for high rates of out-migration. The MMP is also unique
in that it offers valid and reliable information on a constellation of variables, including
age, self-rated health (poor, regular, good, excellent), use of health insurance to pay for
medical care in the U.S., occupation, work history, and frequency of return migration
to Mexico as well as citizenship and green card status. In addition, the survey includes
information on social support and physical infrastructure available to immigrants in
their Mexico home communities.
Interviews are conducted in both the U.S. (less than 5%) and Mexico by MMP staff.
The health questions were implemented starting with the 2007 survey and our analyses
are based on data from the cohort interviewed between 2007 and 2011. Although some
interviews in the MMP took place in the U.S., all of the interviews in our subsample
after omitting missing variables took place in Mexico. Women make up a small portion of the sample (5%) and are therefore omitted from the analysis. The MMP is a
cross-sectional dataset, but it contains retrospective questions about the lifetime work
history and border crossings. We used the retrospective questions to build individual
profiles of work, immigration, health insurance status, and self-reported health history.
Estimating the long-term health effects of insurance. Our outcome variable is the
change in self-reported health between first arrival in the U.S. and time of interview. The
respondents were asked to rate their overall health as Poor (1), Regular (2), Good(3)
or Excellent (4). We collapsed this variable to a dummy variable, where the value 0 is
assigned to self-rated health improving (e.g., moving from poor health to fair health,
fair to good) or staying the same, and 1 is assigned to health declining over time. We

Brown, Wilson, and Angel

993

regress change in health status on demographic and initial health characteristics of the
individual including (a) age at interview, (b) self-rated health prior to U.S. migration,
(c)monthly income (in dollars) at last migration, and (d) years of education. We also
regress on work history by industry sector (agricultural or professional sectors), and
proportion of time spent in the U.S. since first migration (proportion values range
from 0 to 1). Further, we include health utilization and insurance access: (a) a dummy
variable for having been to a doctor or hospital while in the U.S. (1 if Yes), and (b)a
dummy variable for having used private insurance to pay a medical bill while in the
U.S. (1 = Yes, 0 = no and/or did not have a health-related bill while in the U.S.). This
latter variable is, in essence, the interaction of health care utilization in the U.S. with
having U.S. health insurance; due to the structure of the MMP, no main effect insurance variable is available. Finally, we included a trend variable for year of survey. We
excluded individuals missing data for any of the outcome or predictor variables, with
the exception of monthly income. For this variable, we replaced missing values (n=183,
28%) with the average income value (the equilibrium market wage) matching the
occupation category in which the individual was employed.
We estimated four logistic regression models to assess the influence of time spent in
the U.S. on changes in self-rated health. We controlled for age, whether respondents had
spent 10 cumulative years in the U.S., experience in the professional and agricultural
sectors (the two largest consolidated occupational categories in our sample), years of
education and income as is standard,37,38 and region of origin from within Mexico.
Because age is inextricably linked with the predictor variables, and possibly co-linear
with work experience, the first model incorporates all of the covariates except for age
at time of interview and the second model incorporates age. Our third and fourth
models exclude the health care utilization dummy variable in order to test the effect
of our health care use and insurance interaction term. Similar to the first model, we
exclude age at interview in the third model to reveal the substantive importance of
the other covariates.
Recognizing the potential existence of endogeneity in our models, we included
instrumental variables (IVs) for our insurance interaction term related to home community distance from the Mexico border and physical infrastructure available in home
communities. Because the available IVs had no significant effect on having insurance,
we excluded them from our final models.
Estimating the short-term cost of covering insurance. In the second part of our
research, we estimate the relative annual costs of providing health insurance to individuals in the immigrant population. The cost is relative to the current male population
that is likely to acquire coverage through the health insurance exchanges. Estimates are
derived from the household component (HC-129) data file of the 2009 MEPS, a nationally representative survey of 36,855 individuals in the U.S. civilian non-institutionalized
population. The study sampled men over 18 years old and had complete information on
self-rated health. We excluded respondents who (1) were institutionalized, non-civilian
or residing outside the U.S. during a portion of the year surveyed, (2) were eligible for
expanded Medicaid (<=133% FPL), and (3) if employed, worked for firms with more
than 200 employees. The remaining subsample is therefore not likely to be insured

994

Mexican immigrants insurance

under ERISA contracts. This exclusion criteria resulted in a final sample of male adults
who would be eligible and likely to purchase health insurance through the insurance
exchanges either directly or under a small-group employer policy (final N=6,003).
We estimated total annual health care expenditures using 2009 MEPS. The dependent
variable is logged due to health expenditure being right-skewed. The model includes
self-rated health (srhealth), having Mexican ethnicity (Mexican), living in the U.S. less
than 10 years (less10yr), age, years of education (educ), being uninsured (uninsured),
and level of poverty (povcat). Self-rated health and level of poverty are as defined in
the MMP data.
We used average values of the predictor variables from the MMP sample to estimate
average annual total health care expenditures using estimated parameters estimated
with MEPS data, and then estimated average insurance costs for the U.S.-based sample
by multiplying the predicted expenditures by 1.15 (the maximum medical loss ratio
allowed by PPACA). We then compared this with the predicted average insurance costs
for our Mexican migrant sample at two time points, at first migration to the U.S. and
at time of interview based on average values of predictor variables at those two time
points from the MMP data.

Results
Table 1 provides descriptive statistics. In general, the sample is middle aged at the time
of the survey, but most in the sample first immigrated to the U.S. during their midtwenties. Even though the difference between the average age at survey and the average
age at arrival is 20 years, the cumulative years in the U.S. is less than one-third of this,
indicating lengthy returns to Mexico. Most of the sample immigrated from communities in Central and Southern Mexico. Very few were legal residents or U.S. citizens at
the time of survey, and the cumulative years of schooling is low.
The results in Table 1 also show that the health of the people in the sample is good,
which is in line with the healthy migrant hypothesis. Interestingly, no one reported
poor health at the time of the arrival in the U.S., and approximately two-thirds did
not report a decline in health since their first migration to the U.S. (403 of 648). Most
men were in good or excellent health, and only 10.2% declined more than one category
during the time in the U.S. (data not shown). Only 36.4% used health services in the
U.S., which is quite low for being in the U.S. on average six years. However, the six
cumulative years of residence in the U.S. is spread out over an average of 20 years and
2.2 trips, indicating periodic returns to Mexico, where health care could have been
sought at low cost (38.1% of those who used medical services in the U.S. paid for a
health service in the U.S. with insurance).
Columns two and three of Table 1 compare differences in migrant characteristics
between the group with unchanged or improved health and the group that experienced
health decline between first migration to the U.S. and time of interview. Specifically,
those with no health declines were on average 12 years younger, had almost two more
years of education, had $125 more income per month, and spent fewer years in the
U.S. (5.13 vs. 7.84). Moreover, those with no health declines were more likely to be
from either the Northern or Southern region of Mexico, not to have legal status in the

Brown, Wilson, and Angel

995

Table 1.
DESCRIPTIVE STATISTICS BY CHANGE IN REPORTED HEALTH
STATUS AND TOTALa

Reported Health Prior to U.S.

Migration
Fair
Good
Excellent
Age, current
Age at first migration
Cumulative Years in U.S.
Months in U.S. agricultural sector
Months in U.S. professional sector
Visited a doctor while in the U.S.
Visited a hospital while in the U.S.
Used U.S. health insurance (public or
private) to pay a medical bill
Years of education
Monthly income ($ hundreds)
Legal U.S. resident
U.S. citizen
Mexican Region of Origin
Northern
Central
Southern
Year of Interview
2007
2008
2009
2010
2011

No Change
or Improved
Health
Combined
(n=403)
(n=648)

Decline
in Health
(n=245)

Significance of
Between Group
Differences
(p-value)

3.4%
73.3%
23.3%
46.5 (14.6)
26.4 (9.5)
6.2 (8.1)
19.7 (52.1)
25.4 (58.0)
28.4%
29.0%

4.5%
81.9%
13.7%
41.9 (12.2)
26.1 (8.7)
5.1 (5.8)
13.4 (37.4)
22.0 (50.5)
23.3%
24.1%

1.6%
59.2%
39.2%
53.9 (15.0)
26.9 (10.6)
7.8 (10.5)
30.2 (68.7)
30.9 (68.2)
36.3%
37.1%

<.001

13.9%
7.0 (4.2)
14.8 (8.9)
12.5%
1.9%

10.9%
7.6 (3.7)
15.3 (8.4)
8.4%
0.7%

18.8%
5.8 (4.2)
14.1 (9.6)
19.2%
3.7%

.005
<.001
.095
<.001
.007

10.7%
68.8%
20.5%

14.6%
61.3%
24.1%

4.1%
81.2%
14.7%

<.001

37.0%
23.6%
18.4%
14.5%
6.5%

20.6%
21.1%
18.1%
31.8%
8.4%

45.7%
28.6%
13.9%
8.6%
3.3%

<.001

<.001
.37
<.001
<.001
.08
.001
.001

Mean (SD) except where noted.

U.S., and not to have used health care services while in the United States than those
reporting health declines.
Our data (not shown) demonstrated that as the region of origin increases in distance
from the U.S. border, the probability of using U.S. medical services decreases. The
relationship is statistically significant (p=.002). Using Browns argument, this implies
that those from the Southern region may be healthier and in less need of care in comparison to those from other regions. That is, higher initial level of health is required
to immigrate further.39

996

Mexican immigrants insurance

Table 2 reports the results from the four logistic regression models. In each model,
we are predicting the likelihood of decline in health by any amount from initial premigration level.
In the first set of models, a one-unit increase in health prior to U.S. migration
increases the odds of a decline in health by 4.55 when age is excluded from the model.
Other significant variables are monthly income measured in increments of US$100
(thus 14 is equivalent to $1,400/ month), years of education, health care utilization
while in the United States, and immigrating from Central Mexico. Each $100 increase
in monthly income lowers the odds of health declining by .97; similarly an additional
year of education lowers the odds of decline by .89. Both U.S. health care utilization
and being from Central Mexico increase the odds of health declining by 1.83 and 4.45,
respectively.
When the age variable is added, the income and education variables lose their statistical significancealthough years of education remains borderline significant with

Table 2.
LOGISTIC REGRESSION OF CHANGES IN RESPONDENTS
REPORTED HEALTH: ODDS RATIOSa
Model 1b
Health Prior to U.S. Migration
Age
Has spent 10 or more years,
cumulative, in the U.S. (1=yes)
Months spent working in the U.S.
agricultural sector
Months spent working in the U.S.
professional sector
Monthly income ($ hundreds)
Years of education
Used U.S. medical services
Used insurance (public or private) to
pay a U.S. medical bill
Central Mexico region of origin
Southern Mexico region of origin
Trend variable: year surveyed

4.55***
n/a
.55

Model 2c
4.31***
1.05***
.51
(p=.052)

Model 3d

Model 4e

4.55***
n/a
.61

4.36***
1.05***
.58

1.00

1.00

1.01*

1.00

1.00
.97*
.89***
1.83**

1.00
.99
.953
2.15**

1.00
.97*
.89***
n/a

1.00
.99
.95
n/a

1.12
4.45***
2.08
.87

1.08
4.43***
2.01
.95

1.64
4.16***
2.13
.85

1.72
4.02**
2.07
.92

*p<.05
** p<.01
***p<=.001
a
Dependent variable is zero if health status improved or stayed the same, one if it declined.
b
Model 1 includes all covariates except for age.
c
Model 2 adds Age at Interview to Model 1.
d
Model 3 removes health care utilization dummy variable from Model 1.
e
Model 4 removes the health care utilization dummy variable from Model 2.

Brown, Wilson, and Angel

997

a p-value of .065. Age itself is a significant predictor; specifically, each additional year
of age at interview increases the odds of health declining by 1.05.
One of our two main hypotheses is that insurance protects against health decline.
However the coefficient estimate for the variable, Used insurance (public or private) to
pay a U.S. medical bill (1=yes, 0=no), is not significant. Recall that this can be thought
of as an interaction term between Used U.S. medical services (1=yes, 0=no), and using
insurance to pay for part or all of it. Using health services in the U.S. is positively associated with health decline, to a certain extent because individuals use health services
when their health declines (reverse causality) and to some extent because individuals
learn of chronic illnesses through health care service use. Table 1 reveals that slightly
less than 30% of our sample used a hospital or a doctor in 6.2 average cumulative years
in the U.S. Given the potential for using services in Mexico, and the relative good health
of this population, it is likely that our insurance measure provides a fairly accurate and
robust estimate of this samples insurance status.
In Models 3 and 4, we remove the U.S. health care utilization dummy variable from
Models 1 and 2, respectively, to examine the paid for health care in the U.S. with insurance interaction term alone. This interaction does not change the results. While the
odds ratios for the insurance times health service utilization interaction term increased,
they did not become significant at the .05 level. For the model that includes the age
variable, the p-value of the insurance variable is .064. Thus, we are unable to reject the
null hypothesis that insurance is protective of health in this population.
Let us now turn our attention to the cost of covering those still uninsured. Table 3
shows the results of our insurance cost estimation using the parameters from. Column
1 shows that the health status of those who will be eligible to join the exchange in 2014
under PPACA is good, and that their costs are quite low. On the other hand, the MMP
sample reports slightly worse health status prior to immigrating to the U.S. However, the
predicted costs are much lower for immigrants both initially and after time spent in the
U.S. These findings are in accordance with the literature, which shows that immigrants
spend less on medical care than their native-born counterparts.40 The role of insurance
as it protects health is difficult to assess, but the answer to the question of whether the
short-term costs of covering those in the MMP sample are low is definitive.

Discussion
The major findings of this study provide important information about a major minority
group left out of recent health care reform: undocumented male migrants from Mexico.
Our research is consistent with positive selection in immigration. Specifically, members
of the sample were healthier upon arrival than Mexican Americans of their age residing in the U.S. However, their health declined at a faster rate, on average, than their
native-born counterparts in the U.S. Thus, at time of interview, they reported worse
health than their counterparts in the U.S.41
Although we cannot say insurance is protective against health decline, our cost estimate demonstrates that covering Mexican immigrants is inexpensive in the short-term.
This is in line with previous research that shows that the Hispanic population spends
less than non-Latino Whites on health care, and that these differences are inversely

998

Mexican immigrants insurance

Table 3.
AVERAGE PER PERSON ANNUAL INSURANCE COST
CALCULATIONS
Variable
Self-Rated Health
Of Mexico origin
< 10 Yrs in U.S.
Age
Log(Yrs of Educ)a
Uninsured (in U.S.)
Poverty Categoryb
Monthly income
Annualized income
Predicted log(hexp+1)
Predicted health expenditures
Predicted average pp annual insurance cost

MEPS
Sample

MMP, Before
Migration

MMP,
Current

3.44
.15
.05
46.2
2.59
.21
4.19

3.2
1
1
26.4
1.90
1
1.99
$1,083
$13,000
.150
$0
$0.19

2.74
1
.81
46.5
1.90
.86
2.70
$1,483
$17,796
2.40
$10
$11.48

5.43
$227
$260

Assumes all education occurred prior to first U.S. migration.

Take monthly wage (at first migration or last migration, as appropriate, see following row), annualize
it and convert to poverty category based on single-person household FPL ($11,170).
MEPS= Medical Expenditures Panel Survey
MMP= Mexican Migration Project

associated with length of residence in the U.S.42 Rather than being a burden under the
PPACA, including immigrants from Mexico could ease premium costs for citizens, at
least in the short term, because relatively healthy people are added to the pool lowering pooled costs. This is analogous to the State Childrens Health Insurance Program
(SCHIP) program, where coverage is inexpensive, but researchers have been unable to
project the long-term benefits.43
We find that exposure to agriculture increases the risk of poor health, but this appears
to be a function of age, at least partially, as its statistical significance is reduced when
age is added to the model. It is possible that older Mexican migrants are more likely
to have worked in agriculture than their younger counterparts. The literature supports
this assumption.18 Certainly, those who have spent more time in the U.S. will have
accumulated more time working in specific industries. Age, in fact, appears to explain
most of the duration of residence effects we modeled. However, it also, independently,
explains a portion of declines in health.44
Place of residence also matters. The data reveal that individuals who migrate from
the Northern region of Mexico are younger, have fewer years of work experience in
the U.S., and are more likely to have visited a doctor or be admitted to a hospital while
in the U.S. than those from the Central and Southern regions. We should also note
that while going to a doctor or hospital and having private insurance appear in our

Brown, Wilson, and Angel

999

analysis to be positive predictors of greater declines in health, it may be an artifact of

adverse selection (i.e., those who are already sick are more likely to go to the doctor
and purchase insurance).
As in previous studies, our data clearly demonstrate that Mexican men who migrate
for work tend to be younger and healthier upon arrival in the United States than men
who remain in Mexico.21,45,46 Even so, the tenuous nature of the Hispanic paradox
emerges in our results; the health advantage among male immigrants observed may
initially erode with time spent in the U.S. Although it is conceivable that access to health
services may improve with increased time of residence, individuals of Mexican origin
encounter numerous structural barriers (e.g., education and work) to obtaining U.S.
health insurance, which in turn makes it difficult to obtain high quality health care.1,46
Even though policy makers do not fully understand the reasons for the low rates of
health insurance coverage among people of Mexican origin in the United States, some
aspects of the problem are clear from our results. Male Mexican migrants are overrepresented in low wage jobs that do not offer health insurance, and even if they do so,
the premiums employees must pay makes coverage an unrealistic luxury. 1,46
These results have serious implications for undocumented and non-citizen resident
Mexicans, who are more likely than the native-born to be uninsured. Legal and undocumented Mexican-origin migrants living in the United States are expected to become the
largest segment of the U.S. population without health insurance coverage.8 This means
that they are more likely to do without preventive care services and to seek care only
when their health is already seriously compromised, often in emergency rooms where
services are subsidized. Those who remain in the U.S. for many years may develop
serious chronic health problems that will eventually cost more than it would have cost
to provide health insurance coverage earlier in the life course.
Beginning in 2014, the insurance exchanges allowed all lawfully present noncitizens
to purchase insurance through the exchanges and will also provide individuals and
employers a tax credit toward their premium costs and a subsidy for their cost-sharing.
Our results indicate that including the undocumented population in an insurance pool
could help to reduce the average medical cost, through the reduction of premiums of
all individuals in the insurance exchanges.47 The vast majority of this sample consists of
circular or seasonal male migrants who first migrated to the U.S. before turning 40 years
old, a period of the life course requiring less high-intensity medical care.48,49 Whether
having health insurance is protective of health in the long-run is difficult to determine.
Finally, we should note three limitations of the MMP data set arising from how
the data are gathered. One, the dataset lacks information on the insurance coverage
status of those who have visited a doctor or hospital during their time in the U.S. and
how it affects individual health status. Second, the sample used in this analysis was
interviewed in Mexico, and as a result, our findings should not be broadly generalized
to all undocumented Mexican immigrants residing in the U.S. Rather it is likely they
are representative of that segment which travels to the U.S. for temporary or seasonal
work. Finally, our analysis relies solely on subjective measures of health status and
may underestimate the true impact of migration history on health outcomes. While
numerous studies have shown that the four- or five-item Likert scale predicts health care
use, subsequent mortality, and other behaviors, and is highly correlated with clinical

1000

Mexican immigrants insurance

assessments, research also shows a lack of linguistic equivalence in item interpretation,

engendering higher reports of worse health among Spanish-speaking respondents than
what it might otherwise be intended measured alongside Anglos.27,50,51 Such differences
in perceptions of overall health status may affect decisions to seek care, yet as our results
suggest, barriers to insurance may largely account for the health disparities observed
during the study period.52 Even so, given the potential limitations of using subjective
assessments of health in Hispanic populations, larger studies of health care utilization
taken from administrative records are recommended. In addition, future research
should replicate and extend these results by examining the relationship between insurance coverage and migrant health by disentangling the effect of place-of-residence in
Mexico, frequency of border crossings, and employment to determine if they increase
access to health care when returning home.
In conclusion, this research uncovers vital information about a politically sensitive topic, providing a new perspective on the debate about the costs and benefits of
extending health insurance coverage to a group with significant social and economic
ties to the U.S. This is especially important as the world becomes more connected, and
we could expect to see more people working overseas away from their native country,
where access to health insurance resides. Our study also raises critical questions about
the portability of health insurance, not just between employers, but also between the
United States and Mexico.

Acknowledgments
This research was supported by a grant from The University of Texas at Austin, LBJ
School Public Policy Research Institute International Program.

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