The Initiative to extend Medicare into Mexico : A case study in changing

This study examines the geo-political activities of interest groups, governments and multinational corporations involved in an initiative to extend Medicare to U.S. retirees residing in Mexico.  If the initiative to change the current Medicare policy succeeds, the relocation of Medicare-eligible populations from the U.S. to Mexico is likely to increase; the U.S. is expected to gain cost-savings for taxpayers on Medicare; Mexico can develop senior-housing and options for long-term care it currently lacks; and foreign-led multinational corporations will increase their profits and dominance, fostering even more privatization in Mexico’s health care sector. By exploring new issues about retirement migration and health this study seeks to gain knowledge about the phenomena in a number of areas.  First, the retirement migration of North Americans to Latin America is an under-studied phenomenon in the fields of social gerontology, migration research, and health policy studies.  Second, the Medicare in Mexico initiative is even less well-known among health policy scholars than the retirement migration phenomenon into Mexico. Yet this initiative is inherently international in scope and involves a number of US-based institutions and interest groups actively promoting the project from within Mexico. Thus, the initiative has important geo-political and socio-economic implications for reforming health care systems in the U.S. and Mexico.

due to declining Medicare profits, the U.S.-based insurance providers transformed into multinational organizations and expanded into Latin America. 7 US-based corporations solidified their dominant position in Mexico by successfully executing three integrated strategies: (1) Theyinvested in joint ventures with local companies that have established clientele and experience in navigating complex legal systems and avoiding restrictions on foreign enterprise.
(2) Theyimplemented a "trade show approach" that expands a client base, fosters interest in managed care ideals, and influences health care leaders and policy makers through corporate-organized conventions or presentations at professional meetings.
(3) They persuaded their own governments to influence international trade organizations to act in favor of their interests and activities. 8e successful penetration of the Mexican public health care market by US-based MNCs can be attributed to at least two important events that provided conditions ripe for exploitation.First, according to Homedes and Ugalde, the implementation of the North American Free Trade Agreement (NAFTA) in 1994 did little to foster binational collaboration between the different health care systems, but it greatly reduced trade barriers that initially facilitated partnerships between US-based MCOs and Mexican health care providers, ultimately leading to their increased dominance in the Mexican health care industry today. 9Second, Jasso-Aguilar, Waitzkin and Landwehr describe the intervention of International Financing Institutions (IFIs), such as the International Monetary Fund (IMF), which provided loans to Mexico contingent upon implementing major health care reforms that went into effect in 1997, ultimately favoring US-based MCOs by allowing them to compete for public healthcare clients and granting them even greater access to Mexican Social Security funds. 10

II.
International Retirement Migration to Latin America The year 2011 marks the beginning of the largest birth cohort shift in U.S. history as approximately 77 million people (over 25% of the total population) will reach retirement age over the next twenty years. 11Retirees in the 21 st century are healthier, younger and more active than their predecessors, giving rise to a highly mobile and more adventurous form of retirement living. 12A growing trend among retirees today is to seek retirement locations outside the country, especially in Latin America, and mainly in Mexico, where the largest concentration of U.S. expatriate retirees-approximately one million-now reside. 13e southern migration flow of retirees from Canada and the U.S., which includes Mexican-born "returnees" and possibly other individuals from various Latin American nations, is best described as the American International Retirement Migration (the American IRM) in Latin America. 14Indeed, as has been observed, "International Retirement Migration is a highly selective migration process which redistributes (retired) individuals-and their concomitant incomes, expenditures, health and care needs-across international boundaries." 15This phenomenon is perceived as a subset of lifestyle migrations, which share a common theme of "the relocation of people within the developed world searching for a better way of life." 16At least three groups of retirees are migrating from the U.S. to Mexico: a) relatively affluent (compared to Mexico) retired U.S. citizens of non-Mexican origin with $15K to $25K in annual income; b) lower-middle to lower-income (< $15K) retired U.S. citizens of non-Mexican origin; and c) Mexican-origin retirees from the U.S. who have returned to Mexico in retirement after living and working in the United States as U.S. citizens or Permanent Residents. 17One estimate calculates that roughly 200,000 Medicareeligible U.S. citizens are living in Mexico,18 and among those are an estimated 75,000 to 100,000 Mexican dualcitizen returnees. 19survey of American IRM populations in the Mexican communities around Lake Chapala determined that economic conditionsespecially low cost of living, affordable health care and housingwere the main reasons why U.S. retirees chose to relocate there.20 The study found many similarities with north-south migration patterns within the U.S., leading them to conclude that retirement to Mexico is an extension of later-life migration to traditional retirement states in the south, and southwest.21 The current global economic recession, however, could change migration patterns.Some retirees may need to continue working longer, thus delaying their retirement.Other retirees, unable to afford retirement within the U.S.,  The term "American" is often misused in research to represent those populations who are specifically citizens of the United States of America when, in fact, the term more accurately includes all populations found throughout the Americas (North, Central and South America).The "American International Retirement Migration (American IRM)" into Latin America includes the North American nations of Canada, the United States and Mexico, as well as populations born throughout the rest of Latin America.
Therefore, the term as used here, unless stated otherwise, is inclusive of all North, Central & South American populations who relocate to other Latin American nations and is an appropriate term for identifying this retirement migration phenomenon.This study centers primarily on the largest subgroup of North American international retirement migrants who are non-Hispanic, U.S. citizens, 50 years of age or older.may consider alternatives such as moving abroad, most likely to Mexico, because it is near-by and deemed a lowercost alternative, especially if health care costs continue to rise and current economic conditions continue or worsen. 22Some participants in a study of U.S. retirees in northwest Mexico confirmed "that they could no longer afford health care or were not eligible for health insurance in the U.S., which prompted their moves," leading the authors to conclude that "Mexico may become an alternative for those U.S. retirees facing economic challenges in the future." 23If more Baby Boomers lose their jobs and health care benefits, and if the recession continues, the flow of American IRMs to Mexico could actually increase despite the growing concern about escalating narcoviolence within Mexican/U.S. border communities. 24Thus, the increasing trend towards relocation to Mexico has important implications for the future of Medicare policies in the U.S. and the restructuring of health care systems in both nations.

III.
Research on the American IRM in Mexico Accurate population data on the American IRM to Mexico are difficult to obtain.Due to security issues in identifying its citizens and increasing costs to track populations overseas, the U.S. State Department ceased publishing demographic information on U.S. citizens living abroad as of 1999. 25Consequently, depending on the source, population estimates on U.S. retirees in Mexico can vary widely, from ball-park approximations of around 150,000, 26 to 358,000 using Mexican census data, 27 or that "a million American citizens live in Mexico" according to the official U.S. State Department estimate. 28e core research on American IRMs in Mexico is surprisingly sparse, somewhat narrow in scope, and focused mainly on large enclaves of retirees living in central Mexico or in the Baja California peninsula. 29Thus, the research on the American IRM centers on basic themes, such as: the reasons for retiring to Mexico; 30 quality of life at the destination; 31 identity issues; 32 transnational political involvement; 33 and health care issues among retirees. 34n general, the core research on the American IRM phenomenon in Mexico lacks analysis of the roles played by local interest groups, private enterprise or the state in the relocation process.Most researchers 35  interrelationship of U.S. retirees and organizations that inform and influence relocation decisions, such as, real estate developers who build the resort/retirement communities or the health care industry that is dominated by large-scale, foreign-led corporations in Mexico.North American retirees are a catalyst for development in Mexico, but their role in the globalization process of health care systems in Mexico is not well understood nor well defined.
In his study of U.S. expatriates in Lake Chapala, David Truly found that those who had arrived by the early 1990s were predominantly amenity-seekers who preferred and sought warm climates and local culture. 36But the activation of NAFTA in 1994 brought a surge of "New Migrants" to retirement communities in that region.In contrast to the earlier types of retirees who engage in local culture, the new American migrants (the term "Amigrants" will be used to distinguish them in this article) tended to disengage from participation in the local community by "demonstrating less tolerance for the native Mexican culture, particularly regarding business dealings." 37Amigrants seem to avoid patronizing Mexican-owned businesses in favor of shopping at familiar multinational franchises such as Wal-Mart and Price Club that supply the needs of the new consumer-oriented retirees. 38The newcomers were perceived as "importing a lifestyle" that was made possible by a surge of new businesses catering to their cultural and consumer-oriented tastes. 39day, U.S. retirees are more likely to pursue a Medicare in Mexico initiative than previous waves of amenity-seeking retirees.In 2009, the International Community Foundation (ICF), a US-based, non-profit foundation that functions as an intermediary organization for charitable giving, launched a study of U.S. retirees living along the northwest coast of Mexico. 40 Three key findings emerged from their survey: (1) U.S. retirees living in Mexico apparently "weathered" the economic storm of the global recession; (2) health care is by far "the number one issue of concern among U.S. retirees residing in Mexico", and (3) almost 80% of the respondents favored a pilot Medicare program that would reimburse them for medical care provided in Mexico. 41 The majority of retirees surveyed (57%) travel back to the U.S. to get Medicare services given that "73% still have health insurance [in the U.S.]… 17% of those also carry Mexican health insurance, 7% carry only Mexican insurance, and almost 11% of the participants have no health insurance." 42The ICF study reflects health care issues that are unique to U.S. border regions situated in close proximity to densely populated cities in the U.S. southwest and west.Thus, Mexico is well known by medical tourists as having extremely cost-effective health care, estimated at 25% to 30% of the cost for equivalent procedures offered in the U.S. 43 Health care issues among American IRMs, including Medicare, play an important role in the growth of the health care system in Mexico.Over 70% of those surveyed by the ICF indicated that health care in Mexico was affordable, and 61% found the quality of the health care comparable to the U.S. 44 Many U.S. retirees obtain basic Mexican public sector health care insurance from the Instituto Mexicano del Seguro Social (IMSS), which is available to anyone under 65 years old for approximately $250 to $600 a year.Almost all American IRMs over 65 and living in Mexico must pay out-of-pocket for health care, obtain private health insurance, or return to the U.S. every 90 days to maintain eligibility to receive certain Medicare benefits.For U.S. citizens these conditions are frustrating, time consuming and often expensive.Private insurance in Mexico, offered by US-based multinational insurance and management care organizations, runs between $1,500 and $2,500 per year and is relatively expensive when compared to out-of-pocket costs for the same insurance plans in the U.S., which run between $800 and $7,500 per year. 45

Interest Groups as Stakeholders in the Medicare in Mexico Initiative
The earliest attempts to influence the U.S. government to change Medicare policy for retirees living in Mexico began in the early 1990s with a series of border-health policy studies led by David Warner from the Lyndon B. Johnson School of Public Affairs at the University of Texas, Austin (UT-Austin). 46In 2006, health policy scholars at UT-Austin surveyed almost 1,000 U.S. citizen retirees living mainly in central Mexican retirement communities near Guadalajara (i.e.Lake Chapala and Ajijic), the Puerto Vallarta area, and Guanajuato.The study, which examined the availability of health coverage among U.S. retirees and the feasibility of extending Medicare to Mexico, was intended to inform decision-makers in Washington D.C. to change current Medicare legislation, or at least to authorize a demonstration project that would allow Mexican health care providers reimbursement for services rendered to U.S. citizens residing in Mexico.The argument researchers used to advocate for Medicare in Mexico combined an ideology of social justiceelderly retirees have paid into the system all their lives and now they are not getting what they paid forwith an economic inducement for legislators that, in theory, could reduce escalating Medicare costs in the U.S. 47 On March 30, 2007, at a conference held at UT-Austin, Texas, about health care issues for U.S. retirees in Mexico, major stakeholders from Mexico and the U.S. (i.e.developers, hospital officials, insurance companies and policymakers, including the current Mexican Surgeon General), discussed strategies and methods to extend Medicare coverage to Mexico.Representatives from various sectors of the health care and retirement housing industries, who outnumbered academics and other officials presenting, were all decidedly in favor of a Medicare in Mexico demonstration project. 48Despite the growing interest at the time, policy researchers admitted their publication efforts to change Medicare policy over the years received little attention in the nation"s capitol. 49 2009, a non-profit organization called the Americans for Medicare in Mexico (AMMAC), led by its founder, Paul Crist, claimed success on its website in gaining support from U.S. law-makers to consider a Medicare in Mexico project. 50The organization"s ultimate mission is to influence the U.S. Congress to amend Medicare rules to allow health coverage in Mexico, or, at least, to approve a Medicare demonstration project as an initial step in that direction.Crist is a hotel-resort owner in Puerto Vallarta and a former Legislative Aide to Senator Paul Sarbanes (D-MD) who held town hall meetings throughout Mexico informing retirees about the Medicare initiative.Lobbying efforts by Crist emphasized issues of fairness that retirees in Mexico should be getting what they paid for "through payroll deductions for their entire working lives." 51The incentive that was pitched to law-makers is the 44 Ibid, p.9. potential for a substantial reduction in Medicare costs in the U.S. (35% to 70%) if seniors could get medical services reimbursed in Mexico rather than in the U.S. 52 AMMAC leadership activities attracted media attention to the issue and rallied support from other expatriate organizations such as the Association of American Residents Overseas (AARO), which joined in a letter writing campaign. 53Lobbying efforts continued throughout 2009 and garnered support for the project from 85 congressional offices.On the eve of the health care debates in the U.S. Congress, the AMMAC lobbyist was advised by members of Congress to put the initiative on hold until after the health care reform process was concluded. 54Now that health care reform has passed, Paul Crist believes that "the immigration issue is taking center stage and it has been tough to gain attention for [a] proposed bill" for Medicare in Mexico. 55 Potential Medicare savings could increase even more if the flow of medical tourism and the retirement migration of U.S. citizens into Mexico continues to grow.Warner and Jahnke, calculate that with Medicare available in Mexico, the "lower social service costs might offset the increased obligation of covering care in Mexico since many people who would otherwise become dependent on government programs could become self-sufficient," and if U.S. retirees spend $1,000 in medical services in Mexico that replaces $2,000 in medical costs to Medicare in the U.S., both Mexico and the U.S. will gain new revenues and reduced expenditures, respectively. 56However, there is little, if any, mention in any source of information about projected administrative costs for launching and sustaining a Medicare project in Mexico or what it would mean to the U.S. economy if Medicare trust funds were converted into transnational capital that might encourage the health care industry to move more U.S. health service jobs across the border.

Mexico as a Stakeholder in the Medicare Initiative
In late 2009, Mexico"s foreign-investment agency, ProMexico, reported that the Mexican and U.S. governments had been "negotiating a plan that would allow U.S. citizens to use their Medicare and Medicaid insurance at Mexican health-care facilities." 57Mexican authorities deem the plan "health tourism," and it was aimed to attract Medicare and Medicaid users.Apparently, ten U.S. and Canadian companies indicated an interest in building facilities to cater to medical tourists from the U.S. In spring 2010, Mexican President Calderón discussed a "Medicare in Mexico" initiative with U.S. President Obama and both agreed to discuss the idea further in future talks. 58The motivation to push for the initiative is the increasing burden of aging populations on the Mexican health care system.Recent data from northwest Mexico show that 26% of all U.S. retirees surveyed, and 43% of those over 75, are planning to age-in-place and not return to the U.S. for assisted living if and when it becomes necessary. 59Mexico also faces a growing population of elderly citizens of its own, but its health care sector has  limited senior-housing facilities and few options for long-term care.Without significant funds and assistance from experienced health care providers to develop a long-term care sector, the Mexican government fears the increasing retirement migration flow may overload the entire health care system. 60xico has a total of 4,103 hospitals with more private (3,082) than public (1,121), for a rate of 1.1 hospitals per 100,000 people.But, the distribution of hospitals varies by region, and states with more American IRM (i.e.3.2 hospitals in South Baja California) seem to have more hospitals than other, more populated areas (i.e.0.05 hospitals in the State of Mexico). 61There are at least five nursing that serve roughly 40,000 to 80,000 North American retirees in the central Mexican communities of Lake Chapala and San Miguel de Allende, but there are little data available to ascertain how many retirees are actually living in nursing homes throughout Mexico. 62exico is planning to add a bilingual Spanish-English nursing corps, and through established partnerships with a number of U.S. providers such as the Mayo Clinic, Baylor University Medical Center and the Children"s Hospital of Boston, they plan to develop more assisted-living facilities, nursing care and long-term health care options for all its citizens. 63rner and Jahnke estimate that if an annual increase of 100,000 U.S. retirees relocate to Mexico and spend on average $1,000 in medical services, and $10,000 on other goods and services, it could add an additional $1B or more in foreign exchange dollars for Mexico.The estimated revenue from medical services alone could generate approximately $100M or more a year to invest in the long-term care sector: "It could also mean that major retirement properties would be more viable if [Medicare] reimbursement and high quality medical facilities were available [in Mexico], attracting more retirees." 64Although revenue increases also would create health care jobs for Mexico, the potential to lose those jobs in the U.S. could be a hindrance for approving a change in Medicare policy.
Mexico clearly favors a change in U.S. Medicare policy.The government supports a multi-year pilot program to provide Medicare coverage in Mexico in order to evaluate quality of health care, secure hospital accreditation and test the Medicare payment system. 65According to Paul Crist of AMMAC, there is a lot of interest from the Ministries of Economy and Finance in Mexico who view this as an economic development issue that will encourage more North Americans to retire, buy homes and spend money on goods and services in Mexico. 66However, if Medicare trust funds are converted into transnational capital for access in Mexico, the benefits to the Mexican government would come with a high price.The new revenue would provide opportunities for Mexico to develop a long-term care sector, but the nation cannot do it alone.They must pay for the direct intervention of experienced and high priced US-based health care industry organizations. 67Ultimately, those MNCs would financially benefit the most with not only increased profits, but also greater domination of Mexico"s health care system.

The Effects of Economic Recession on the Real Estate and Retirement-Housing Industry in Mexico
According to David Truly, around the end of the last century, local realtors in Lake Chapala noted that the initial increase in Amigrants also increased housing rentals by roughly 30% to 40%. 68That growth was followed by a construction boom that attracted North American-based developers who built modern-style gated communities that resembled exclusive resort living with onsite stores and services to accommodate the new North American, consumer-oriented retiree. 69These compound-like housing subdivisions, often situated on the outskirts of Mexican communities, reflect an exclusive, resort living style.They showcase large ranch-style homes with more modern appliances than found in local community homes and walls surrounding individual adobe-style homes that signify a more private existence. 70The Amigrant retreats project a "fortress mentality," characteristic of retirees in the Sun City retirement communities in the U.S. who choose to live in relatively safe, age-segregated enclave communities. 71Some retirees who choose to live in those Sun Belt communities hold a deep-seated fear that "the world is not a safe place," filled with forces that could invade ones privacy, safety and autonomy. 72Thus, familiar patterns of culture are retained and their accustomed lifestyle is protected within walled compounds as a safeguard to the perceived dangerous, external influences.
The 2008 economic recession battered the housing and real estate market in Mexico.In 2009 "there were 957 new vacation and retirement-focused development projects across Mexico, with … a total inventory of 49,983 [units] on the market…," but only 7,000 units were projected to be sold in 2010. 73According to Kiy and McEnany, some developers responded by shifting their business strategies from home-buying to home renting. 74But aging populations and health care may dictate housing trends for future development and set the stage for more globalization in Mexico.Mexico is attractive to foreign-led retirement-housing developers 75 because of a misperception that mainly wealthy U.S. retirees live there.Even before the recession, real estate developers and industry leaders in the Mexican Association for Retiree Assistance (AMAR) were "actively promoting active living, "aging in place" and assisted living facilities to attract U.S. retirees" and to increase sales in housing developments throughout Mexico. 76 According to the US-based Association of Homes and Services for the Aging, some U.S. companies with experience in offering care for Alzheimer"s patients, stroke victims and senile dementia are beginning to invest in assisted-living facilities in Mexico. 77 67 See note 29, 270.

68.
Ibid; see also Truly, "The Lake Chapala Riviera: The Evolution of a Not So American Foreign Community," in Adventures into Mexico: American Tourism beyond the Border, ed., Nicholas Bloom (2006), 182-186.69   Truly, "The Lake Chapala Riviera, 183 and 186.

74
. One example of a global retirement housing project is the Spanish-U.S. venture called Sensara Vallarta, a 250-unit luxury condominium complex targeting American IRMs near the resort town of Puerto Vallarta (see note 61).The project is an experiment in one of two retirement-home development markets in Mexico.One market is intended to attract "second and third generation Mexican families who are very accustomed to the same kinds of quality that other Americans find in their homes."[T ]he Sensara Vallarta project, fashioned after the Sensara retirement development in Spain, is designed for the North American retiree market, offering amenities familiar to U.S. retirees" (see note 22, pg.16).One selling point for perspective buyers in Sensara is its location near a major airport that has frequent departures to the U.S. for easy access to major medical care. 75 Kiy and McEnany (2010b), 16-17   76.
Hawley, "Seniors Head South to Mexican Nursing Homes."

Corporate Interests in Health Care and Medicare for American IRMs in Mexico
Edited transcripts of presentations made at the 2007 Medicare in Mexico conference held in Texas provides information about the strategic interactions of MNCs that are interested in, if not directly involved in, the initiative. 78n many respects, the conference was a professional health policy meeting aimed at influencing health care leaders and policy makers in Washington D.C. Health care industry presenters reflected a corporate perspective that fostered managed care ideals.
The primary message among health care, insurance and housing industry representatives attending the Texas conference, reflected a corporate-oriented rationale for further privatization of health care systems in Mexico.The message from corporate representatives was clear: "[F]ree enterprise is going to drive the development of health care in Mexico, not retirees." 79The rationale was that problems hindering a Medicare initiative in Mexico, such as hospital certification for Medicare in Mexico, could be solved by private sector institutions.The "Medicare [program] probably is never going to certify a hospital in Mexico under the certification process that we are currently using in the United States"….because"there is not a single hospital in Mexico that is currently certified by the Joint Commission for Healthcare International," 80 an essential accrediting body for Medicare certification.
According to many health care industry executives attending the conference in Texas, Medicare has a public mandate to provide health care to certain people, and they predict that it will arrive in Mexico and possibly elsewhere around the world. 81The concern is how to convince the U.S. government that fraud and abuse-rampant in the U.S-82 will be prevented from occurring to the same extent in Mexico.According to corporate health insurance presenters, the solution to reducing fraud and abuse is for Medicare to pay providers through "another managed health care group,"… "[I]t will be a private health care group, not Medicare, that pays directly, that sells that as a health care product to retirees like they manage health care in the United States for people on Medicare." 83n insurance company executive proposed that U.S. health insurance companies, in joint ventures with Mexican insurers, are best suited to be the intermediaries for Medicare and for payment to Mexican health care providers.His concern for the initiative is the potential for over-regulation of the industries involved.Because Medicare providers are highly regulated in the U.S., Medicare in Mexico faces even stricter regulatory laws and policies.That increase in "regulation adds administrative costs, so even though we see that costs are substantially better in Mexico than they are in the United States, that cost difference could be eroded when you overlay the need for additional regulations."84According to the insurance executive, the solution for reducing these government costs is to promote the growth and extension of Medicare Advantage, "an HMO plan where private insurers (mostly HMO plans) receive a per capita payment from the government, and then take on the responsibility of providing care, not only the same care that you get in traditional Medicare [Part A], but additional care that you can get with the savings achieved with coordinated or managed care." 85 unsuccessfully in the past and suggested that the solution would work if larger insurance companies (MNCs?) managed the plans.
The primary conference message reflected the integrated strategies of managed care organizations in Mexico as described by Jasso-Aguilar, Waitzkin and Landwehr. 86The presentations resembled a "trade show approach" whereby selling the benefits of managed care ideals were wrapped inside a message to health care leaders and policy makers that private enterprise, not the government, would bring Medicare to Mexico and make it work successfully and economically for all stakeholders involved.The enterprise they described as most likely to succeed is a multinational or transnational can engage in joint ventures with local Mexican corporations, and together they can navigate national and international barriers, access financial resources and avoid regulations that smaller organizations or governments cannot.The conference intended to persuade the governments and policy-makers in both nations to favor private enterprise in the initiative.
Conference presenters seem inclined towards supporting groups of multinational corporations that control the health care market, in which Medicare plays a key role in actualizing the next step towards greater privatization in Mexico"s health care sector.Reflective of the broader privatization strategies in the global health paradigm, if the initiative is successful, U.S. public trust funds would become new capital for the use in Mexico.In all likelihood, the Mexican government will use those funds to purchase the expertise of foreign-led, multinational corporations to help build the long-term and assisted care sectors of their health care system.If the initiative is successful, it could once again restructure the health care system in Mexico.

IV. Conclusion
AMMAC founder Paul Crist reportedly believes that Medicare in Mexico is inevitable based on several important reasons or observations 87 : (1) Recent studies suggest that an increase in U.S. retirees migrating to Mexico is an almost guaranteed fact.In addition to a natural increase in the number of retirees, recession-impacted Baby Boomers who face sustained unemployment, or who have little time to recover retirement investments in savings or home equity that were lost to the housing market collapse in 2007 and the Wall Street economic meltdown in 2008, may have few alternatives but to consider leaving the U.S. to survive financially.Faced with rising costs of living and fixed or reduced incomes, many less-than-affluent retirees may swell the already increasing number of U.S. citizens migrating across the border.
(2) The Mexican government is seeking ways to increase economic development, especially in the health care sector.Although Mexico has encouraged the in-migration of American IRMs as part of an economic development strategy for quite some time, it knows that it cannot grow a suitable health care infrastructure to sustain a growing foreign or domestic elderly population without the help of Medicare revenues and the expertise of foreign-led health care corporations.For example, Mexican multi-billionaire, Carlos Slim, is involved with developing a sector of the Mexican health care system that targets Medicare-eligible U.S. retirees in Mexico.In 2007, Slim formed a partnership with GrupoStar Médica, a fast-growing national hospital chain in Mexico, that plans to open new medical centers catering specifically to U.S. retirees living in Puerto Peñasco, Sonora, and in Los Cabos on the Baja Peninsula. 88While Slim is providing the hospital chain with infrastructure, acquisition and financing for their expansion, all of Mexico-based health care service developers plan to get private U.S. insurance companies to pay for medical treatment in Mexico. 89 This step would require the U.S. government to extend Medicare to eligible retirees in Mexico.
(3) Collaborations among U.S.-based multinational health insurance companies, real estate housing developers and Mexican-based private enterprises are working to build active adult and elderly assistedliving retirement communities in Mexico.Although the AMMAC initiative is on hold, Crist states that "[b]oth the senior-housing industry [i.e.independent-living communities, nursing-care facilities] and the health-care industry are internationalizing, and the U.S. players in these industries will be big winners.They have the capital and the experience to dominate this industry in Mexico and elsewhere because the senior-housing industry, in particular, is so new in many countries."And, he adds, "[s]ome of the developers in Mexico are affiliated with firms in the U.S., so there will certainly be support in Washington from those firms."90Thus, Crist claims that the biggest changes to Medicare policy are being made through the influence of private insurance companies. 91e largest population of U.S. expatriate retirees in the worldapproximately one millionresides in Mexico, and that age cohort is growing.The population of elderly Mexican citizens, including Mexican-born "returnees" from the U.S. who may be ineligible for Mexican social security health care benefits when they retire, is also increasing.But the Mexican health care system lacks senior-housing facilities or options for long-term care.Without restructuring this sector, the whole system could become weighed down in the near future.Thus, the initiative to extend Medicare in Mexico is expected to provide: medical services for eligible retirees at a lower cost to U.S. taxpayers; economic development of long-term health care facilities for Mexico; and the opportunity for dominant corporations in the health care, insurance and senior-housing industries to reap significant profits from the initiative.
The American IRM phenomenon plays a central role in the evolving effort to get Medicare into Mexico.If the initiative succeeds, then streams of American IRMs relocating to Mexico will likely grow significantly.An increasing number of those populations will be Amigrants who are noted for "importing their culture" and who are likely to support the Medicare in Mexico initiative.If socio-economic conditions, such as unemployment in the U.S., remain unchanged or deteriorate, it could further swell the ranks of this southern migration flow.Declining economic conditions (e.g.poor housing market, loss of retirement investments) could have a detrimental effect that will delay retirement for many who wish to migrate.However, Medicare-eligible populations, which include USborn citizens and Mexican-born U.S. Permanent Residents, will be a large segment of the IRM population directly benefiting from the initiative.Those aged 65 and older are excluded from getting Mexican Social Security and health benefits and must pay for health care out-of-pocket or through private health insurance that is relatively expensive and often excludes previous health conditions.The only alternative is to return to the U.S. for Medicare services and to maintain eligibility.The Medicare in Mexico initiative would eliminate logistical difficulties, greatly reduce personal expenses, and could improve long-term or assisted-care systems for aging-in-place in Mexico.
Interest groups, including health policy researchers, play a leading role in framing the Medicare in Mexico initiative.They can attract favorable media attention and achieve some measure of success lobbying decisionmakers to support the idea.Interest groups, such as the Association of American Residents Overseas, have the potential to grow new memberships, increase external funding and enhance their credibility by demonstrating abilities to influence successful outcomes.Single-issue interest groups, such as the Americans for Medicare in Mexico, are likely to claim success and dissolve if the initiative succeeds.However, leaders of these groups, like hotel owner Paul Crist, could personally benefit from the initiative if tourism and retirement migrations increase.
The U.S. and Mexican governments play important roles in the Medicare in Mexico initiative.The initiative is now an important agenda item for Mexico in future talks with U.S. President Obama.If the initiative succeeds, Mexico will initially gain some new resources from an estimated $1B in foreign exchange. 92This sum would likely be used to nourish an experienced, foreign-led health care industry to build long-term health care facilities that the nation currently lacks.This development will come with greater privatization in health care and some loss of control by both nations over Medicare funds and the assisted-care care sector in Mexico.
The U.S. Congress recently completed a rancorous process of health care reform, 93 and there is no evidence that a Medicare in Mexico initiative was included in the agenda of debate.Growing deficits, rather, are the current administrative concerns.Raising the retirement age and increasing Medicare premiums are two of many recommendations for deficit reductions that were proposed in a recent report from the bipartisan National Commission on Fiscal Responsibility and Reform. 94The reductions could have direct effects on Baby Boomer retirement patterns, but the report also provides advocates with a new incentive to push for the approval of Medicare in Mexico as a future cost-reduction initiative.
The foreign-led health care and senior-housing industries in Mexico play an important backstage role in the Medicare initiative.They will realize substantial profits if the initiative succeeds.Given the evidence of MNC involvement in the current initiative to push for "Medicare in Mexico," and given the fact Mexico needs outside resources to develop long-term health care facilities that it lacks, it is very likely that strategies similar to those described by Jasso-Aguilar, Waitzkin and Landwehr are being activated by foreign-led enterprises to tap into new economic opportunities.For example, comments in the media about the influence of housing and health care corporations changing Medicare policy in the U.S. provide some evidence that these organizations are persuading their own government to favor corporate stakeholders in changing Medicare policy. 95What appear to be extensions of strategies that were partially successful in gaining control of public health care systems in Mexico in 1997 are (1)   91 See note 18. efforts to expand Medicare to American IRMs in Mexico (e.g.joint ventures with Mexican medical facilities); (2) links with developers eager to promote "a trade show-like approach" to build assisted-care facilities; and finally, (3) according to Crist (see above) it is very likely that large insurance companies are involved in efforts to persuade their own governments to change Medicare policy.
The implications of extending Medicare to eligible retirees in Mexico will entail a globalization process that transforms Medicare trust funds, and indeed health, into mobile transnational capital.If private enterprise is given the freedom to restructure the program, it would likely be led by large-scale multinational organizations now operating in Mexico.These processes will engage only if multinational intermediaries can successfully influence the U.S. Congress to extend Medicare for eligible retirees residing in Mexico.

15Williams,
King and Warnes, "A Place in the Sun: International Retirement Migration from Northern to Southern Europe, European Urban and Regional Studies (1997), 132.16 Benson and O"Reilly, "Migration and the Search for a Better Way of Life: A critical exploration of lifestyle migration," The Sociological Review (2009), 608. 17 Warner and Jahnke, "Toward Better Access to Health Insurance Coverage for U.S. Retirees in Mexico," Salud Pública de México (2001), 3. 18 Hylton, "Medicare Savings: Is the Answer in Mexico?"Time, (2009). 19Warner and Jahnke, "Toward Better Access to Health Insurance Coverage for U.S. Retirees in Mexico."Full bibliographic referencing needed 19 Sunil, Rojas and Bradley, "United States International Retirement Migration: The Reasons for Retiring to the Environs of Lake Chapala, Mexico," Ageing and Society (2007).
, Health Care Across the Border; Warner, Getting What You Paid For.
Health Care for Americans Studied," San Diego Union-Tribune, (2010); Prentice, "Mexico President Visits Washington," International Living Magazine, (2010); Scott, "Real Estate Investment Tied to Passing Medicare in Mexico," Mexico Real Estate Investment: Information about living in Mexico and investing in Mexico real estate, (2009).
70McHugh, "The "Ageless Self"?Emplacement of Identities in Sun Belt Retirement Communities," Journal of Aging Studies (2000Housing and Real Estate Trends among Americans Retiring in Mexico"s Coastal Communities, International Community Foundation, U.S. Retirement in Mexico Research Series, (2010c), 3.73  Ibid.

92
Quadagno, "Institutions, Interest Groups, and Ideology: An Agenda for the Sociology of Health Care Reform," Journal of Health and Social Behavior, (2010).93.National Commission on Fiscal Responsibility and Reform, Co-Chairs Proposal, (2010).94.See note 52.

ignore the 21 Amin and Ingman, "Retiring in a Foreign Land: How Do the American Retirees Deal with Health Care Issues in Mexico?" Journal of Aging and Emerging Economies (2010). 22 Kiy and McEnany, Health Care and Americans Retiring in Mexico, 2. 23 Kiy and McEnany, U.S. Retirement Trends in Mexican Coastal Communities. 24 Dixon, Murray and Gelatt, "America's Emigrants," 23. 25 Masterson, "Yanks Abroad: The Numbers Game."The People"s Guide to Mexico, (2000).
He mentioned that smaller insurance companies have tried this 83Ibid.