With health insurance reform efforts taking center stage in Sacramento, Calif., this year, cross-border policies such as the one used by Mijia offer an enticing path for covering more workers from Mexico and other Latin American countries. They account for 57 percent of the state's 6.7 million uninsured, according to figures from the California HealthCare Foundation.
Advocates of the plans say they offer the best of both worlds: emergency room access and basic health care services in California and hospital services in Mexico, where prices for surgeries and other serious procedures are significantly lower. They say some workers prefer receiving the bulk of their care from doctors and nurses who speak Spanish and are familiar with Mexican culture.
Membership in Health Net's cross-border plan has grown to 23,700 since its introduction six years ago, said Brad Kiefer, spokesman for the health maintenance organization. That's up 64 percent over last year. Sistemas Medicos Nacionales S.A., the only Mexican HMO licensed to operate in California, has about 19,000 members in San Diego and Imperial counties, said Christina Suggett, SIMNSA's chief operating officer.
Health Net members who subscribe to the company's cross-border plan use SIMNSA's network of doctors and hospitals in Tijuana, Tecate and Mexicali.
PacifiCare, another California HMO, also has teamed up with SIMNSA to offer a binational insurance product.
Blue Shield of California offers a cross-border group plan through employers using its own network of health care providers in Baja, Mexico, but a spokeswoman with the insurer declined to say how many members it has.
Aetna hopes to become the newest competitor in the binational market. The company is awaiting a decision by the state Department of Managed Health Care on licensing its cross-border health plan. Like several others, Aetna's plan would rely on SIMNSA's network to provide care across the border.
Sekure Healthcare, a private venture in Chula Vista, has taken a slightly different approach. The company offers low-priced, employer-sponsored plans that pay limited benefits - $50 per doctor's visit and $300 to $1,500 for a day in a hospital - to California workers who can't afford plans with broader benefits. The 2,000 Sekure members can receive care from a wide range of physicians and hospitals on both sides of the border.
Some estimates have placed the total number of California workers enrolled in cross-border health plans at between 150,000 and 200,000, with most receiving care through plans sponsored by farming associations, such as the Western Growers Association. Several barriers stand in the way of expanding coverage to larger numbers of Latino workers.
Most plans restrict care in Mexico to border cities, making the policies less attractive to migrants who come from other parts of Mexico and prefer doctors and hospitals near their families.
Since the plans require workers to cross into Mexico to receive most care, they are risky for migrants who lack proper documentation.
And though the policies can cost half as much as conventional U.S.-only health plans, they are still unaffordable for many employers and workers in low-paying industries.
"Cost has been and continues to be a major barrier to expansion," said Margaret Laws, director of the California HealthCare Foundation's Innovations for the Underserved program.
Mijia, the sous chef, said he pays about $80 a month in premiums for the cross-border SIMNSA policy that covers his family. His monthly premiums for a more conventional U.S.-only policy would be at least $140 a month, he said.
One answer could come from an effort by the Health Initiative of the Americas, a project of the California Policy Research Center in the office of the president of the University of California Berkeley.
The project has been working with Mexican health policy officials to devise an affordable cross-border health insurance plan for Mexican citizens working in the United States. It would pair HMO coverage in the United States for routine and emergency care with coverage under Mexico's Salud Popular, a government-sponsored program, for hospitalization in Mexico.
Salud Popular provides free health coverage to Mexico's poorest citizens and charges others a sliding scale based on income. Other government-sponsored plans provide coverage to most Mexicans who are employed. Only the country's wealthiest citizens buy private health insurance.
Standing in the way of opening Salud Popular to Mexican workers in the United States is the daunting task of creating a system to move payments between insurers in both countries, said Daniel Karam, who works for Mexico's National Commission for the Protection of Public Health.
The Mexican program, which is administered at the state level, will not have a nationally unified billing system until after 2010, Karam said. This would be required because setting up a payment system with multiple Mexican state governments is too difficult, he said.
"The good news is that we have this issue on the agenda," Karam said. The Mexican government also has an increasingly lucrative financial incentive for keeping Mexican workers here healthy.
Immigrants north of the border sent home $24.2 billion in remittances last year, according to the World Bank. That was nearly double the amount of payments sent to Mexico three years earlier and nearly five times the amount delivered a decade earlier, according to a report by the Health Initiative of the Americas, the California Policy Research Center at UC Berkeley and the University of California Los Angeles Center for Health Policy Research.
Workers in San Diego County sent $1.1 billion to Mexico last year, up from $800 million in 2004, according to the World Bank.
But migrant workers' lack of health care jeopardizes one of Mexico's largest sources of foreign currency, according to the report.
"As immigrants, they arrive in the U.S. healthy. However, their health dramatically deteriorates after several years of living in this country. The grueling work they perform in the U.S., often deplorable living conditions and lack of access to health care all contribute to their decline in health," the report said. That makes improving health insurance coverage for Mexican citizens in the United States as much in the interest of the Mexican government as it is of the U.S. government and the companies that hire them, said Xochitl Castaneda, director of the health initiative and co-author of the report.
"We are convinced there is a need for co-responsibility. You cannot just benefit from remittances," she said.
Charles Brzezinski, vice president of Lakeside Poultry Ranch, has no doubts about the value of cross-border insurance.
The bakery supplier started offering Health Net's binational plan about three years ago. The plan has reduced by more than 30 percent the company's cost for providing coverage to the five workers who use it, Brzezinski said.
Premiums, which are paid for by the company, are $140 a month for a 46-year-old worker covered by the cross-border plan, compared with $210 a month for the same worker covered by a conventional plan, he said.
The $5 co-payments for doctor's visits and other care are far less than those paid for the same services by ranch workers covered by the company's conventional insurance plans.
One of the workers had knee surgery in Mexico under the cross-border plan, and another had his appendix removed, Brzezinski said.
"They were in the hospital for a few days, and they said it was clean and good," he said. "The guys who are on this policy are happy as heck."
Mijia seems equally satisfied with his cross-border insurance experience. Since triple bypass heart surgery 14 months ago in a Tijuana hospital, he has lost 45 pounds by sticking to a diet and an exercise regimen.
Mijia said the care he received in Tijuana was comparable with his earlier treatment in a Chula Vista hospital. "Doctors over there do a pretty good job, too."
He also was spared from interpreting for his wife and family members who speak little or no English. "For me, it was a little bit better," Mijia said.