United States–México 

Border Health Commission 

Health Care Reform 

and the U.S.-México Border: 

Challenges and Opportunities 

A White Paper 

December 07, 2009
United States–México Border Health Commission 

Providing Leadership on Border Health Issues to— 

Facilitate Identification, Study, and Research 

Be a Catalyst to Raise Awareness 

Promote Sustainable Partnerships for Action 

Serve as an Information Portal 

The mission of the United States-México Border Health 

Commission (BHC) is to provide international leadership to 

optimize health and quality of life along the 

United States-México border.
 

United States-México Border Health Commission 

1 

 Health Care Reform and the U.S.-México Border 

Executive Summary 

 

The United States-México border region is a unique, dynamic area where various 

cultures come together and interrelate across geopolitical boundaries. Though 

border residents may possess different economies and politics, they share a common 

culture, language, environment, and health status. 

The border region poses particular challenges to the U.S. health care system: It is 

one of the fastest growing in the nation, with a majority Hispanic population, in 

addition to having lower educational attainment, lower income status, higher rates 

of unemployment and poverty, and a significant shortage of health care providers. 

Challenges 

• Rapidly growing, young, and Hispanic population 

Between 1990-2000, the population of the southwest border counties 

increased by 29.3 percent. According to 2008 estimates, persons under age 

19 comprised 31 percent of the population in border counties. In addition, 

52 percent of the population in the border region was Hispanic. 

• Lower educational attainment 

As of 2000, if the border counties were a state, it would rank 50th in the 

nation in the percent of population at age 25 or above who completed high 

school (excluding San Diego County). 

• Lower income status 

In 2007, the annual per capita income ($26,842) in the border counties was 

only about two-thirds the level in the border states ($39,013) and the overall 

U.S. population ($38,839). 

• Higher poverty rates 

Poverty is almost twice as high in the border region (25%) compared to the 

United States (13%). 

• Higher rates of uninsured 

Border region residents lead the nation in lacking health coverage: 23 

percent of border residents lack health insurance coverage, as compared to 

14.7 percent nationally. 

• Inadequate number of health care providers 

Physicians per 10,000 population for all border counties is 16.3 compared to 

23.2 for the border states as a whole, 26.2 for non-border counties in the 

border states, and 26.1 for the United States as a whole. 

These challenges contribute to diminished health, well-being, and access to health 

care. 
 Health Care Reform and the U.S.-México Border 

United States-México Border Health Commission 

2 

 Despite these challenges, the border region can serve as a source for identifying 

innovative models that ensure collaboration among various levels of government 

and the private sector. Some of these opportunities include improving access to 

health care on the border; creating a culture of wellness and prevention and 

strengthening the public health infrastructure; and promoting evidence-based 

interventions and models of excellence. 

Opportunities 

• Improving access to health care on the border 

The history of border collaboration and cooperation provides a strong 

foundation for developing creative solutions and reducing the high 

uninsurance rates among border communities, especially among children 

and Hispanics. 

• Creating a culture of wellness and prevention and strengthening the 

public health infrastructure 

Public health and prevention are the cornerstones of healthy 

communities. Shifting the focus of the healthcare system from the 

treatment of disease to health promotion and prevention is the key to 

overall good community health. 

• Promoting evidence-based interventions and models of excellence 

Drawing on lessons learned and evidence of best practices in improving 

access to health care along the border can serve as a model for diverse 

communities in the United States. 

Improving access to health care on the border, creating a culture of wellness and 

prevention, and promoting evidence-based interventions and models of 

excellence can ensure deliberate and sustained actions to improve health 

conditions that can serve to elevate the health of the nation. 

 

 
 Health Care Reform and the U.S.-México Border 

United States-México Border Health Commission 

3 

Background

In recognition of the need for an international commission to address border health problems, the United 

States-México Border Health Commission (BHC) was created in July of 2000 with the signing of an 

agreement by the Secretary of Health and Human Services of the United States and the Secretary of Health 

of México. Since its creation, the BHC’s sole mission has been to provide international leadership to 

optimize health and quality of life along the United States-México border. 

The Commission is seeking to raise the visibility of border health issues that impact health care access as 

well as identify opportunities for addressing these issues that may extend beyond the U.S.–México border 

region. 

The border is a unique binational region. 

The border region is approximately 2,000 miles long and is defined as the area 100 kilometers (62 miles) 

north and south of the U.S.-México border (Figure 1).1

 This region shares environmental, social, economic, 

cultural, and epidemiological characteristics, but each side operates under different legal and political 

systems, health systems and policies. This binational region comprises: 

• Two sovereign nations 

• Four U.S. states 

(Arizona, California, 

New Mexico, and 

Texas) and six 

Mexican states (Baja 

California Norte, 

Chihuahua, 

Coahuila, Nuevo 

León, Sonora, and 

Tamaulipas) 

• A total of 44 

counties in the 

United States and 80 

municipalities in 

México2

 

• Fifteen pairs of 

sister cities3

 

• Twenty-six U.S. 

federally recognized 

indigenous tribes (4 

in Arizona, 20 in 

California, and 2 in 

Texas) some of 

whom have 

citizenship rights on both sides of the border.4

 

Figure 1

U.S.-México Border Region 
 Health Care Reform and the U.S.-México Border 

United States-México Border Health Commission 

4 

The United States-México border region is a dynamic area where 

multiple cultures (U.S., Mexican, indigenous) come together and 

interrelate across geopolitical boundaries.5

 Border residents are 

often bound by inseparable ties among binational families and 

economically intertwined communities. The mobility of millions of 

daily legal crossings and a large portion of families who have 

strong social networks on both sides create vibrant binational 

communities. This social dynamic requires effective collaboration 

between government agencies on both sides of the border to 

address complex policy issues surrounding health care as well as 

economic and social conditions. 

Border health is a range of shared

public health issues that span the

international border and

necessitate binational

collaboration to be effectively

addressed.  

Border Health Research Report

National Latino Research Center, 2004

 Border Voices: Daily Crossers

Among the millions of daily crossers is Claudia, who was born in the United States and grew up in Mexicali, Baja

California. She now lives with her husband, Alejandro, and their three children: Gabriela (9 years old), Alejandro Jr. (8

years old), and Ana Claudia (5 years old) in San Diego. Every day she crosses the border south into Tijuana to take her

children to private school. Claudia explains, “My children [girls] go to a private school in Tijuana for the quality of

education and because they can have bilingual education.”

6

  

The border population poses challenges to the U.S. health care system: 

It is one of the fastest growing in the nation with a majority Hispanic 

population.

Population growth in the 

border region has increased at 

a far faster rate than the U.S. 

population as a whole. In the 

United States, the four border 

states have accounted for more 

than one-third of the nation’s 

population growth since 

2000.

7

 Between 1990 and 

2000, the population of the 

collective southwest border 

counties has increased by 29.3 

percent.7

 

Figure 2

More than 13 million people 

live in the U.S.-México border 

region, 53 percent of them on 

the United States side. If rapid 

population growth trends 

persist (more than twice that 

of the overall growth in each 

country), the total population, 

on both sides combined, is expected to reach 20 million by 2020.7
 Health Care Reform and the U.S.-México Border 

United States-México Border Health Commission 

5 

In 2008, 52 percent of the population living in border counties was Hispanic as compared to 36 percent in the 

border states and 15 percent in the United States as a whole (Figure 2). Counties in Texas have the highest 

percent of Hispanics: Starr 97.3 percent, Maverick and Webb 94.5 percent, and Hidalgo 89.6 percent, 

followed by Santa Cruz (AZ) at 80.2 percent, Imperial (CA) at 76.7 percent, and Doña Ana (NM) at 64.9 

percent.8

 

 

Five percent of the U.S. border region is tribal. The twenty-six U.S. indigenous tribes contribute to the 

unique population and health challenges in the border region as well. For example, the Tohono O'odham 

Nation of Arizona and Sonora, straddle the border with members living on both sides.9

 

According to the 2008 U.S. Census, persons under 19 years of age comprised 31 percent of the population in 

border counties, 29 percent in border states, and 27 percent in the United States.8

 

Border challenges contribute to diminished health, well-being, and 

access to health care. 

 

Border residents tend to experience socio-economic vulnerabilities that can lead to poor health, including 

persistent poverty, low educational achievement, high rates of unemployment, and the impact of rapid 

population growth. 

Lower educational achievement 

The socio-economic gap between the border counties and the rest of the United States is the widest in the 

nation. As of 2000, if the border counties were a state, it would rank 50th in the nation in the percent of 

population at age 25 or above who completed high school (66.1% for border counties, excluding San Diego 

County, compared to 80.4% for the U.S.).7,10

Figure 3

Lower income status 

and high poverty rates 

Data Source:  U.S. Census Bureau, ACS, 2008

U.S.

Persons Living below Poverty Level in the U.S. and Border Region

In 2007, the per capita 

annual income ($26,842) in 

the border counties was 

only about two-thirds the 

level in the border states 

($39,013) and the overall 

U.S. population ($38,839). 

In addition, poverty is 

almost twice as high in 

border counties (25%) 

compared to the United 

States (13%) (Figure 3). 
 Health Care Reform and the U.S.-México Border 

United States-México Border Health Commission 

6 

Higher unemployment Figure 4

The unemployment rate in border 

counties has been chronically high 

(excluding San Diego and Pima 

Counties) ranging from 15.7 in 

1990 to 11.5 in 2008 as compared to 

the United States which was at 5.6 

for those respective years (Figure 

4).11

The border economy is 

characterized by low wages and 

composed mostly of services, 

manufacturing, and agribusiness 

industries that typically do not 

provide employer sponsored 

insurance coverage. Additionally, 3 

of the 10 poorest counties in the 

United States are located in Texas 

(Starr, Maverick, and Hudspeth) with 21 of the 4

2,12

4 border counties designated as economically distressed 

reas.

order communities often suffer from avoidable health disparities. 

us 

otentially avoidable through improved social conditions, prevention, and early 

etection and treatment. 

ulosis 

t 

order 

er.13 Intergovernmental collaborations at 

d binational 

sson that diseases do not respect political borders. 

as 

a

B

As a result of these socio-economic disparities, border residents disproportionately suffer from infectio

diseases and health conditions such as tuberculosis as well as chronic diseases, including diabetes and 

obesity, all of which are p

d

Tuberculosis

According to a recent 2009 United States-México Border Health Commission (BHC) report, the tuberc

(TB) rate in the United States is highest among foreign-born persons and racial/ethnic minorities.13 In 

addition, México has a higher case rate of TB, 20 per 100,000 population as compared to the United States a

4.4 per 100,000.13 Numerous converging factors contribute to elevated tuberculosis incidence in the border 

region including the following: 1) widespread poverty and limited access to health care; 2) frequent b

crossings into both countries for employment, commerce, health services, and leisure; and 3) lack of 

coordinated care across health jurisdictions on the U.S.-México bord

all levels are necessary to prevent and control TB and prevent other 

future infectious diseases and virus outbreaks.13 Undoubtedly, the 2009

outbreak of Influenza A (H1N1) was a stark global an Border childhood obesity must

be integrated into all health

reform discussions given the

potential impact on the health of

our nation.

E n

P

Obesity, Institute of Medicine

duardo Sanchez, MD, Committee o

rogress in Preventing Childhood

le

Childhood Obesity

Another BHC report recognizes that childhood obesity is reaching 

epidemic proportions in the border region.14 For example, the Tex

Department of State Health Services’ 2004 Youth Risk Behavior 

Survey (YRBS) shows that among 4th graders, 22.4 percent were obese 

and 38.7 percent were overweight, which is up to 1.5 times higher than 
 Health Care Reform and the U.S.-México Border 

United States-México Border Health Commission 

7 

the U.S. average.14 The health of border children has a huge impact on the nation’s future given its unique 

characteristics as a fast growing and youthful population with higher obesity risks. Thus, as Dr. Eduar

Sanchez has stated, “Childhood obesity along the border must be integrated into all discussions abou

care reform 14

do 

t health 

 given the impact on the overall health of our nation.” 

Diabetes 

Diabetes is also a growing concern in the U.S.-México border region. Diabetes prevalence among Hispanics 

living in the border region is more than twice the prevalence among non-Hispanic whites.15 In 2007, 9.5 

percent of adults in the U.S. border region reported having ever been told by a health professional that they 

have chronic diabetes. This was slightly higher than the overall U.S. adult population (8.0 %).16 But, limited 

access to care may inhibit professional diagnosis of diabetes. Border county residents living in California, 

Texas, and Arizona have a significantly higher diabetes hospital discharge rate (16.6 per 10,000) compared 

to their counterparts living in non-border counties (14.9 per 10,000).17 

These are just a few examples of avoidable health disparities that have serious individual and social costs.

Border residents who have chronic conditions suffer needlessly as a result of not receiving early diagnosis, 

appropriate treatment, and guidance on how to manage their disease. 

 Border Voices: Avoidable Health Disparity 

Such is the case of Roberto, an elderly African‐American man in his 60s. “After weeks of complaining that my legs

were sore, I was taken to an emergency room where I learned that I was suffering from complications from diabetes.

Though emergency measures were taken, the slit on my foot had progressed to the point where I needed an

amputation.”18  

Adverse health conditions in the border region such as tuberculosis, obesity, and diabetes incur high costs to 

the health care system, the economy, and society. For example, high proportions of obesity and diabetes in 

adults and children, when left undetected or untreated, result in high emergency room utilization. Uninsured, 

low income adults with chronic conditions (diabetes, heart disease, and depression) often delay or do not 

receive needed care because of the cost of primary care leading to expensive hospital care.19 Second, the 

long-term consequences of childhood obesity include a shortened life expectancy and a host of other related 

health problems and diseases into adulthood, which will ultimately become an increased burden on the 

nation’s taxpayers. Finally, research examining diabetes and the labor market in South Texas shows that the 

indirect costs of diabetes extend to lost labor income due to lost productivity and a reduction of spending to 

the local economy.20

Lack of health coverage in the border region has adverse 

consequences for health and health care. 

 

Residents in the border region lead the nation in lacking health coverage. Low coverage rates are partially 

explained by the fact that fewer workers, particularly those with lower wages, are offered employersponsored insurance, and fewer among the workers that are offered such insurance can afford the 

premiums.21 From 2000 to 2003, 23 percent of persons of all ages living in border states lacked health 

insurance coverage, as compared to 14.7 percent nationally (Figure 5).22 Border states also had the lowest 

private insurance coverage in the nation with New Mexico ranking the lowest at 57.2 percent, Arizona at 

61.1 percent, Texas at 61.9 percent, and California at 65.9 percent compared to the U.S. average at 70.3 

percent.23 In addition, Hispanics living in border counties were significantly more likely than any other 
 Health Care Reform and the U.S.-México Border 

United States-México Border Health Commission 

8 

group to be without health insurance coverage for more than a year (86.9% compared to 68.6% non-His

border residents, 82.5% Hispanics, and 68.5% non-Hispanics in the United States).

panic 

ore 

e 

21 

Children living in the border 

region are also at high risk for 

being uninsured. For example, 

Texas leads the nation in the 

proportion of children without 

coverage at 18.7 percent 

compared to the United States 

average at 9.3 percent. New 

Mexico’s children are the least 

likely in the nation to have 

private insurance coverage at 

42.2 percent compared to the 

United States at 61.5 percent.23

Furthermore, citizen children in 

families where one or more 

parents are non-citizens are m

likely to live in poverty than ar

those in native-born families 

(21% vs. 13.4%), to be 

uninsured, less likely to have 

employer sponsored coverage, and less likely to have a usual source of health care.24 

Figure 5

C urren t L ack o f H ealth Ins u ranc e C overag e o f

US vs. U ‐2003

14.7

22.9

0

5

10

15

20

25

P erc ent S ‐Mexic o B order, 2000

Ultimately, long-term disparities in insurance coverage result in inadequate access to health care services and 

significantly compromise health outcomes. Without coverage, the uninsured receive fewer services, or no 

care at all, than their insured counterparts.25 

 Border Voices: The Uninsured

 

Such is the case of Guadalupe, a 64 year old Hispanic mother of two who works part‐time: “I had a gallbladder attack.

It was horrible pain and I could not sit down. I could not have the surgery because we did not have insurance. I would

walk the house until the pain went away. It took about four or five years to get insurance and we just did not go to

doctors because they were too expensive. We just didn’t go, even if we were sick. We took home remedies like

aspirin, milk of magnesia, over the counter remedies, herbs. But I would not go to doctors because just the visit was

$75. And that means my kids too; two boys that did not go.”18  

Research confirms that many border families experience barriers to obtaining needed preventive and medical 

care.22 From 2000 to 2003— 

• Border residents were more likely to self-report a significant inability to afford and access medical 

care such as contact with a general doctor, dentist, and professional mental health services.22 

• The adult population on the border was less likely than the average U.S. individual to have seen or 

talked to a general doctor in the past year (56.7% vs. 68.2%) and a specialist in the past year (19.9% 

vs. 25.7%). 

• Women living on the border were less likely to have an OB/GYN visit in the past year than the 

average woman in the United States (40.8% vs. 45.6%). 

US US ‐Mex ic o Borde r

Current Lack of Health Insurance Coverage of

U.S. vs. Border Region

Data S ourc e: 2000‐2003, National Health Interview S urvey, In‐hous e data file,

C DC /NC HS ;  R etrieved by Notz in, F . & A lbertorio‐Diaz , J .

Data Source:  2000‐2003, National Health Interview Survey, In‐house data

file, CDC/NCHS; Retrieved by Notzon, F. & Albertorio‐Diaz, J.  

U.S. U.S. Border Region
 Health Care Reform and the U.S.-México Border 

United States-México Border Health Commission 

9 

• Border residents were also less likely to have visited a dentist in the past 12 months (61% and only 

44% for border Hispanics) compared to the rest of the United States at 64 percent. 

Lack of access to appropriate care is even greater for Hispanics living in the border region compared to nonborder Hispanic residents in the border states and the overall U.S. population. According to a 2009 study 

published by the National Center for Health Statistics,23 Hispanics who live on the border are— 

• Less likely than the average U.S. Hispanic to have a usual source of care (31.9% vs. 28.4%) 

• Less likely to have seen a doctor during the previous year (45.2%) compared to the non-Hispanic 

border population (64.2%) 

• Less likely than non-Hispanics to report contacts with a specialist (11.7% vs. 25.2%), and 

• Twice as likely to report that they could not afford dental services (16.8%) compared to nonHispanic border residents (8.1%). 

High rates of uninsurance and lack of access to care affect the health care for the insured population in the 

border region. When community-level rates of uninsurance are relatively high, insured adults in those 

communities are more likely to experience difficulties obtaining needed health care (less likely to report a 

usual source of care, having seen a doctor or received routine preventive care, and having seen a specialist) 

and to be less satisfied with the care they receive. For example, analysis of the Community Tracking Study, 

conducted by the Center for Studying Health System Change, found that women aged 40 to 69 were less 

likely to report they had a mammogram screening within the last year if they resided in communities with 

relatively high uninsurance rates.26 

Border hospitals, health care providers, and community health centers 

continue to absorb growing uncompensated health care costs.

Figure 6

According to the 

American Hospital 

Association’s annual 

survey, southwest 

border county 

2007 T yp rage:

US

B o

12 13 15

39

35

8

45

30

8

0

10

20

30

40

50

Uninsured Me dicaid Me dica re

Data S ource: National A s s oc iation of C ommunity Health Centers , Uniform Data

S ys tem, 2007; Retrieved by M. Pros er

P ercent

e of Ins uranc e C ove

, Health C ente rs Nation‐wide, Health C ente rs in

rder C ounties

hospitals reported US

uncompensated care 

totaling nearly $832 

million in 2000.27 In 

addition, federally 

qualified health centers 

located in the border 

region provide a 

primary care home to 

the largest proportion 

of uninsured in the 

nation (Figure 6). 

AIl Health C enters

H

B s

ealth C enter

order C ountie

Health Centers in

Border Counties

All Health Centers

U.S.

Insurance Coverage:  

U.S., Health Centers Nationwide, and Health Centers in  

Border Counties

For example, in 2007, 

of the total border residents served by community health centers, 45 percent were uninsured compared to 

residents served by health centers nationwide where 39 percent were uninsured.28 While it is critical to 
 Health Care Reform and the U.S.-México Border 

United States-México Border Health Commission 

10 

increase access to healthcare services in border communities, it is also necessary to increase the number of 

health care professionals serving the health needs of border communities. 

A national “911” call to report missing persons along the border: 

health care professionals. 

The lack of health care providers is in a state of emergency in the border region because of the shortage of 

physicians, dentists, and other health providers. Data from the Health Resources and Services Administration 

(HRSA), an agency of the U.S. Department of Health and Human Services (HHS), demonstrates the state of 

emergency due to health professional shortages along the border region including physicians, dentists, 

physician assistants, nurse practitioners, registered nurses, and pharmacists. For example, physicians per 

10,000 population for all border counties is 16.3 compared to 23.2 percent for the border states as a whole, 

26.2 for non-border counties in the border states, and 26.1 percent for the United States as a whole.29 Other 

bleak shortage disparities include low rates of dentists (5.1 per 10,000 for border counties excluding San 

Diego vs. 6.5 for the U.S.); almost half the supply of nurse practitioners than the national rate (1.4 for border 

counties vs. 2.3 for the U.S.); registered nurses also fall below the national rate (43.1 vs. 57.6); and while a 

bit more in supply, the rate of pharmacists in border counties (4.4) are lower than the United States (5.3).29

 Border Voices: Shortage of Health Care Professionals 

Community health center administrators like Marcos struggle to serve the mass of patients needing primary care:  

“One of the major problems on the border is the lack of doctors. Take El Paso, for example. At this very moment we

are in need of at least 600 doctors. Just at this very moment! An individual may come into our health center and they

will get an appointment three months from now. If they go to the county hospital, it may be six months. If the person

has cancer, [the lack of doctors] is a death sentence.”30    

The under-representation of minorities in the health professions and 

the educational pipeline also affect the availability and quality of 

health care services for border communities. For example, in 2002, 

only 3.3 percent of physicians practicing in the United States were 

Hispanic. African-Americans represented only 2.2 percent and 

American Indian/Alaskan Natives .05 percent.31 

The shortage of supply and lack of culturally and linguistically 

competent providers are barriers to health care. For instance, cultural 

and linguistic compatibility between patients and providers is shown 

to improve communication32 and adherence to treatment,33 promote 

higher levels of patient satisfaction,34 and improve the likelihood of 

preventive screening.35

A positive step has been the increased funding for medical and health 

professional pipeline programs such as the recently inaugurated 

Texas Tech University Health Sciences Center Paul L. Foster School of Medicine in El Paso, Texas, the first 

four-year medical school in Texas in the last 30 years. “We are centrally located in border communities and 

serve as a national model of excellence for training our future health care leaders equipped to tackle the 

unique health conditions of border communities,” stated Dr. Jose Manuel de la Rosa, Founding Dean of the 

Texas Tech University Health Sciences Center Paul L. Foster School of Medicine. 

We (The Texas Tech University

Health Sciences Center Paul L.

Foster School of Medicine in El

Paso, Texas) are centrally located

in border communities and serve

as a national model of excellence

for training our future health care

leaders equipped to tackle the

unique health conditions of

border communities.  

Dr. Jose Manuel de la Rosa,  

Founding Dean  
 Health Care Reform and the U.S.-México Border 

United States-México Border Health Commission 

11 

Border residents who are uninsured often cannot afford the high costs of medical services in the United 

States or live in areas where there are no available health care professionals and, therefore, opt to seek care in

México for more affordable services such as prescription drugs and dental care. 

U.S. residents often head south of the border due to the high cost of 

health care. 

The availability of lower cost health services in México, including prescription drugs and dental care, is 

considered by many U.S. residents as a cost effective alternative source of care. For instance, a study

conducted in Texas border counties found that among those under age 65 who reported no health insurance 

were 3 to 7 times more likely to use medical care in México than the insured.36 A San Diego study of two 

urban emergency departments found that 7 percent of those surveyed reported using medications purchased 

outside of the United States, mostly in México.37 Two studies in Texas found that 41 percent of Hispanic 

residents residing in Laredo, Texas, utilized cross-border health care services in México38and that 86 percent 

of low income El Paso residents surveyed said they received medical care or bought prescription drugs from

México. In New Mexico more than 37 percent of uninsured border residents seek medical care in México.39 

The border region can serve as a source for identifying innovative 

models. 

The border health care burden offers an opportunity to identify innovative models that bring together 

multiple levels of government and leaders across geographic and jurisdictional borders by improving access 

to health care, creating a culture of wellness and prevention, and promoting evidence-based interventions and 

models of excellence. 

 Improving access to health care on the border. 

The history of border collaboration, and cooperation provides a strong foundation for developing creative 

models for reducing the high uninsurance rates among border communities, especially among children and 

Hispanics. 

Greater access to care will require improved health workforce development, training, placement, and 

retention. Opportunities could include the following: 1) promoting new exchange programs to train border 

and binational health professionals, 2) promoting health professions education beginning in primary schools, 

3) building on successful models such as the HHS Health Careers Opportunity Program, National Health 

Service Corps, the U.S. Public Health Service, and 4) increasing culturally and linguistically competent 

training for health care professionals.
 Health Care Reform and the U.S.-México Border 

United States-México Border Health Commission 

12 

 Creating a culture of wellness and prevention and strengthening the public 

health infrastructure. 

Public health and prevention are the cornerstones of healthy communities. Shifting the focus of the 

healthcare system from the treatment of disease to health promotion and prevention is the key to good health. 

Improvements in the border public health infrastructure as well as the institutional and human resource 

capacities are necessary to prevent diseases and eliminate health disparities. For example, research 

demonstrates that increased access to a medical home is “associated with better health, on both the individual 

and population levels, with lower overall costs of care and with reductions in disparities in health between 

socially disadvantaged subpopulations and more socially advantaged populations.”40 Other health 

infrastructure strategies could include improved disease surveillance systems such as the Early Warning 

Infectious Disease Surveillane (EWIDS) and the Border Infectious Disease Surveillance (BIDS) programs, 

efficient and effective data collection, and the promotion of electronic health records. 

 Promoting evidence-based interventions and models of excellence. 

Drawing on lessons learned and best practices can also improve access to health care, not only for border 

communities, but for diverse communities in the United States. Examples of effective interventions from

public health research include the following: 

 

1) Enhance outreach efforts such as the use of community health workers (CHW) or promotoras(es), popular 

along the border region, as patient navigators who ensure access to and promote optimal patient utilization of 

health services. CHWs are both a growing model and network that are promising in reducing the disease 

burden among U.S.border communities.41 Promotoras are socially positioned to bridge the divide between 

rural and underserved communities and the health care systems in the United States. In 2003, The BHC 

conducted the Border Models of Excellence initiative to identify promotora-based best practices and models 

along the border region.42 The Border Models of Excellence Compendium can be found on the BHC website 

at http://www.borderhealth.org. The promotoras model was proven to be a successful framework that can be 

replicated throughout the country as it has in some regions to date. 

2) Build on the enterprise of cross-border health care exchanges. Multiple “borderless” innovations have 

been piloted and have shown positive outcomes for improving health care access and increasing the quality 

of care. For example, since the 1990s, several organizations from both countries have been exploring the 

options for binational health insurance. Binational health insurance has been implemented in California, 

allowing employers to purchase insurance coverage for their employees who either live in México or prefer 

to use health services in that country.

43,44 

3) Promote Healthy Border 2010 and the forthcoming Healthy Border 2020, an initiative for health 

promotion and disease prevention developed by the BHC, as a valuable framework for addressing 

borderwide health disparities,45 and as a model that can be replicated in other multi-state regions in the 

United States. 

Improving access to health care on the border, creating a culture of wellness and prevention, and promoting 

evidence-based interventions and models of excellence can ensure deliberate and sustained actions to 

improve health conditions in the border region and thereby elevate the health of the nation. 
 Health Care Reform and the U.S.-México Border 

United States-México Border Health Commission 

13 

References: 

 

1

 Defined in P.L. 103-400 (22 U.S. Code, 290 n-5) and the La Paz Agreement of 1983. 2

 United States-México Border Health Commission. (n.d.) U.S.-México border region at a glance. Retrieved May 31, 

2009 from http://www.nmsu.edu/~bec/BEC/Readings/10.USMBHC-TheBorderAtAGlance.pdf 3

 United States-México Border Health Commission,U.S. Section Outreach Offices, personal communication, September 

22, 2009. 

4

 U.S. Environmental Protection Agency. U.S.-Mexico Border 2012 Program: people along the border. Retrieved 

November 27, 2009 from http://www.epa.gov/Border2012/framework/people.html#tribes. 5

 U.S. Department of Health and Human Services. (2000). Health on the U.S.-Mexico Border: past, present, & future.

Washington, D.C. 

6

 International Community Foundation. (2004). Blurred borders: Transboundary issues and solutions in the San 

Diego/Tijuana border region. Retrieved May 30, 2009 from 

http://www.calendow.org/uploadedFiles/blurred_borders(1).pdf. 7 U.S.-Mexico Border Counties Coalition. (2006). At the cross-roads: U.S.-Mexico border counties in transition. El Paso, TX: 

Soden, D.L. Retrieved May 30, 2009 from http://www.bordercounties.org/index.asp?Type=B_BASIC&SEC={62E35327-

57C7-4978-A39A-36A8E00387B6}. 8

 United States Census Bureau. Vintage 2008 Population Estimates [Data file]. Retrieved October 1, 2009 from 

http://www.census.gov/popest/cities/cities.html. 9

 Border 2012 National Coordinators Meeting. (April 25-27, 2006). Tribal Accomplishments & Issues Report. Ensenada, 

Baja California, Mexico. Retrieved July 17, 2009 from http://www.epa.gov/usmexicoborder/publications.html#tribal. 10 Not including San Diego where the income, educational, and employment levels are much higher than the rest of the border. 

Thus, San Diego is a socio-economic and demographic outlier. 

11 United States Department of Labor. Local Area Unemployment Statistics [Data file]. Retrieved from 

http://data.bls.gov/PDQ/servlet/SurveyOutputServlet?data_tool=latest_numbers&series_id=LASST39000003. 12 United States Census Bureau. American Community Survey, 2008 [Data file]. Retrieved May 30, 2009 from 

http://www.census.gov/acs/www/. 13 United States-México Border Health Commission. (2009). Tuberculosis along the United States-México border: A white 

paper. El Paso, TX: United States-México Border Health Commission. 14 United States-México Border Health Commission. (2009). Childhood obesity and the U.S.-México border: A white paper. 

El Paso, TX: United States-México Border Health Commission. 

15 Teufel-Shone, N.I., Drummond, R., & Rawiel, U. (2005). Developing and adapting a family-based diabetes program at the 

U.S.-Mexico border. Preventing Chronic Disease, 2(1), 1-9. 16 Centers for Disease Control & Prevention. Behavioral Risk Factor Surveillance System [Data file]. Retrieved May 30, 2009 

from http://www.cdc.gov/nccdphp/. 17 Albertorio-Diaz, J.R., Notzon, F. S., & Rodriguez-Lainz, A. (2007). Diabetes hospitalization at the U.S.-Mexico 

border. Preventing Chronic Disease, 4(2), A28. 18 Bruna, S. P., personal communication, July 14, 2009. 

19 Reed, M.C. &Tu, H.T. (2002). Triple jeopardy: Low income, chronically ill and uninsured in America. Center for Studying 

Health System Change, 49, 1-4. Retrieved May 30, 2009 from http://www.hschange.com/CONTENT/411/411.pdf. 20 Brown, H.S., Estrada, J.K., Gautam, H., & Bastida, E. (2005). Diabetes and the labor market: The community-wide 

economic cost in the lower Rio Grande Valley. Diabetes Care, 28 (2), 2945-2947. 21 Institute of Medicine of the National Academies. (2009). America’s uninsured crisis: Consequences for health and health 

care. Washington, D.C.: The National Academies Press. 22 Notzon, F.S. & Albertorio-Diaz, J. (2008). Access to and use of health care. In Border lives: Health status in the United 

States-Mexico border region. El Paso, TX: United States-México Border Health Commission. 23 Cohen, R.A. & Makuc, D.M. (2008). State, regional, and national estimates of health insurance coverage for people under 

65 years of age: National health interview survey, 2004 - 2006. Hyattsville, MD: National Center for Health Statistics. 24 Acevedo-Garcia, D. & Cacari Stone, L. (2008). State variation in health insurance coverage for U.S. citizen children of 

immigrants. Health Affairs,2 (2):434-446. 25 Institute of Medicine of the National Academies. (2002). Care without coverage: Too little, too late. Washington, D.C.: 

The National Academies Press. 

26 Pagan, J.A., Asch, D.A., Brown, C.J., Guerra, C.E. & Armstrong, K. (2008). Lack of community insurance and 

mammography screening rates among insured and uninsured women. Journal of Clinical Oncology, 26 (11): 1865-1870. 27 U.S.-Mexico Border Counties Coalition. (2002). Medical emergency: Costs of uncompensated care in southwest border 

counties. Washington, D.C.: MGT of America. 
 Health Care Reform and the U.S.-México Border 

United States-México Border Health Commission 

14 

 28 National Association of Community Health Centers. Uniform Data System, 2007 [Data file]. (non-public use data).

29 Health Resources and Services Administration. Area Resource File, 2007 [Data file]. Retrieved by the Robert Wood 

Johnson Foundation Center for Health Policy at the University of New Mexico. (non-public use data).

30 Bruna, S. P., personal communication, July 15, 2009. 

31 The Sullivan Commission. (2004). Missing persons: Minorities in the health professions. A report of the Sullivan 

Commission on diversity in the healthcare workforce. Washington, D.C.: The Sullivan Commission. 32 The Commonwealth Fund. (2002). Diverse communities, common concerns: Assessing healthcare quality for minority 

Americans. New York, NY: Collins, K. S., Hughes, D. L., Doty, M. M., Ives, B. L., Edwards, J. N., & Tenney, K. Retrieved 

May 30, 2009 from http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2002/Mar/Diverse-CommunitiesCommon-Concerns--Assessing-Health-Care-Quality-for-Minority-Americans.aspx. 33 Cooper-Patrick, L. (2002). Patient-provider communication: The effect of race and ethnicity on 

process and outcomes of healthcare. In B. Smedley, A. Stith, & A. Nelsen (Eds.), Unequal 

treatment: Confronting racial and ethnic disparities in healthcare (552-593). Washington, D.C.: 

The National AcademiesPress. 

34 LaVeist, T., Nickerson, K. J., & Bowie, J. (2000). Attitudes about racism, medical mistrust and 

satisfaction with care among African American and White cardiac patients. Medical Care Research 

and Review, 57, 146-161. 35 Ponce, N. A., Gatchell, M., Liu, J. T., Dimas, J., & Quan, K. (2005). Cultural concordance between patient and primary 

care provider and cervical cancer screening [Oral presentation]. Philadelphia, PA.: American Public Health Association. 36 Brown, H.S., Pagan, J.A., & Bastida, E. (2009). International comparison and the demand for health insurance in the US: 

Evidence from the Texas-Mexico border region. International Journal of Health Care Finance Economics, 9, 25-38. 37 Guzman, G.C., Khaleghi, M., Riffenberg, R.H., & Clark, R.F. (2007). A survey of the use of foreign-purchased medications 

in a border community emergency department patient population. The Journal of Emergency Medicine, 33 (2), 213-221. 38 Landeck, M. & Garza, C. (2002). Utilization of physician health care services in Mexico by US Hispanic border residents. 

Health Marketing Quarterly, 20 (1), 3-16. 

39 Macias, E.P. & Morales, L.S. (2001). Crossing the border for health care. Journal of Health Care for the Poor and 

Underserved, 12 (4), 77-87. 40 Starfield, B. & Shi, L. (2004). The medical home, access to care and insurance: A review of the evidence. Pediatrics, 113 

(5),1493-1498.

41 Anders, R.L., Balcazar, H., & Paez, L. (2006). Hispanic community-based participatory research using a promotores de 

salud model. Hispanic Health Care International, 4(2), 71-78. 42 United States-México Border Health Commission. (2003). Border models of excellence compendium. El Paso, TX: 

United States-México Border Health Commission. Retrieved May 31, 2009 at 

http://www.borderhealth.org/extranet/files/file_1359.pdf. 43 University of Texas Teresa Lozano Long Institute of Latin American Studies. (2004). Cross-border health insurance: 

Options for Texas. Austin, TX: Warner, D.C. & Schneider, P.G. 44 Witmer, A., Seifer, S.D., Finocchio, L., Leslie, J., & O’Neil, E.H. (1995). Community health workers: Integral members of 

the health care work force. American Journal of Public Health, 85(8),1055-1058. 45 United States-México Border Health Commission. (2009). Healthy border 2010 midterm review: U.S. border area. El Paso, 

TX: United States-México Border Health Commission. Retrieved July 14, 2009 from 

http://pm3.stantonstreetgroup.com/newsletters/us_border_health/files/newsletters_article8174.pdf. 

Credits: 

A special thanks to Lisa Cacari Stone, Ph.D., at The Robert Wood Johnson (RWJF) Center for Health Policy at the University 

of New Mexico, for her invaluable research, writing, and consultation provided to this project. Other contributions made by 

Sean Bruna, M.A., Doctoral Fellow, Blake Boursaw, M.S., and Maurice Moffett, Ph.D. at the The Robert Wood Johnson 

Center for Health Policy and Jack Baker, Ph.D. at the Bureau of Business and Economic Research at the University of New 

Mexico. Thanks to Robert O. Valdez, Ph.D., RWJF Center, for review of an earlier draft. 
The United States–México Border Health Commission 

Providing Leadership on Border Health Issues to – 

Facilitate Identification, Study, and Research 

Be a Catalyst to Raise Awareness 

Promote Sustainable Partnerships for Action 

For additional information please visit our website at www.borderhealth.org. 

United States–México 

Border Health Commission 

211 N. Florence, Suite 101 

El Paso, TX 79901 

Tel: (915) 532-1006 

Fax: (915) 532-1697 

Toll Free (866) 785-9867 

www.borderhealth.org

Comisión de Salud Fronteriza 

 México-Estados Unidos 

Avenida Durango No. 247 

4o piso 

Col. Roma, Delegación Cuauhtémoc 

C.P. 06700 México, D.F. 

Tel./Fax (01152-55) 3611-0765 

www.saludfronteriza.org.mx