Health insurance coverage in Mexico: progress, inequalities and remaining challenges towards UHC2030.

backgroundUniversal health coverage (UHC) requires strong institutional capacity, equity-oriented policies, sustained political and financial commitment and public trust. However, public confidence in many health systems, including Mexico's, has been chronically undermined. This study aims to document Mexico's health coverage trajectory by offering a comprehensive, disaggregated and longitudinal assessment of insurance coverage from 2000 to 2023 - highlighting both achievements and setbacks in the context of UHC2030 goals.

methodsThis study used nationally representative data from Mexico's National Household Income and Expenditure Survey (ENIGH) from 2000 to 2022, with projections for 2023. Households were classified into mutually exclusive health insurance categories on the basis of institutional affiliation. National and subnational trends in coverage were analysed, with attention to major reforms and disruptions. A distance-to-frontier metric quantified the gap between 2023 coverage and each state's historical maximum, enabling assessment of progress toward UHC goals.

resultsBetween 2000 and 2015, Mexico reduced the uninsured population from 55% to 6.2%, largely driven by Seguro Popular (SP) expansion benefiting Indigenous peoples, rural and low-income households in high-deprivation states. Following SP's dismantling in 2019, the launch of Health Institute for Welfare (INSABI), and the COVID-19 pandemic, uninsured rates rose sharply to 29.1% by 2023. The greatest losses in coverage occurred in southern states and among marginalized groups, deepening territorial and social inequalities. The decline in mixed public coverage further reflects system fragmentation and eroding public trust. The distance-to-frontier analysis revealed that several states need to more than double their coverage to regain previous levels.

conclusionsMexico's experience highlights that health coverage gains are reversible without strong institutional foundations, political consensus and social legitimacy. Rebuilding and sustaining UHC requires deliberate efforts to address structural inequalities, strengthen institutions and restore public trust. For other low- and middle-income countries, this case emphasizes the urgent need for institutions restructured to foster adaptive capacity alongside equity-focused strategies to achieve and sustain UHC.