The termination of Seguro Popular: impacts on the care of high-cost diseases in the uninsured population in Mexico

Despite the documented achievements of Seguro Popular —a public policy designed to provide healthcare protection to individuals without social security —, the government of President López Obrador decided to cancel it in 2019 and establish the Health Institute for Welfare (Instituto de Salud para el Bienestar or INSABI) in its place.¹ One of the main consequences of this decision was a dramatic reduction in access to high-specialty services for the population in poverty.

According to DeLeon, three factors determine the termination of a public policy: budgetary constraints, governmental inefficiencies, and political ideologies.² Budgetary constraints factors refer to the economic limitations that may lead to reductions in public spending and the elimination of certain interventions. Governmental inefficiencies arise when an intervention fails to fulfill its intended function, prompting its termination. Finally, political ideologies consist of a set of ideas that shape government actions, which may lead to the discontinuation of interventions that no longer align with prevailing political values.

Some authors suggest that the termination of Seguro Popular was not due to budgetary constraints or governmental inefficiencies but was primarily driven by ideological factors.^3,4 Regarding financial limitations, a 2019 study conducted by the Ministry of Finance of Mexico classified the policy as indispensable.⁵ In terms of governmental efficiency, Seguro Popular's objective was to reduce impoverishment due to health issues by providing medical insurance for the population without social security. Various studies have documented a reduction in catastrophic and impoverishing health expenditures during its operation.^6,7

Ideological factors were the primary force behind the decision to terminate Seguro Popular.⁴ President López Obrador secured an overwhelming electoral victory in 2018. His core narrative opposed past administrations led by the center-left Institutional Revolutionary Party (PRI) and the right-leaning National Action Party (PAN). According to López Obrador, these parties had imposed a neoliberal model since 1983, characterized by reduced state intervention in the economy and the promotion of free-market policies that primarily benefited a small group of powerful businesses.⁸ Much of his government's agenda was framed around abandoning neoliberal policies.

Seguro Popular was created during the administration of Vicente Fox (2000–2006) of PAN, maintained by the government of Felipe Calderón (2006–2012), also of PAN, and continued under Enrique Peña Nieto (2012–2018) of PRI. The fact that both parties supported Seguro Popular suggested that the policy was a product of the neoliberal model and, therefore, had to be dismantled. This decision was made without consideration of its achievements, without documentation of its limitations, and, most importantly, without a clear alternative.³

The latter became evident with the establishment of INSABI. Unlike Seguro Popular, which functioned as a financial mechanism, INSABI was directly responsible for outpatient and inpatient care. In the case of catastrophic illnesses, INSABI provided the necessary medications, equipment, and supplies to public high-specialty hospitals to deliver specialized services to the uninsured population.

The fundamental difference in the delivery of these services lay in the fact that INSABI acted as a service provider through public establishments, while Seguro Popular operated as a public insurer that reimbursed health service providers, including some private hospitals.

Comparative data from the last two years of Seguro Popular's operation and INSABI's two years of existence show a significant decline in specialized care between 2018 and 2021: 80.7% for acute myocardial infarction, 78.4% for neonatal intensive care, 74.5% for childhood cancer (mainly leukemias), 50.1% for breast cancer, 48.2% for cervical cancer, and 41% for prostate cancer.^9,10 Additionally, average healthcare expenses in Mexico increased by 31% between 2018 and 2022, and the prevalence of catastrophic and impoverishing health expenditures rose from 3% of households to 3.3% in the same period.¹¹

INSABI's poor performance led the López Obrador administration to terminate it in 2023 and establish the Health Services for Welfare under the Mexican Institute for Social Security (IMSS-Bienestar).¹² This new institution is now responsible for directly providing healthcare services to the uninsured population.

In conclusion, although President López Obrador's health policy reforms aimed to promote greater equity, their outcomes indicate a decline in the system's ability to manage costly interventions, thereby reducing the financial protection available to the Mexican population. This underscores the need for a more technical approach to health policy design. Additionally, this case illustrates that dismantling existing policies without a solid transition plan can exacerbate preexisting challenges.

Contributors

LJCA was responsible for the conception of the comment, gathered most of the support references and generated the first draft of the text. OGD refined the original concept, incorporated additional references, contributed to the final version of the comment and was responsible for the decision to submit the manuscript.

Declaration of interests

OGD was Director General for Performance Evaluation at the Ministry of Health of Mexico during the initial period of implementation of Seguro Popular (2001–2006).