The evolution of both, however, has been very different. In June 2021, the US Supreme Court declared that legal challenges to the ACA were without merit. This decision was the product of popular support for the ACA and the existence of mature democratic institutions that have checks and balances mechanisms.
In contrast, in November 2019, the Mexican Congress reformed the General Health Law to eliminate the SP, despite the fact that it had managed to extend health coverage, until December 2018, to 53 million people (44.7% of the population) . This was the result of the absence in Mexico of institutions capable of protecting the well-being of the population against irrational political decisions.
There have been clear impacts both with the disappearance of the SP —which was first replaced by the Health Institute for Well-being (INSABI) and, recently, by the IMSS-Well-Being program (IMSS-B)—, as well as with the cuts to structure of the Ministry of Health (SSa). These impacts are discussed here with reference to six regressions.
The first regression is the recentralization of health services. Both the decree that gave rise to INSABI, and the announcement of the transfer to IMSS-B of the provision of health services for the population without social security, indicate that agreements will be signed with the 32 states to federalize health care. This will restore the vertical relationship between the central government and the state health authorities, which operated until before 1983. This will also make it difficult to provide timely and effective health services, given the magnitude and geographic complexity of the country.
The second has to do with benefits. Both INSABI and IMSS-B committed to providing outpatient and general hospitalization services, but not specialty services, which were previously guaranteed by law. SP affiliates had access to a package of 294 essential services and 66 specialty interventions. Neither INSABI nor IMSS-B will provide this last type of service. This can be considered an ‘expropriation’: the deprivation of a right.
The third is budget. Thanks to the SP, the SSa budget increased almost four times in real terms between 2000 and 2015. This trend was interrupted between 2016 and 2018, in the government of Enrique Peña Nieto, when very important cuts were made. As a presidential candidate, in 2018, López Obrador promised to increase public spending on health by one percentage point of the Gross Domestic Product. However, not only has he failed to keep his promise, but he further reduced the budget of the SSa.
The fourth regression is the cuts in care coverage and the increase in the so-called “out-of-pocket expenses” of the population. According to the National Council for the Evaluation of Social Development Policies, the “lack of access to health services” increased 75% in the first years of this government, going from 16% of the total population (20.1 million people) in 2018 to 28% (35.7 million) in 2020. This triggered the use of private services and out-of-pocket spending. According to the 2020 National Household Income-Expenditure Survey, the average health expenditure of Mexican households increased 40% during those first two years of the current government.
The fifth regression has to do with the cuts to the structure of the SSa and the rearrangement of various autonomous agencies. The disappearance, due to austerity reasons, of the Undersecretariat for Integration and Development stands out, which affects planning, evaluation and accountability activities. Another sign of institutional breakdown is the decision to undermine the autonomous nature of the main regulatory entity in health matters, the Federal Commission for Protection against Sanitary Risks, by transferring its structure to the SSa and subjecting it to political swings. This degradation will affect the independence of this agency, while its politicization will weaken the control of health risks and access to all kinds of health supplies, as has already happened with the supply of medicines in the country.
Finally, there is the regression related to health conditions. According to the Organization for Economic Cooperation and Development, the excess mortality in Mexico between January 2020 and June 2021 was almost 55%, compared to the average of 2015-2019. This is one of the highest figures in the world. Most of these deaths were due to COVID-19 and reflect poor handling of the pandemic. However, a not insignificant number of deaths was the product of the combination of the poor strategy to combat COVID-19, which affected the attention to other health needs, and the changes introduced in 2019. One of the most dramatic effects of this inadequate management of the health system is the increase in maternal mortality: maternal deaths increased from 670 in 2019 to 899 in 2020, and to 1,036 in 2021.
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Innovative programs, such as Seguro Popular at the time, will continue to be essential to face the challenges of global health. For this to happen, public policies need to be based on the best available evidence. However, it is essential to protect these functional policies against irrational attacks such as those carried out by this government.
Advocates of the ACA used the mechanisms of mature democratic institutions to protect sound public policy and preserve its achievements. Unfortunately, the defenders of the SP were unable to stop the attacks perpetrated by the current administration because they lacked the necessary checks and balances. The alternative now is to have a necessary discussion to promote a change of course and generate a new reform that allows Mexico to establish a true universal health system.
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