Restructuring Health Reform, Mexican Style

ABSTRACT Mexico’s health system is undergoing major restructuring by the administration of President Andrés Manuel López Obrador (known as AMLO) starting in December 2018. The government has eliminated the 2003 health reform (Seguro Popular) from national laws and government agencies and is returning Mexico to a centralized health system with integrated public financing and delivery and reduced private participation. This article looks at the political drivers of Mexico’s restructuring reform. Three main ethical principles are identified as the foundation for the government’s health system vision: universality, free services, and anti-corruption. The article then compares what existed under Seguro Popular with the new system under the Instituto de Salud para el Bienestar (INSABI), which began on 1 January 2020. The analysis uses the five policy levers that shape health system performance: financing, payment, organization, regulation, and persuasion. The article concludes with five lessons about the reform process in Mexico. First, undoing past reforms is much easier than implementing a new system. Second, the AMLO government’s restructuring emerged more from broad ethical principles than detailed technical analyses, with limited plans for evaluation. Third, the overarching values of the AMLO government reflect a pro-statist and anti-market bias, swimming against the global flow of health policy trends to include the private sector in reforming health systems. Fourth, the experiences in Mexico show that path dependence does not always work as expected in policy reform. Finally, the debate of Seguro Popular versus INSABI shows the influence of personality politics and polarization.

Health reforms are constructed through politics but they are also dismantled and restructured through politics.Both the United States and Mexico are now witnessing this restructuring of reforms-but with important differences.In the US, President Donald Trump has been constrained in his efforts to undo Obamacare, by his lack of control of the votes in his own party in the US Congress (remember McCain's dramatic opposing vote in the US Senate? 1 ) and by the decisions of judges around the country.But in Mexico, President Andrés Manuel López Obrador (known as AMLO) has bulldozed ahead in eliminating the national health insurance plan of Seguro Popular and creating a new health system, through his electoral victory with a majority of the popular vote, his majority control of both houses of the Mexican Congress, and support received from a majority of state governors.
Mexico's tectonic changes in its health system are transforming the country, as the old comes down and the new pushes forward.In early 2020, the costs and uncertainties of these transitions were fiercely debated in the press 2 and in the President's morning press conferences. 3Major transformations were unfolding in the five main policy levers that shape health system performance: financing, payment, organization, regulation, and persuasion. 4This article looks first at the political drivers of Mexico's restructuring health reform, and then summarizes the policy changes according to these five policy levers.The article concludes with five lessons about the process of this massive reform ongoing in Mexico.

Political Drivers for the New Reform
Outside Mexico Seguro Popular has often been viewed as a landmark national health reform moving toward universal health coverage, 5 but within Mexico criticisms have been harsh and long-standing, especially from the left. 6When AMLO was mayor of Mexico City in the early 2000s, he and his health secretary resisted the reform from a leftist perspective 7 and refused to sign an agreement with the federal government to join the Seguro Popular.Mexico City only joined after AMLO left office in 2005.AMLO continued his criticisms of Seguro Popular in his unsuccessful presidential campaigns in 2006 and 2012, and in his third and successful run in 2018.
AMLO's most succinct criticism of Seguro Popular is a play on words of the reform's name: "ni es seguro, ni es popular." 8,9The first word, seguro, means insurance but also means safe; and the second word, popular, means for the people but also popular.This critical phrase ("neither safe nor popular") provided political salience and polemical value.The phrase also reflected AMLO's core criticisms of Seguro Popular, which can be summarized as follows 10 : (1) Not universal in coverage of population: Critics have pointed out that Seguro Popular did not provide coverage for the entire population, with AMLO's Minister of Health stating in 2019 that 20 million Mexicans still lacked coverage after 15 years of the program 11 -even though Mexico declared in 2012 that the country had achieved Universal Health Coverage (and put up a bronze plaque in the Ministry's headquarters, shown in Figure 1).( 2) Not universal in coverage of services: Critics have argued that the specified packages of services and medicines covered by Seguro Popular denied people medical care that they needed and produced economic costs to patients and families 6 (in contrast to the theoretical access to all services and medicines in social security provided by the Instituto Mexicano de Seguro Social or IMSS for formal sector workers and the Instituto de Seguridad y Servicios Sociales de los Trabajadores or ISSSTE for government workers).(3) Not sufficient reduction in out-of-pocket spending: Critics have argued that Seguro Popular did not sufficiently reduce high levels of out-of-pocket spending by people for services and medicines 12,13 (although out-ofpocket spending did decline as a proportion of total health spending from 52.2% in 2000 to 41.4% in 2015 14 ).( 4) Resulted in widespread corruption: AMLO and his government have criticized Seguro Popular as a major source of corruption, due to its involvement of the private sector and lack of effective accountability for public funds sent to the states. 3,155) Not improve people's well-being: The overarching political arguments against Seguro Popular are that it did not improve the health conditions of the Mexican people and did not contribute to reducing poverty. 6erall, AMLO and his advisors viewed Seguro Popular as a public policy that was an externally generated "neoliberal" creation, and that wasted public resources and did not benefit the Mexican people. 6It is worth noting, however, that Seguro Popular did improve access to many health services in Mexico (including high-cost services under the Fund for Protection Against Catastrophic  Expenses, as well as services for basic maternal care 16 ), and that the federal government over time made various policy changes to address problems in implementation and improve health system performance. 17he above criticisms provided the foundation for the AMLO government's vision of a new Mexican health system, founded on three main ethical principles: (1) Universality: a system that provides all health services (not just financing to pay for services) from public providers to all Mexicans without social security as a right based on citizenship, without any process of application or affiliation.(2) Free services: a system that provides all health services for free from the public sector, not through private providers, to reduce out-ofpocket spending by individual patients.(3) Anti-corruption: a system that reduces corruption by centralizing control over purchasing and service delivery and by reducing private sector participation in the public health sector.
These three principles emerge from public statements by the President and top officials in the Ministry of Health, 2 and from policy documents for the new system. 10For example, in his morning press conference on 11 February 2020, President López Obrador stated 3 : The goal is that on December 1 of this year there will be a totally different, efficient public health system, with medicines, high quality and free medical care … The purpose is to guarantee the right to health of those without social security.

Restructuring Mexico's Health System
In broad terms, AMLO's team of health policymakers since coming to office in December 2018 has sought to remove all traces of Seguro Popular 18 from national laws and government agencies and return Mexico to a centralized health system with integrated public financing and delivery and reduced private sector participation.The six-year single term for Mexican presidents encourages the AMLO administration to take fast executive and legislative action.
The government thus is engaged in a complex, radical, and still ongoing restructuring of Mexico's health system, with a focus on the "public sub-system" (outside of social security and under the Ministry's control).This paper examines that restructuring through the five policy levers that affect health system performance, comparing what existed under Seguro Popular with what the AMLO government is introducing under the Instituto de Salud para el Bienestar (INSABI), which began operations on 1 January 2020 (see Table 1).
(1) Financing Financing involves the sources of money for a health system.At the broadest level, Seguro Popular was financed with a national health insurance model.Seguro Popular received about 80% federal funds and 20% state funds-in short, almost entirely from general taxes, because almost no one paid an individual premium (due to the lack of an effective assessment of income at the time of enrollment, nearly everyone self-declared in the three lowest income deciles, all exempt from premium).INSABI, by contrast, is financed with a national health system model, with all funds from general taxes, and no expectation of individual premiums.
In terms of financing levels, Seguro Popular was intended to increase government spending on health, so that more personnel could be hired, more facilities could be operated, more services could be delivered, and the population covered could be expanded.Seguro Popular thus represented a reform designed to spend more money on health (reflecting Mexico's low level of health spending as a proportion of GDP within OECD countries and Latin America 14 ).INSABI's budget for 2020 included an extra 40 billion pesos (about a 35% increase on top of the base budget of 112.5 billion pesos previously allocated to Seguro Popular) to improve health facilities and services and hire more health workers, to assure free care for then 69 million Mexicans without social security. 19An independent cost analysis of selected health services for this entire population, however, estimated the amount needed as 793 billion pesos (plus an additional annual 18 billion pesos for regularizing the contracts of health workers), suggesting that INSABI was seriously underfunded to pay for what the government promised to deliver. 20nother key dimension of financing is how funds are transferred from the federal level to Mexico's 32 states.Under Seguro Popular, the federal level sent funds to states as block grants, calculated according to the number of affiliated persons in the state, as an incentive to increase enrollment.The center provided funds to new institutions created in each state (called Regimen Estatal de Proteccion Social en Salud or REPSS).The REPSS were designed to exist outside of the state health agencies, in order to separate financing from provision, as a mechanism to improve the efficiency and quality of service delivery.INSABI, by contrast, will provide financing directly to state hospitals and primary care clinics (which will become part of INSABI as federal institutions) and the hire workers directly for those facilities.At the end of January 2020, INSABI had signed agreements (Acuerdos de Coordinación) with 23 state governments making INSABI responsible for providing free health services to the population without social security in those states, with discussions ongoing with the remaining 9 states. 21Some states, such as Jalisco, signed agreements with the federal government to opt out of INSABI, while still agreeing to provide free services in accord with federal principles. 22uestions remained, however, about how accountability would be achieved for millions of previously "lost" finances from Seguro Popular in various states around Mexico (where the use could not be verified by the Federal Audit Office). 23) Payment Payment is how money (collected through financing) is used to purchase health services and medical products, including how hospitals and doctors are paid and how medicines are procured.As noted above, under Seguro Popular, funds to provide basic health services from the federal government went to a new organization in each state (REPSS) that was created outside the state Secretary of Health. 1 The REPSS were over time removed from the state health agencies, in order to separate purchasing from delivery, and they were responsible for buying services (facilities and health personnel) according to state-decided payment policies.INSABI, by contrast, has re-integrated financing and provision, bringing them back together at the federal and state levels (the REPSS were eliminated).INSABI thus has a direct fiscal relationship with the state Secretary of Health but also with health facilities and health personnel located in states, and will directly own and operate facilities and employees in states.Within states, under Seguro Popular, the REPSS were supposed to implement the principle of separation of purchasing from provision (as a step toward "strategic purchasing" 24 ).This principle, however, was unevenly implemented by states, and in some cases was resisted by health workers and unions, by governors, or by state Secretaries of Health, who did not want to lose control of resources.Purchasing by the REPSS allowed states to contract with private providers for clinical, pharmacy and other services, such as maintenance and laundry, and many states did so, especially for medicines and equipment.Private contracting was intended to introduce competition at the state level, and thereby improve performance, accountability, quality, and efficiency, but had mixed results and problems with implementation along with cases of corruption.25 INSABI, by contrast, has re-centralized purchasing and provision and reduced decentralized state authority to purchase separately.INSABI embodies a strong statist, public sector, and centralized approach.In its centralized purchasing, INSABI has changed certain companies that provide medicines and equipment, sometimes creating supply chain disruptions.INSABI also plans to regularize more than 17,000 health workers directly as federal employees in 2020 to deliver health services in states, 26 and seeks to reduce the private sector's role in health.
A major question under payment is: What is purchased?In Mexico, the federal agency of CNPSS (Comisión Nacional de Protección Social en Salud) decided on a single national set of services that would be covered by states in primary and secondary level facilities for Seguro Popular (a specified package known as CAUSES, with 294 medical interventions) plus 66 catastrophic conditions that would be delivered in tertiary care institutions (under the Fund for Protection of Catastrophic Expenses) plus all health services for children under five years old (from the Seguro Medico Siglo XXI). 27Patients were not required to pay a copayment or deductible for listed services under these three programs.Patients who required non-listed services or suffered from non-specified conditions had to pay out of pocket for services and medicines (even at public facilities).INSABI, by contrast, operates under the principles of universality and free services.Even though by law national tertiary hospitals in Mexico can charge for services, the AMLO government has forced them to provide services for free while implementing "drastic cuts" to budgets. 28This approach has created financial problems and limited supplies in top-tier national hospitals, 28 contributing, for example, to the firing of the Director of the National Institute of Neurology when service delivery problems and other irregularities were reported. 29) Organization The most dramatic organizational changes in Mexico's health sector were the elimination of CNPSS as a government agency and Seguro Popular as a public policy and the establishment of INSABI as a new government entity.The disappearance of Seguro Popular on 31 December 2019 had significant organizational consequences: its employees were either fired or transferred, individual enrollment files were packed up and warehoused, and computer databases around the country were erased.At the same time, INSABI began operations under the direction of Juan Ferrer, an archeologist and public administrator with limited experience in the health sector but with a close personal relationship with the President. 30rganizational restructuring also occurred at the state level.As noted above, the state purchasing agencies for services and medicines (REPPS) disappeared, and their employees were transferred to state health agencies and were asked to engage directly in service delivery or health promotion (rather than administration).Some REPPS functions were assigned back to the state Secretaries of Health, and some functions-such as procurement of medicines and hiring of health personnel-were transferred to INSABI in Mexico City under the new policy of centralization.Exactly which functions are going where and how was still being worked out in January 2020, creating various uncertainties in the health system. 2 With state health facilities to be owned by INSABI, most Mexican states will in effect no longer be responsible for the delivery of personal health services.
The AMLO government also reorganized the purchasing of medical inputs by the federal government.Along with Seguro Popular, Mexico created a central purchasing agency, called the CCPNM (Comisión Coordinadora para la Negociación de Precios de Medicamentos y otros Insumos para la Salud).This entity included the social security agencies, in order to reduce huge variations in purchase prices across health agencies and across states. 31The CCPNM used its enhanced market power (for purchasing large volumes pooled across various organizations) to negotiate lower prices for patented medicines with pharmaceutical companies.Under INSABI, purchasing has been centralized in the hands of the Ministry of Finance (known as Hacienda), and the CCPNM disbanded (even though it was working relatively well), as part of efforts to reduce corruption and increase efficiency, with the first tender announced in March 2019. 32Problems in implementing the new purchasing system, however, have created disruptions in Mexico's supply chain for anti-cancer medicines (and other medicines and supplies), and given rise to public dissatisfaction, including emotional public protests by parents of children with leukemia. 33nother major organizational change is reducing the private sector's role in the health system.Seguro Popular allowed state REPPS to purchase services and supplies from the private sector, and states used this flexibility in various ways, contributing to some instances of corruption (for example, in the purchase of medicines and contracting of human resources 34 ).The private sector also had a significant role in providing cancer treatment (for example, through nonprofit organizations) financed by the Fund for Protection of Catastrophic Expenses under Seguro Popular.INSABI, in contrast, has followed the AMLO government's antiprivate sector orientation.INSABI announced that it will not ban the use of the private sector in delivering services for public agencies, but it will no longer provide money to purchase those services in private facilities (including nonprofit organizations) and instead will provide medicines and physicians to those private facilities as support in kind.A major private nonprofit provider of breast cancer treatment in Mexico City, for example, announced on 20 February 2020 that it would no longer provide free care to poor people because of the lack of a financing agreement with INSABI. 35NSABI responded by saying that the private provider had an "ethical, moral and juridical obligation" to continue providing free care to existing patients. 36After public protests by women with breast cancer, 37 the government and the provider reached an agreement, with the government reimbursing services already provided in 2019, the provider agreeing to continue free services for existing patients, and the government saying that federal facilities would treat all new patients in 2020 moving forward. 38 major organizational challenge is how to deliver medical services in rural areas of Mexico, where doctors and nurses are reluctant to live.This distributional problem occurs in many countries throughout the world. 39Seguro Popular sought to solve that problem but was not fully successful since many rural areas remained without effectively functioning health services or health workers.And the pasante system of sending medical students in their last year of studies continued to face multiple problems related to insecurity, supervision and quality of care. 40INSABI plans to improve services in hard-to-reach rural areas by directly hiring 33,000 Medicos de Bienestar to work as federal employees and by directly building and owning health clinics as federal facilities. 17It will be important to assess how effective INSABI will be in encouraging health workers to take positions in insecure and isolated rural communities.
A final organizational challenge is who receives coverage for services.Seguro Popular developed a mechanism to provide on-demand enrollment at any time for individuals, and over time developed systems to identify social security members and exclude them from Seguro Popular services and coverage. 17This reflected a concern about "double affiliations." 17If INSABI's benefits are provided to people based on basic human rights, then questions arise about beneficiaries: Who will be given free medicines and free services?Can people be denied services, and if so on what basis?For example, will people with social security in Mexico be allowed to receive free services from INSABI without reimbursement from their insurance plans?More broadly, will migrants from other countries be given free medical services (for example, citizens of Guatemala or the United States in border areas)?If people cannot receive free services and are charged for services received, then how will prices be determined?

(4) Regulation
One important area of health system regulation involves money, especially health spending by states.Under the financing mechanism of Seguro Popular, states initially had substantial discretion in deciding how to spend the federal money they received.The amount of money was calculated according to the number of affiliated persons in the states, as an incentive to increase enrollment.That incentive process worked to encourage affiliation (although the incentive initially was calculated by family, 34 which resulted in many one-person families, as states abused the process to receive more central funding).But there were initially few restrictions over state spending, resulting in diverted funds for other uses (as theories of corruption predict 41 ).Over time, the federal Seguro Popular introduced spending guidelines (such as proportions on personnel and on medicines) in order to shift state spending patterns to more "desirable" patterns, with some limited success. 17For INSABI, federal authorities are seeking to reclaim control of state health spending by directly hiring workers and purchasing medicines for distribution to the states.A second area for regulation involves health workers.Under Seguro Popular, many states hired new health workers on three-month contracts without benefits, and these workers did not qualify for union membership.Over time, states revised some of these contracts in a process of "regularization" that produced a diversity of contracting situations but including longterm contracts with full benefits and union membership. 34Under INSABI, the federal government is directly hiring new health workers under regularized contracts that qualify them for union membership.The government is also promising to convert job positions from temporary contracts to permanent unionized contracts progressively over time (although this has not yet started and could be difficult to implement).This direct hiring of physicians and other health workers seeks to fulfil a major promise of the AMLO government to expand access to doctors and nurses especially at the primary care level.Regularized contracts and union membership, however, do not necessarily lead to adequate performance by health workers.Seguro Popular did not include effective supervision or incentives to improve the performance of new health workers, 25 and it is not clear how INSABI will monitor or assess the performance of the expanded health workforce, especially if they are federal employees who are working in health facilities in states around the country.
A third area for regulation is for medicines and facility quality.Mexico's health regulatory agency is called COFEPRIS (Comisión Federal para la Protección contra Riesgos Sanitarios) and was created in 2001, in the same time period as Seguro Popular, as an autonomous technical agency within the Ministry of Health.COFEPRIS covers the regulation of healthrelated drugs and technologies, toxic or dangerous substances, products and services, health at work, risks derived from environmental factors, and basic maintenance. 42The full policy of the current government toward regulation of health risks is still evolving, but in January 2020, the AMLO administration announced in the Diario Oficial de la Federación that it would now be officially authorized to import medicines from certain high-quality regulatory nations (Switzerland, EU, USA, Canada and Australia) without requiring review and approval by COFEPRIS. 43This step legalized what the government began in 2019directly purchasing and importing medicines abroad without regulatory approval by COFEPRIS, in order to address supply chain problems (such as methotrexate for childhood cancers) created by actions taken against domestic manufacturers. 44This action by the AMLO government suggests a willingness to weaken regulatory controls in order to allow government imports from new foreign sources, raising concerns about potential quality problems in imported medicines, although the government argued this would improve access to affordable and approved medicines.
(5) Persuasion Under Seguro Popular, various forms of persuasion were used to encourage enrollment in the insurance scheme.At the individual level, enrollment centers at health facilities "caught" potential members when they showed up for services, and enrolled them on the spot.Seguro Popular did not have a specified enrollment period and had no exclusions for existing health conditions.In addition, Seguro Popular had no means testing: individuals self-declared their income level, predominantly in a low-income group that waived payment of a premium.As mentioned above, federal payments to the state were calculated based on the number of enrollees, as an incentive for states to enroll as many people as possible.In addition, members were required to re-enroll, with the idea that this would create an incentive for states to improve the quality of services, in order to encourage individuals to re-enroll.These strategies were successful in encouraging large numbers of people to enroll (reaching 53.5 million people in January 2018 or 43.3% of total population, 17 ) although the impacts on quality improvement were doubtful.
INSABI has not so far engaged in persuasion-based interventions, reflecting the AMLO government's general emphasis on making services available and free for all people without social security in Mexico.More generally, the AMLO government has opposed the use of incentives to change behavior, as reflected in its decision to eliminate Mexico's conditional cash transfer program known as Prospera Programa de Inclusión Social (started in 1997 and previously called Progresa and Oportunidades).This program provided direct payments to poor families when they engaged in specific education, nutrition and health activities.At the end of 2007, Prospera included around 6.6 million Mexican families, covering just over 20% of the national population. 45Although the program was rigorously evaluated and showed important impacts on the behavior and well-being of poor families, 46 the AMLO government ended Prospera because they stated that it did not reduce poverty, was vulnerable to political abuse and corruption, and was connected with the neoliberal perspective. 47The government assigned the budget previously used for Prospera to a new educational scholarship program, to encourage students from poor families to stay in school. 48

Challenges Ahead
Through INSABI, the AMLO government is massively restructuring the Mexican health system, dismantling policies that have been in place since the early 2000s, and introducing new structures and processes that are still under development.The impacts of these changes will take time to manifest, assess, and evaluate.It will be important to assess the consequences for health system outputs (for example, service utilization or vaccination rates) and health outcomes (for example, cancer survival rates or child growth), and both national averages as well as distributional measures (for example, by income group, by state, by ethnic group, and by rural residence).
While the government's policies are still evolving, several lessons about the restructuring can be suggested, especially about the processes of reform.These are offered here to help explain what is currently happening in Mexico, how a major reform that survived two changes in national political administration did not survive a third.
First, undoing past reforms is much easier than implementing a new system.In many ways, the AMLO government moved to eliminate the existing system of Seguro Popular before it had fully planned or designed a new system.This approach is consistent with what AMLO has done in other policy areas (such as education 49 ), and follows a populist pattern seen in other countries.In some cases, the decision was to eliminate and not replace, as with the package of specified services provided under Seguro Popular.In this case, the government issued broad policy statements about "everything for everyone" (todo para todos) leaving specific questions unanswered and creating confusion among both providers and patients.For example, INSABI has to deliver services within the limits of the available budget each year, which effectively constrains the principle of "everything for everyone" (although how resources will be allocated is not clear since the agency started without the usually required "rules of operation" [reglas de operación]).In other cases, a past policy has been replaced by a new policy with a new name but without major changes in substance.For example, the AMLO government replaced the list of medicines provided under Seguro Popular (known as CAUSES or Catálogo Universal de Servicios de Salud) with a new list under INSABI (now known as the Compendio Nacional de Insumos de Salud) and with mostly the same products. 2The continuation of a limited list of specific medicines would seem to contradict the broad policy statement of "everything for everyone."Effectively integrating the different policy actions on financing, payment, organization, regulation and persuasion (described above) with the broad goals of the AMLO government represents a major substantive policy challenge.
Second, the AMLO government's restructuring emerged more from broad ethical principles than detailed technical analyses, with limited plans for evaluation.The government has not published technical analyses to justify its policy choices, or provided a clear plan for evaluating impacts of the new policies adopted.The current government's sweeping restructuring of the health sector is troubling to academics and technocrats, civil society organizations and citizens who believe that the careful collection and analysis of information should be the basis for evaluating and reforming public policies.Concerns have been raised about how the consequences of the current policies will be evaluated over coming years.
Third, the overarching values of the AMLO government reflect a pro-statist and anti-market bias, swimming against the global flow of health policy trends to include the private sector in reforming health systems.AMLO's policies are restoring the Mexican state to a model of centralized power and reducing the role of private facilities and companies.Policies with a market orientation, performance incentives, or private sector involvement are viewed as "neoliberal" and the source of corruption.But the restoration of a centralized-state system may reintroduce problems such as widespread inefficiency and underperformance.The prevailing assumptions are that removal of the private sector will reduce corruption and therefore reduce waste, and that federal control of state health services will reduce public sector corruption, so that health budgets can provide more services than previously. 10It will be important for the AMLO government to put in place effective mechanisms for measuring corruption, wastage, and efficiency in the new health system as it takes shape, to assess these assumptions.
Fourth, the experiences in Mexico show that path dependence 50 does not always work as expected in policy reform.Path dependence predicts that the beneficiaries of reforms will aggregate into effective support for existing policies and will oppose efforts to undo and dismantle policies that provide tangible benefits to them.AMLO's restructuring of the health system shows that even major reforms like Seguro Popular can be undone, when the positive feedback loops are not sufficiently clear or appreciated, when the reform's beneficiaries are persuaded to vote for a populist politician, and when the new administration controls not only the executive branch but also the legislature.AMLO's promise to expand unionized health workers probably helped avoid potential opposition from powerful trade unions, and the decision not to touch the social security organizations also may have helped reduce potential resistance to restructuring.In addition, AMLO promised to deliver more benefits with his new plan than provided by Seguro Popular, an approach that could have undermined popular opposition to the changes. 3AMLO is doing in Mexico to Seguro Popular what Trump would have done to Obamacare in the USA if he had more control over majority votes in both houses of the US Congress.In short, massive shifts in elections can change political institutions in ways that undermine the expected path dependence of policy reforms like Seguro Popular and produce massive policy changes-and in ways that may be difficult to reverse.
Finally, the debate of Seguro Popular versus INSABI shows the influence of personality politics and polarization.Mexico's disagreement over health policy is playing out between the former national Minister of Health who created Seguro Popular (Julio Frenk), and the former Mexico City Minister of Health who refused to join the system in the early 2000s and now serves as national Vice-Minister of Health (Asa Cristina Laurell).Over the past two years, Frenk has written frequently in the Mexican and international press protesting the decision of AMLO to eliminate Seguro Popular and criticizing the problems of INSABI and health policies of the current government.Frenk and his supporters seem to support a restoration of past policies that have now been eliminated.On the other side, Laurell and her supporters seem to support a removal of past policies, pushing the government to erase all elements of the health policies that Frenk initiated, without a careful assessment of the benefits provided previously and the harms likely to occur if a substitute cannot be effectively implemented.The losers in this kind of polarized policy reform are the Mexican people who will pay the costs with their health and well-being and their lives.

Notes
1. Payment for selected services associated with the 66 specified conditions under the Fund for Protection of Catastrophic Expenses used a fee for service method, and were provided at tertiary care institutions accredited for the condition by Seguro Popular.2. The new list of medicines (Compendio Nacional de Insumos de Salud) was apparently decided by comparing the lists used by Seguro Popular and the major social security institutes and then including those products shared by all of them.
3. A national monthly poll, however, showed significant increases in dissatisfaction related to the AMLO government's actions on health in February 2020 as INSABI was implemented, reaching 53% disapproval (bad/very bad) and 29% approval (good/very good). 51

Disclosure of Potential Conflicts of Interest
No potential conflict of interest was reported by the author.

Figure 1 .
Figure 1.Mexico celebrates achievement of universal health coverage in 2012.

Table 1 .
A comparison of Seguro Popular and INSABI