There are world-class hospitals in San Diego, not far from where Luis Gonzales lives. But when he or a member of his family needs a doctor, they drive 50 miles south to a clinic in Tijuana.
The Gonzaleses are members of a Blue Shield of California HMO that provides all of the family's nonemergency care in Mexico. They are among 20,000 California workers and their dependents in health plans that cost 40 to 50 percent less than comparable care in the United States because the doctor's visits are outsourced south of the border.
With health care costs in the United States continuing to rise, many employers in Southern California are turning to insurance plans that send their workers to Mexico for routine care, plans that are growing by nearly 3,000 people a year. And Gonzales, for his part, is happy about it.
"They have everything I need," Gonzales said. "They're clean. You don't see a difference between a doctor over here and over there."
Despite Gonzales's satisfaction with the quality of his family's care, the new trend has some medical professionals in the United States worried that care is being sacrificed to low prices.
"There are quality standards that we are developing and implementing in America that are not going to be implemented there for a long time," said Jack Lewin, chief executive of the California Medical Association. "In terms of specialized care, it's critically important that we look beyond just cost savings."
Five years ago, California became the only state to regulate insurance programs that require border crossing for basic health care. Since then, more than 700 non-agricultural businesses have offered plans requiring treatment in Mexico. Hundreds of farms offer similar coverage for about 120,000 migrant laborers.
In Texas, legislators explored the possibility of allowing health maintenance organizations to operate on both sides of the border. But physicians in South Texas lobbied against the changes, arguing that local doctors could not compete with the lower costs in Mexico.
Lower-priced labor, malpractice insurance and overhead in Mexico mean both basic and sophisticated medical procedures can be performed at a small fraction of the cost. A hysterectomy that averages $2,025 in the United States costs $810 in Mexico, said Mary Eadson, director of legal compliance for the Western Growers Association, an agricultural organization that provides health insurance for California workers in Mexico.
The movement of U.S. health care across the border has sparked a boom in hospital construction in Tijuana, with clinics and pharmacies opening a short walk from the border.
Francisco Carrillo owns and operates a Mexican HMO plan for California workers called SIMNSA, and he owns the Centro Medico clinic, where large windows face the border bridge many of his patients cross on their way to the waiting room.
On a recent weekday, half the cars in the parking lot bore California license plates. On two of the clinic's six floors, a new surgical center and a dentist's office are under construction. The clinic's other floors were crowded with patients.
"Things are moving very fast," Carrillo said. "We're growing."
David Castillejos Rios has performed laser eye surgery on both sides of the border. At a small hospital in Tijuana, he charges one-third as much as he does in San Diego.
"The medicine is the same, and to me, whether I do it here or there, it's the same," Castillejos Rios said. "Only the price changes."
The difference can translate into the kind of affordable monthly premiums most American businesses have not seen in a decade. At Health Net, the cost of insuring a family of four whose treatment was covered in the states is $631 a month. Using physicians in Mexico, the same family would pay $306 a month, company officials said.
At the Santaluz golf resort in San Diego, where Gonzales supervises golf course maintenance, workers can sign up for a Blue Shield of California plan called Access Baja. Their doctor visits are covered in the United States or Mexico, while their families are covered only in Mexico. Dale Standfast, the resort's controller, said several workers whose dependents were not covered switched plans to cover their families.
Offering Access Baja saves the resort about $1,000 per month in premiums, he said. This year the club used the savings to offer vision coverage to all employees for the first time, Standfast said.
Representatives of Blue Shield of California and Health Net, both of which offer cross-border HMO plans in California, said the quality of care is comparable in both countries. Their doctors are credentialed in Mexico, and the HMO operations are subject to California oversight. The insurance companies audit Mexican clinics themselves, and then report to the California Department of Managed Health Care.
Company officials emphasize the warmth of the Mexican medical culture.
"Mainly, the patients that come here are searching for more attention," said Juan Carlos Helu Vazquez, a gastroenterologist in Tijuana who sees Mexican and American patients. "They want the doctor to talk to them, be warm to them. There are a lot of patients who like the old-time medicine. They like the doctor asking about your family, your work."
Gonzales said he had better care in Mexico than in the San Diego region.
"I went to the doctor over here and he never cured the problem, he never gave me a good medicine, never sent me to a specialist. He never cared about my health," Gonzales said. "When I went over there, the first doctor I saw, he sent me to a specialist. He wasn't just going to say, 'Take this and go home.' "
Administrators at cross-border HMOs expect their plans to grow because the cost of health insurance in the United States is out of reach for an increasing number of working families.
That is what worries Lewin of the California Medical Association.
"It's understandable that lower-income workers are trying to seek health care they can afford," he said. "But these people are largely paying taxes and contributing some of their own financial resources to this country. It's high time we provided good care for these people through enlightened public policy."