Increase of catastrophic and impoverishing health expenditures in Mexico associated to policy changes and the COVID-19 pandemic

Background In 2003, the Mexican Congress approved a major reform to pro-vide health care services to the poor population through the public insurance scheme Seguro Popular. This program was dismantled in 2019 as part of a set of health system reforms and substituted with the Health Institute for Welfare (INSABI). These changes were implemented during the initial phases of the coronavirus (COVID-19) pandemic. We aimed to examine the impact of these reforms and the COVID-19 pandemic on financial risk protection in Mexico between 2018 and 2020.Methods We performed a population-based analysis using cross-sectional data from the 2018 and 2020 rounds of the National Household Income and Expen-ditures Survey. We used a pooled fixed-effects multivariable two-stage probit model to determine the likelihood of catastrophic health expenditure (CHE), impoverishing health expenditure (IHE), and excessive health expenditure (EHE) among Mexican households. We also mapped the quintiles of changes in EHE in households without health insurance by state. Results The percentage of households without health insurance almost dou-bled from 8.8% (three million households) in 2018 to 16.5% (5.8 million house-holds) in 2020. We also found large increases in the proportion of households incurring in CHE (18.4%; 95% confidence interval (CI) = 6.1, 30.7) and EHE (18.7%; 95% CI = 7.9, 29.5). Significant increases in CHE, IHE, and EHE were only observed among households without health insurance (CHE: 90.7%; 95% CI = 31.6, 149.7, EHE: 73.5%; 95% CI = 25.3, 121.8). Virtually all Mexican states (n/N = 31/32) registered an increase in EHE among households without health insurance. This increase has a systematic territorial component affecting most-ly central and southern states (range =-1.0% to 194.4%).Conclusions The discontinuation of the Seguro Popular Program and its substitution with INSABI during the first stages of the COVID-19 pandemic reduced the levels of health care coverage in Mexico. This reduction and the pandemic increased out-of-pocket expenditure in health and the portion of CHE and EHE in the 2018-2020 period. The effect was higher in households without health insurance and households in central and southern states of the country. Further studies are needed to determine the specific effect both of recent policy changes and of the COVID-19 pandemic on the levels of financial protection in health in Mexico.