U.S. Insurers Tapping a Market for Cross-Border Health Coverage

When the buses, unlicensed taxis and cars packed with families stream south across the border toward a profusion of clinics and pharmacies, doctors here know it must be “Holy Saturday.”

That’s what they call their busiest day of the week, when thousands of Latinos from across Southern California make a pilgrimage to Baja California for health care. They could get similar treatment and medications closer to home, but not, they say, with the same south-of-the-border cultural empathy, speed--and low cost.

Now, some U.S. insurers are tapping into this market of mostly cash-paying consumers to offer lower-cost “cross-border” policies. Between them, California-based insurers like Blue Shield and Health Net cover an estimated 25,000 people who get some or all of their care in Mexico.

California officials hope the low cost of this coverage will make a dent in the state’s population of uninsured, estimated at 4 million to 6 million people. Many of these are low-paid Latino service workers whose employers don’t offer health plans. Cross-border plans might entice some workers who have no insurance now.

Some doctors, however, fear that people will be forced by employers and the lower cost to get treatment hundreds of miles from home--and that the care is both inferior and poorly regulated.

Patients who choose a cross-border plan “are taking a risk not having the access to the kind of technology that we consider minimal in the United States,” said Santa Monica gastroenterologist Richard Corlin, past president of the American Medical Assn. “You may be relying on the hunch of a doctor.”

That doesn’t worry San Diego hotel worker Raul Jimenez, who went to Sistemas Nacionales de Salud, just steps from the U.S. border, to get an explanation for dizzy spells. He jumped at the chance to buy a cross-border plan when it was offered by his employer through Health Net.

“When we had the choice between insurance in the U.S. or insurance in Mexico, we picked Mexico,” Jimenez said. “For us, it was cheaper and the doctors seem to understand us better.”

Plans offered by the cross-border insurers, who team up with Mexican doctors or medical networks, can include primary care in Mexico and emergency coverage in the United States. A different plan can cover one family member in California and others living in Mexico.

Gov. Gray Davis recently directed the state Department of Managed Health Care to encourage health insurers to enter the market, which began growing more quickly after a 1998 state law allowed foreign companies to offer health insurance here.

Some U.S. companies already were beginning to offer cross-border insurance. Since then, some have teamed with Mexican groups.

Laying Down the Rules

Under the law, say state officials, employers are required to offer a choice of at least one U.S.-based plan in addition to any cross-border insurance. The cross-border plans also are legally responsible if patients are improperly denied care in Mexico, officials say.

“Even if they are going to a place in Mexico, they have the same rights as if they went to a doctor in California,” said Joy Higa, deputy director of the state managed-care agency.

Patients seem less worried about protection than fast solutions, cultural comprehension and price. So much so that some with stateside insurance pay for unreimbursed tests and care in Mexico.

Throughout this border city, other patients echo the mantra: U.S. doctors tell them to take over-the-counter drugs instead of prescribing more aggressive treatment and medication. Many seem eager for a quick fix that can return them quickly to jobs that provide no sick pay.

Some patients are miffed by U.S. doctors who don’t understand their accented English, by nurses and assistants who make them wait weeks for appointments or send them to distant labs for tests.

Debate on Quality

Lower costs remain a primary draw: A Baja doctor’s visit can cost as little as $20; drugs can cost one-fifth as much.

Proponents of cross-border insurance say cheaper does not necessarily mean inferior.

“It’s like comparing San Diego to Fresno,” said Jim Arriola, who established Blue Shield’s nonprofit cross-border health group, Access Baja. “Things are cheaper in Fresno [than Los Angeles], but does that mean that Fresno is worse?”

Dr. Jose Ramiro Lopez, a Mexican native who has practiced medicine in San Diego and Tijuana, agrees that specialty care in the United States is superior because there have been advances in such things as liver transplants, brain surgery and treatment for unusual diseases.

For primary care, however, “what is provided in Tijuana is the same as in California,” said Ramiro Lopez, who is certified as a physician in both countries. “For the Latino community, the communication is better in Tijuana. I live in San Diego and when I have a problem, I go to Tijuana.”

Corlin, the Santa Monica gastroenterologist, disagrees sharply on the quality comparison. Cases in which Mexican pharmacies have dispensed drugs banned in the United States demonstrate that “there are not as many checks and balances,” he said.

The best health care is that available close to home, Corlin added, “not from a doctor 150 miles away that you can only see on Saturdays.”

Health Net and Blue Shield officials say they do evaluate Mexican doctors participating in their plans. They inspect their offices, review medical licenses and even call the medical schools to verify that the doctors earned degrees.

Tijuana-based Sistemas Medicos Nacionales was the first Mexican HMO to get a California license, teaming with Health Net to offer Salud con Health Net (“Health With Health Net”).

Eighty-five employers--representing more than 11,500 Health Net enrollees--include the Salud con Health Net option in their employee benefits package. The plan, available in Los Angeles County, will be offered in Orange County by early 2003.

Health Net’s regular HMO coverage, offered for a family of four, is about $500 per month. A comparable Salud con Health Net plan is about $303 per month, Health Net spokeswoman Lisa Kalustian said.

The cost of a typical Blue Shield benefit plan for a California family of four is about $600 a month, Arriola said. The same family would pay about $300 a month for coverage in Tijuana through the company’s Access Baja plan. Enrollees can opt for primary care in Mexico and emergency care in California.

Some 3,500 people will be covered through Access Baja by the end of 2002, Arriola said.

Another company, Transwestern Insurance Administrators Inc., oversees a network of Mexican doctors for self-insured California employers--mostly agricultural companies that pay for some of their workers’ care. There are 25,000 employees covered through Transwestern, owner Roger Boman said.

For all the growing numbers, some insurance companies are waiting to see how the pioneers fare. Others have bowed out. Aetna, for example, offered cross-border coverage in 1998 and 1999, but sold its Mexican subsidiary and halted the plan.

A Long Bus Trip

U.S. residents like Cristina Iniquez are proof of the demand.

The Santa Ana woman awoke before dawn on a recent Saturday to catch the 6:30 a.m. bus in downtown Santa Ana. She arrived at the Tijuana border two hours and 45 minutes later.

Iniquez has health coverage in the United States but preferred to pay $300 at Hospital Delat--a clinic that more closely resembles a budget hotel lobby--for doctors, lab work and medicine that she says has cured her of anemia and a kidney infection.

She has considered asking her employer to put cross-border insurance in the benefit package. “If I could,” she said, “I would have a plan in Mexico because it would cover me for what I really want.”