Health Insurance and the Aging: Evidence From the Seguro Popular Program in Mexico


Aimed at covering the large fraction of workers in the informal sector without access to a social security program, the Mexican public health insurance program Seguro Popular began in 2002 and now reaches more than 50 million individuals. We estimate impacts of Seguro Popular for the population aged 50 and older on a set of indicators related to health care including utilization, diagnostic/preventive tests, and treatment conditional on being ill. Using the longitudinal Mexican Health and Aging Study over the period 2001–2012, we conduct before and after difference-in-difference matching impact estimators. Our results suggest large and important effects of the Program on utilization and diagnostic tests. We find overall smaller effects on the probability of being in treatment for individuals with chronic diseases, but these effects are concentrated in rural areas with relatively more health services versus rural areas with lower levels of health services. These results suggest that, to the extent that health services become more available in rural areas lacking services, effects of health insurance may increase.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2


  1. 1.

    For the purposes of this article, the aging population is defined as the population aged 50 and older.

  2. 2.

    An interesting research question is how Seguro Popular might affect the supply and quality of services. The Seguro Popular program does not have or build health facilities of its own but might affect construction of health facilities by the Secretary of Health through increased demand for health services associated with participation in the program. If this occurs, any impacts of Seguro Popular would reflect not only program characteristics but also these new facilities.

  3. 3.

    Lloyd-Sherlock et al. (2014) studied hypertension in six low- and middle-income countries, including Mexico, and found that for the case of hypertension, only about 44 % of Mexicans with hypertension were aware of their condition. They also found that only about 12 % of the ill population has effective control of their hypertension.

  4. 4.

    We do not use the MHAS 2012 subsample biomarker data to study impacts of the Seguro Popular for two reasons. First, our empirical strategy requires pre- and postprogram data, and the MHAS 2001 baseline does not include biomarkers. Second, the sample size of those with biomarkers in 2012 in our sample who report having a chronic disease is small.

  5. 5.

    Individuals in the subsample with biomarkers in 2012 are informed about the results of these tests. However, the biomarker tests were conducted after the self-report of treatment-seeking behaviors (in a subsequent health visit); thus, responses on treatment for ill individuals should not be biased by the results of the tests.

  6. 6.

    We also carry out impact estimates using nearest neighbor matching (two and five neighbors). Given their similarity to the estimates reported here, we report only estimates based on local linear matching.

  7. 7.

    Heckman and Smith (1995) coined the term “substitution bias” to refer to the situation in which individuals in a comparison group obtain a close substitute of the treatment. In our context, approximately 40 % of nonbeneficiaries in 2012 had an alternative form of health insurance in rural areas versus more than 60 % in urban areas.

  8. 8.

    Some studies (e.g., Maloney 1999) have shown substantial worker mobility in Mexico between formal (i.e., with social security benefits) and informal jobs (i.e., without social security benefits). Bosch and Campos-Vazquez (2014) demonstrated that the Seguro Popular program has reduced the number of employees affiliated with IMSS from small firms by approximately 4 %.

  9. 9.

    Censuses were conducted in 2000, 2005, and 2010. INEGI constructs population figures between census years by using a geometric model to extrapolate. The National Population Council (CONAPO) provides its own population series, adjusting for possible underreporting of census numbers. Results using either the INEGI series or the CONAPO series are extremely similar.

  10. 10.

    We analyze the effect of the Seguro Popular program on mortality in more detail in a separate study using survival analysis techniques (Parker et al. 2015).

  11. 11.

    We carry out balancing tests based on Dehejia and Wahba (2002), which examine whether the distribution of the covariates included in the propensity score model is independent of program participation conditional on the estimated propensity score—as it should be if the propensity score model is correctly specified, and the estimator is consistent. The test stratifies treatment and control observations into strata, based on the estimated propensity score (in quintiles), and then tests for significant differences between the covariates within each stratum. Nearly all of our covariates did not show significant differences.


  1. Alatinga, K. A., & Williams, J. J. (2015). Towards universal health coverage: Exploring the determinants of household enrolment into national health insurance in the Kassena Nankana District, Ghana. Ghana Journal of Development Studies, 12(1–2), 88–105.

    Article  Google Scholar 

  2. Babitsch, B., Gohl, D., & von Lengerke, T. (2012). Re-revisiting Andersen’s behavioral model of health services use: A systematic review of studies from 1998–2011. GMS Psycho-Social-Medicine, 9(Doc11).

  3. Barros, R. (2008). Wealthier but not much healthier: Effects of a health insurance program for the poor in Mexico (Stanford Institute for Economic Policy Research Working Paper No. 09-002). Stanford, CA: Stanford University.

  4. Bitran, R. (2014). Universal health coverage and the challenge of informal employment: Lessons from developing countries (Health, Nutrition, and Population Discussion Paper No. 87077). Washington, DC: World Bank Group.

    Google Scholar 

  5. Bleich, S. N., Cutler, D. M., Adams, A. S., Lozano, R., & Murray, C. J. (2007). Impact of insurance and supply of health professionals on coverage of treatment for hypertension in Mexico: Population based study. BMJ, 335, 875.

    Article  Google Scholar 

  6. Bosch, M., & Campos-Vazquez, R. M. (2014). The trade-offs of welfare policies in labor markets with informal jobs: The case of the Seguro Popular program in Mexico. American Economic Journal, 6(4), 71–99.

    Google Scholar 

  7. CONAPO. (2005). Envejecimiento de la población de Mexico: Reto del siglo XXI [Aging of the population of Mexico: Challenges for the 21st century]. Mexico City, Mexico: Consejo Nacional de Poblacion.

    Google Scholar 

  8. Cutler, J. A., Sorlie, P. D., Wolz, M., Thom, T., Fields, L. E., & Roccella, E. J. (2008). Trends in hypertension prevalence, awareness, treatment, and control rates in United States adults between 1988–1994 and 1999–2004. Hypertension, 52, 818–827.

    Article  Google Scholar 

  9. de Salud, S. (2013). Carta de derechos y obligaciones [Letter of rights and obligations]. Mexico City, Mexico: Secretaría de Salud.

  10. Dehejia, R. H., & Wahba, S. (2002). Propensity score matching methods for nonexperimental causal studies. Review of Economics and Statistics, 84, 151–161.

    Article  Google Scholar 

  11. Galárraga, O., Sosa-Rubí, S. G., Salinas-Rodríguez, A., & Sesma-Vázquez, S. (2010). Health insurance for the poor: Impact on catastrophic and out-of-pocket health expenditures in Mexico. European Journal of Health Economics, 11, 437–447.

  12. Gonzalez-Pier, E., Juan, M., Sepulveda, J., Garcia-Junco, D., Frenk, J., Chertorivksi, S., . . . Soberon, G. (2013). Hacia la cobertura universal en salud: Protección social para todos en Mexico [Toward universal health coverage: Social protection for all in Mexico]. Salud Pública de México, 55, 207–235.

  13. Grogger, J., Arnold, T., Leon, A. S., & Ome, A. (2014). Heterogeneity in the effect of public health insurance on catastrophic out-of-pocket health expenditures: The case of Mexico. Health Policy and Planning, 30, 593–599.

    Article  Google Scholar 

  14. Hadley, J. (2007). Insurance coverage, medical care use, and short-term health changes following an unintentional injury or the onset of a chronic condition. JAMA, 297, 1073–1084.

    Article  Google Scholar 

  15. Ham Chande, R. (2003). El envejecimiento en Mexico: El siguiente reto de la transición demográfica [Aging in Mexico: The next challenge of the demographic transition]. Tijuana, Baja California, Mexico: El Colegio de la Frontera Norte.

    Google Scholar 

  16. Harris, J., & Sosa-Rubí, S. (2009). Impact of “Seguro Popular” on prenatal visits in Mexico, 2002 2005: Latent class model of count data with a discrete endogenous variable (NBER Working Paper No. 14995). Cambridge, MA: National Bureau of Economic Research.

  17. Heckman, J. J., Ichimura, H., & Todd, P. E. (1997). Matching as an econometric evaluation estimator: Evidence from evaluating a job training program. Review of Economic Studies, 64, 605–654.

  18. Heckman, J. J., & Smith, A. S. (1995). Assessing the case for social experiments. Journal of Economic Perspectives, 9(2), 85–110.

    Article  Google Scholar 

  19. Hidayat, B. (2015). Financial sustainability of the national health insurance in Indonesia: A first year review (Policy brief of the Indonesian-German Social Protection Programme). Retrieved from

  20. Instituto Nacional de Salud Pública. (2012). Encuesta Nacional de Salud y Nutricion: Resultados nacionales [National Survey of Health and Nutrition: National results]. Cuernavaca, Mexico: Instituto Nacional de Salud Pública.

    Google Scholar 

  21. Knaul, F. M., González-Pier, E., Gómez-Dantés, O., García-Junco, D., Arreola-Ornelas, H., Barraza-Lloréns, M., . . . Frenk, J. (2012). The quest for universal health coverage: Achieving social protection for all in Mexico. Lancet, 380, 1259–1279.

  22. Knaul, F. M., Arreola-Ornelas, H., & Méndez-Carniado, O. (2016). Protección financiera en salud: Actualizaciones para México a 2014 [Financial protection in health: Updates for Mexico in 2014]. Salud Pública de México, 58, 341–350.

  23. Knox, M. (2008). Health insurance for all: An evaluation of Mexico’s Seguro Popular program. Unpublished manuscript, Department of Economics, University of California, Berkley, Berkeley, CA.

  24. Lagomarsino, G., Garabrant, A., Adyas, A., Muga, R., & Otoo, N. (2012). Moving towards universal health coverage: Health insurance reforms in nine developing countries in Africa and Asia. Lancet, 380, 933–943.

    Article  Google Scholar 

  25. Limwattananon, S., Neelsen, S., O’Donnell, O., Prakongsai, P., Tangcharoensathien, V., Van Doorslaer, E., & Vongmongkol, V. (2015). Universal coverage with supply-side reform: The impact on medical expenditure risk and utilization in Thailand. Journal of Public Economics, 121, 79–94.

    Article  Google Scholar 

  26. Lloyd-Sherlock, P., Beard, J., Minicuci, N., Ebrahim, S., & Chatterji, S. (2014). Hypertension among older adults in low- and middle-income countries: Prevalence, awareness and control. International Journal of Epidemiology, 43, 116–128.

  27. Maloney, W. F. (1999). Does informality imply segmentation in urban labor markets? Evidence from sectoral transitions in Mexico. World Bank Economic Review, 13, 275–302.

    Article  Google Scholar 

  28. Mboi, N. (2015). Indonesia: On the way to universal health care. Health Systems & Reform, 1, 91–97.

    Article  Google Scholar 

  29. Parker, S., Saenz, J., & Wong, R. (2015, April). Can health insurance improve health and reduce mortality? Evidence from the Seguro Popular program in Mexico. Paper presented at the annual meeting of the Population Association of America, San Diego, California.

    Google Scholar 

  30. Partida-Bush, V. (2006, August). Demographic transition, demographic bonus and ageing in Mexico. Proceedings of the United Nations Expert Group Meeting on Social and Economic Implications of Changing Population Age Structures, Mexico City, Mexico. Retrieved from

  31. Rivera-Hernandez, M., Rahman, M., Mor, V., & Galarraga, O. (2016). The impact of social health insurance on diabetes and hypertension process indicators among older adults in Mexico. Health Services Research, 51, 1323–1346.

    Article  Google Scholar 

  32. Shi, L., & Starfield, B. (2001). The effect of primary care physician supply and income inequality on mortality among blacks and whites in US metropolitan areas. American Journal of Public Health, 91, 1246–1250.

    Article  Google Scholar 

  33. Somkotra, T., & Lagrada, L. P. (2008). Payments for health care and its effect on catastrophe and impoverishment: Experience from the transition to Universal Coverage in Thailand. Social Science & Medicine, 67, 2027–2035.

    Article  Google Scholar 

  34. Sosa-Rubí, S. G., Galárraga, O., & Harris, J. E. (2009a). Heterogeneous impact of the “Seguro Popular” program on the utilization of obstetrical services in Mexico, 2001–2006: A multinomial probit model with a discrete endogenous variable. Journal of Health Economics, 28, 20–34.

    Article  Google Scholar 

  35. Sosa-Rubí, S. G., Galárraga, O., & López-Ridaura, R. (2009b). Diabetes treatment and control: The effect of public health insurance for the poor in Mexico. Bulletin of the World Health Organization, 87, 512–519.

    Article  Google Scholar 

  36. Tejeda, S., Darnell, J. S., Cho, Y. I., Stolley, M. R., Markossian, T. W., & Calhoun, E. A. (2013). Patient barriers to follow-up care for breast and cervical cancer abnormalities. Journal of Women’s Health, 22, 507–517.

    Article  Google Scholar 

  37. Travis, P., Bennett, S., Haines, A., Pang, T., Bhutta, Z., Hyder, A. A., . . . Evans, T. (2004). Overcoming health-systems constraints to achieve the Millennium Development Goals. Lancet, 364, 900–906.

  38. World Health Organization (WHO). (2014). Global status report on noncommunicable diseases. Geneva, Switzerland: WHO. Retrieved from

  39. Wong, R., Michaels-Obregon, A., & Palloni, A. (2017). Cohort profile: The Mexican Health and Aging Study (MHAS). International Journal of Epidemiology, 46, e2.

    Article  Google Scholar 

Download references


The authors gratefully acknowledge the assistance of Ana Cristina Perez Gea. They also acknowledge support from the Sealy Center on Aging at the University of Texas Medical Branch in Galveston, and the Health of Older Minorities T32AG00270 training grant from the National Institutes of Health/National Institute on Aging (NIH/NIA), as well as support from the Davis School of Gerontology at the University of Southern California from the Multidisciplinary Research Training Grant in Gerontology (T32AG000037) and award P30AG043073—all from the NIH/NIA. The MHAS (Mexican Health and Aging Study) is partly sponsored by the NIH/NIA (R01AG018016) and the Statistical Bureau (INEGI) in Mexico. Data files and documentation are public use and available at The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Author information



Corresponding author

Correspondence to Susan W. Parker.

Electronic supplementary material

Table S1

(DOCX 63 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Parker, S.W., Saenz, J. & Wong, R. Health Insurance and the Aging: Evidence From the Seguro Popular Program in Mexico. Demography 55, 361–386 (2018).

Download citation


  • Aging
  • Health insurance
  • Mexico
  • Evaluation
  • MHAS