Will Juárez and Mexico be an escape valve for the U.S. health care crisis?

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Antonio Suárez waxed nostalgic as he drove his truck through old, bumpy streets in downtown Ciudad Juárez, Mexico. He steered past his old elementary school, the church he attended, and the closed children’s music school founded by the late iconic singer Juan Gabriel. He passed by a restaurant, saying the joint serves steaks so big and sumptuous locals call them “elephant ears.”

The native Juarense grew excited as he pulled into the Pronaf district, recalling a generation or two ago when busloads of U.S. tourists would ramble in to the Mexican border city for shopping, dining, nightlife — and, yes, trips to the doctor of dentist. These days Suárez and others are working to rejuvenate the U.S. tourist stream, long slowed to a trickle by the post 9-11 border security tightening, heavily-publicized outbreaks of violence and a lingering stigma that keeps the neighbors away.

A smile protruding from his lips, Suárez promised, “Give us a weekend and we’ll return a better version of you.”

Mexican flag

iivangm / flickr

The Mexican flag.

Suárez’s words might be taken literally. As the operations director of the Ciudad Juárez Medical Tourism Cluster, he’s working to elevate his city’s appeal to U.S. residents seeking affordable health care. The citywide organization rests on three stated principles: “Human Dignity+Common Good+Affordable Cost.”

Dr. Francisco Berumen, leading cluster member, explained the cluster concept as coordinating health care visits with food, lodging and transportation services. “Hand in hand they are being promoted,” he said.

“We had 20 years thinking about this but we had the wrong ideas,” Suárez said of previous attempts to combine tourism and health care in an organized fashion. Then in 2015, after a round of new meetings, the cluster was launched with a core group of eight professionals that convenes weekly. Based in the private sector, the cluster currently consists of four Mexican federal government-certified private hospitals, 40 dentists and 13 ophthalmologists. Collaborators from the hotel, convention and other business sectors have jumped aboard the bandwagon.

Prior to starting their own cluster, local organizers studied successful models in Costa Rica, Malaysia and elsewhere, Suárez said.

Noting the graying of society and the corresponding need for more specialized medical services, Ciudad Juarez Mayor Armando Cabada earlier this year strongly endorsed the cluster. “The (cluster) is thinking as a community and that’s fundamental,” he said.

Dentist Mario Torres, another member of the cluster leadership, has already treated patients from the U.S. for decades. “We had people not just from El Paso but Las Cruces (New Mexico) and many places,” Dr. Torres said in an interview in his downtown office.

Open for business on Avenida Lerdo, a quick walk or drive from either the Santa Fe or Stanton Street bridges that connect to neighboring El Paso, Texas, Torres’ staff now see many former Juarenses who moved across the border but return for dental work and other purposes.

“It’s cheaper to come visit their families than get treatment over there,” Torres said. “They speak perfect English but prefer to speak their native language when they come here for treatment. … There is personalized treatment from the dentist. They feel like they are in the family.”

Torres described many of his patients as women above 40 years of age.

“Most of them don’t have insurance, or the cost of it makes it convenient for them to come with us since in the majority of cases what they pay in deductibles pays for the treatment here; besides, they don’t have to wait much time for their appointment,” he added.

Torres said dental care costs in Juárez average 40 percent of the U.S. tab for the same quality of treatment. The Mexican dentist said he and other colleagues belong to national and international dentists’ associations, attend the same conferences as their U.S. counterparts and acquire the latest equipment. “Like everyone else, we see all the new technology,” Torres said. “We have all the technology they have in the U.S.”

A graduate from the Autonomous University of Coahuila, Torres entered dentistry 35 years ago, when no dental school existed in Juárez. Nowadays, though, the Autonomous University of Ciudad Juárez trains dentists.

“It was normal (for Juárez dentists) to come from Coahuila, UNAM (the national university in Mexico City) and Chihuahua also,” he recalled.

An ophthalmologist, Dr. Berumen hails from a multigenerational line of health care professionals running from his grandfather to his own son, who is studying medicine. Berumen is part of a family Suarez reverently called “an institution” in Juárez.

Berumen estimated U.S. consumer savings reach 70 percent for eye-related treatments in Juárez.

Like Torres, Berumen zeroed in on quality as the key to the cluster’s future and ultimate success, with ongoing trainings of providers and even inspections and certifications of hotels needed to ensure certain rooms are fitted with the appropriate beds and bathrooms necessary to handle long-term stays of delicate patients.

“These are all details that seem small, but it really takes time. It’s an investment (hotels) have to make,” Berumen said.

Suarez is the “go-to-guy” in the cluster, handling everything from negotiating payments with health insurance companies to arranging appointments. If potential visitors contact him ahead of time, Suarez pledged he will arrange personal “tailor made” packages that include transportation from El Paso and a hotel stay. A recent contact was with a potential patient examining Juárez as an alternative to Veterans Administration waits in the U.S., he added.

The changing faces of Juárez and Mexican medical tourism

According to University of Arizona historian Dr. Oscar Martinez, Ciudad Juárez’s Medical Tourism Cluster builds on more than a century-old, cross-border exchange, catalyzed by an economic crisis at the turn of the 20th Century that prompted a search for economic alternatives, including tourism.

Pitched to U.S. residents and soldiers at El Paso’s Fort Bliss, a race track and a bull ring drew crowds. Instant divorces, sex for money and ample drinking opportunities during Prohibition were among tourist lures. Somewhere in the swirl of cross-border visitation, trips to doctors and dentists became part of the mix, generating an unorganized and individualized form of medical tourism.

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Nonetheless, after experiencing its ups and downs over the years, Juárez tourism ultimately was “practically destroyed” by the well-publicized drug violence of recent years, Martinez said.

In contemporary Juárez, health care-related businesses are scattered across a big city of 1.4 million residents, with two big hubs spanning the downtown area roughly from Avenida Juárez to Avenida Lerdo and around Avenida Las Americas in the Pronaf area. Close to El Paso, the two zones host dozens of hospitals, clinics, pharmacies, optometry stores and dentists’ offices.

A brief stopover at the private Centro Medico de Especialidades (CME) on Las Americas, which is among the four federally-certified hospitals belonging to the medical tourism cluster, revealed a busy facility with a pharmacy, an optometry store and a cafeteria in addition to the hospital wards. CME was offering 20 percent discounts payable in 2018 for work done in November and December, Mexico’s busy shopping season. At the receptionists’ desk a price list with the 16 percent value added tax tucked in detailed check-ups ranging from about $37 for the basic to approximately $325 for a comprehensive heart exam, including all the latest technological bells, whistles and measurements.

Mexico goes for medical tourism

Increasingly, Mexico’s federal government has recognized the potential of medical tourism, illustrated by this year’s founding of the Medical Tourism Consultative Council.

According to the Secretariat of Tourism (Sectur), revenues from medical tourism more than tripled from $1.54 billion in 2006 to $4.8 billion in 2016. Based on a projection by EuroMonitor, federal Tourism Secretary Enrique de la Madrid recently declared the sector was anticipated to rake in $6 billion in 2017.

The most ambitious project in the works is New City Medical Plaza, a massive medical tourism complex planned for Tijuana, Baja California. Construction of the 28 story building, which will be the tallest in Tijuana, is expected to be finished in 2019, New City CEO Issac Abadi told this reporter. A five-minute walk from the U.S. border, New City will count on security cameras and staff, he said.

The complex will house at least 400 doctors of different specialties ranging from classic surgeons to psychologists and everything in between, backed by 1,000 other staff, Abadi said. Other amenities will include a 154-room hotel plus commercial plaza encompassing pharmacies, labs, a food garden and a conference center. The project is attracting the interest of doctors from the Mexican interior and even from across the border, who are fed up with lawsuits and “the high cost of maintaining services in the U.S.,” Abadi said.

In New City’s vision, Baja style-medical and health tourism doesn’t have to be a gray, drab and teeth-grinding experience. New City will showcase Baja’s famous wines and feature a pool with beach-style huts.

What gives Abadi’s company the certainty their $100 million investment will pay off? “We’re so confident. It’s already happening,” Abadi said, adding that medical tourism in Tijuana is growing at the rate of 30 percent per year.

Until now, with Medicare still intact in the U.S., most medical tourists in Tijuana range from 30 to 55 years of age, Abadi estimated. His company sits on the board of directors of the Tijuana medical tourism cluster, he added.

Sectur estimates 230,000 economic units Mexico are currently linked to a countrywide medical tourism value chain embracing hospitals, clinics, laboratories, transportation companies, hotels, restaurants, tourism operators and other businesses. The federal agency reports that 15 medical tourism clusters in 12 states have emerged in Mexico.

More than one million foreign residents, including Mexican migrants returning for health care, engage in medical tourism every year in Mexico, according to Sectur. Last summer, Juárez hosted the Medical Tourism Congress, an event drawing participants from the U.S. and Latin American nations.

Dr. Howard Campbell, sociology and anthropology chair at the University of Texas El Paso (UTEP) and longtime Juárez scholar, said medical tourism could be a “win win” for both the U.S. and Mexico if it’s done right, bringing jobs and income to the south and cost savings to the north in a relationship that’s often defined by U.S. domination and exploitation.

Border historian Oscar Martinez, who grew up in Juárez, said medical tourism could even fill a potentially big economic hole in his old hometown if negotiations over the future of the North American Free Trade Agreement (NAFTA) with the Trump administration end badly.

With more than 300 foreign owned factories (maquiladoras) employing about 275,000 workers who produce electronics, auto and other goods for export, Juárez’s economy is extremely vulnerable to changes to NAFTA, according to Martinez.

The author of books on the Paso del Norte borderland is skeptical that Juárez factories could find viable replacement markets for all the maquiladora products if NAFTA goes to pot. A bigger and strategic opening could then appear for medical tourism and the jobs related to it, he contended.

“I think it has very good prospects. I’ve been disappointed it’s taken them so long to get this going,” he said.

Challenges confronting the tourism cluster

Juárez and other Mexican border locales are greatly favored by several converging forces. Geography, rising U.S. medical and dental costs, Washington and state politics, the historic aging of the Baby Boomers (and not far behind them the Generation Xers, who are expected to peak at 65.8 million in 2018, according to the Pew Research Center) are chief among them.

Bordering Texas and New Mexico and astride major U.S. highway, train and air links, Juárez could even conceivably emerge as a significant escape valve for the U.S. health care crisis, a new and ironic twist for a city that’s historically served as an escape valve for migrants fleeing Mexican and Central American crises and headed to north the U.S.

At a time when Obamacare is being eroded and Medicare and Medicaid face cuts, Juárez’s medical tourism prospects are bolstered by the presence of modern hospitals, bilingual staff and highly educated doctors, dentists and eye specialists.

On the other hand, exploding medical tourism in this city confronts obstacles. For one thing, some U.S. insurance companies that formerly paid the dentist directly now only reimburse a patient after treatment, a practice creating potential cash flow problems for the service provider, Dr. Torres said. “It would be ideal to pay the insurance to us,” he said.

Suarez said preauthorization is the rule of U.S. companies, a policy that forces him to spend considerable time getting advance permission from an insurance firm for individuals receiving care through the cluster. A major goal of the medical tourism initiative, he continued, is to set up a centralized clearinghouse within the cluster that will process all insurance payments.

Nonetheless, most U.S. medical tourists to Juárez pay in cash because of the lower overall costs, he stressed. For older health-care seekers, the U.S. government still doesn’t allow Medicare and Medicaid to cover Mexican medical or dental services.

Suárez and Torres jabbed some U.S. dentists for giving Juárez’s professionals a bad rap.

“The majority of U.S. dentists are very jealous and reserved if (patients) say (previous dental work) was done in Juárez. They’ll say it was done badly,” Torres asserted, recalling one patient who complained to him after a U.S. dentist criticized Torres’ work but later apologized after realizing the complaint was based on misinformation.

Terri Heeter, president of Santa Fe-based Beyond Borders Dental, coordinates treatments for U.S. residents with Mexican dentists in Juárez and Palomas, a small Mexican border town to the west of Juárez. Teeter said some of her clients headed to Mexico have encountered run-arounds in obtaining files or negative comments from their dentists, with some even telling patients not to come back to them after Mexico. Other dentists, however, are more understanding, she said.

Heeter contended that Mexico gives options to people financially squeezed by the U.S. dental system. “We think it is more of an ethical issue,” she added. “Why would you punish someone who can’t afford you?”

For Suárez and Torres, ironies abound in U.S. dentists’ attitudes toward their Juárez counterparts. Not only are some of El Paso’s dentists originally from Juárez, but they also “aren’t happy we do publicity over there,” Suarez said.

Both men also cited the case of Align Technology, a U.S. company that manufactures trendy invisible braces at a Juárez factory and then exports the products to this country.

In fact, Mexico produces many health care related products sold in the U.S., including the over-the counter Mucinex children’s medication found on store shelves everywhere. According to the Tucson-based The Offshore Group, a private outfit that promotes offshoring, Mexican plants exported $7.7 billion worth of medical devices to the United States in 2014. The products shipped included medical, surgical, dental, respiratory therapy and veterinary instruments, devices, and other goods.

Suárez said another issue revolves around “junk” practitioners, like the businesses closed down or slapped with legal charges in Baja California in recent years after scandals broke in the Mexican and U.S. press about the death of several foreign patients allegedly because of malpractice by Baja surgeons. Upholding standards and certifications so patients won’t be at the mercy of any random corner business is a primary goal of the Juárez cluster, Suárez said. The cluster’s certification, he insisted, is “your window of safety.”

Tijuana’s Issac Abadi sounded a similar note. “We’re filtering our doctors. We’re making sure they have certifications. We have rejected some of the doctors because they don’t have certifications,” Abadi said. What’s more, New City is digging into prospective doctors’ legal records for lawsuits and such, he said. Abadi dismissed the notion that qualified Mexican doctors are below the par of U.S. doctors. “A lot of doctors in Mexico have done their fellowships and studies in the U.S.,” he said.

The violence question in Juárez

Though insurance hassles and professional standards concern Juárez cluster members, their biggest challenge will be in overcoming the stigma that’s kept U.S. tourists away in droves since the so-called drug war of 2008-12, a cataclysm of violence that left nearly 11,000 people murdered in the city and its environs, according to New Mexico State University researcher Molly Molloy.

Apart from trips to work or school, many Juarenses shuttered themselves at home. Coinciding with the Great Recession, businesses boarded up, a good portion of the city’s population moved to El Paso or other places and main boulevards emptied of traffic. Fort Bliss and universities in El Paso and New Mexico banned, restricted or conditioned their personnel from visiting Juárez. Even attending the conferences, seminars and lectures regularly held in the Mexican city is a complication for U.S. scholars and students.

UTEP, for instance, is subject to a University of Texas system-wide policy implemented in September 2017 that requires the review of and approval by a special university committee for university-sponsored travel to areas deemed at high risk, including places carrying U.S. Department of State travel warnings such as Juárez or anywhere the university committee considers potentially dangerous.

The city’s bad reputation persists in El Paso, where the reporter frequently encounters surprised or shocked reactions from locals about visiting the neighboring city.

A November 2017 report in U.S. News and World Report that ranked El Paso as the fifth best place to retire, partly based on the presence of highly-rated medical facilities and professionals in the Texas city, received wide press play. Notably, however, the report, did not mention El Paso’s proximity to health care providers in Juárez.

Dr Berumen was among Juarenses who endured the worst years, which forced him to lower his business profile and take security precautions like disallowing walk-in customers and requiring appointments. A once thriving U.S. patient load dropped to 2 percent of his clientele, he estimated. Patients are returning back from across the border, mainly individuals with previous ties to Juárez, while “tourists are still low” in the scheme of things, Berumen said.

“I think that downtown Juárez is much safer than six years ago. That’s a brute fact,” UTEP scholar Howard Campbell said. “Most people will tell you about that.” Killers don’t target tourists from the U.S., he underlined.

“It’s not the same. There’s a lot of tranquility. A lot of clients from the U.S. have come back. They’re having fun in museums and filling restaurants,” Torres argued, adding that today’s Juárez is a far cry from yesteryear’s violence as an urban redevelopment of the city’s downtown is underway.

Recent excursions by the reporter to both the downtown and Pronaf areas detected some new businesses opening, lots of traffic, bustling eateries and shopping by locals galore. On one day, the newer downtown pedestrian mall was jammed with street vendors, Jehovah’s Witnesses, Spiderman and other human statues, and the dancing Pachucos who’ve reemerged in the border city during the past few years. A rock group playing outside entertained crowds with Deep Purple’s “Smoke on the Water” and a Santana medley including “Black Magic Woman” and “Oye Como Va.”

But Juárez is not yet quite over the hump. After an 80-90 percent drop in homicides from 2013 to about mid-2016, murder is again on the uptick, though still below the levels of 2008-11. Different accounts attribute the latest bout of violence, as well as an even worse one in Tijuana, to violent competition between smaller-scale methamphetamine traffickers. Dated August 2017, the U.S. Department of State’s most recent travel advisory for Juárez that warned of certain zones beyond the urban center.

“There are certain areas you shouldn’t visit,” Torres acknowledged.

Suárez compared risks in Juárez with the U.S., mentioning the recent Las Vegas massacre, Texas church slaughter and Thanksgiving violence in Chicago. “It’s almost impossible that you would have 50 people killed in a church in Mexico,” he said.

Suárez might have also mentioned neighboring New Mexico, where in 2017, drug-saturated Albuquerque broke a 20 year record for homicides. In December, the little town of Aztec, N.M., was stunned into mourning after a gunman killed two students apparently at random in a high school.

Terri Heeter said she relies on experience when discussing Juárez with prospective clients. “I can tell them I go on a regular basis for myself. In the couple of years we’ve been going down there we’ve had nothing bad happen,” Heeter said. “(Patients) feel it is a very safe place to go.”

Oscar Martinez is optimistic about the potential of medical tourism in his old hometown. But, “the whole thing needs to be highly organized and sold to prospective clients in the U.S. in a way that they will be safe,” he cautioned. Secure transportation and patient safety during regular business hours can be provided, evidenced by the maquiladoras that kept their assembly lines running even at the height of the violence several years ago, Martinez insisted.

UTEP’s Howard Campbell also pointed to the maquiladora example as proof that visiting and doing business in Juárez can be done safely.

“I think the prospects are excellent if it could be made very clear to Americans going to Juárez that they will be safe. Clearly they’ll save money,” he said, adding that increasing health care costs could encourage more people to take a second look at Mexico. “Americans are people who are always trying to get a good deal, and they don’t care if it’s in Mexico or the U.S., as long as they don’t get killed,” he said.

Dr. Berumen said talks have been held with the city government and a local university about training and certifying a tourism police force for deployment in zones where tourists go. “It’s still in discussion but that’s where we want to go,” he added.

Campbell viewed the creation of a safe tourist zone, or enclave, as a “compromise solution.” He contended that while the medical tourism cluster portends needed jobs and income for Juárez, it also poses an opportunity to make the entire city more secure, whether in the business districts or in the poorer neighborhoods where most violence takes place. “I think that’s the challenge — to make it beneficial as a whole so this initiative brings in safety to all,” he said.

The ‘Welcome Back to Juárez’ tour

Cluster leaders, meanwhile, plan to ramp up their new promotional campaign, “Welcome Back to Juarez,” in 2018. The road show kicked off this fall in Phoenix, Arizona, and San Antonio, Texas. Held in conjunction with Mexican consulates, events are planned between January and April for Houston, Dallas, Atlanta, Los Angeles, Denver, Chicago, Albuquerque, and El Paso-Las Cruces.

The last two events are scheduled for April 5 in Albuquerque and El Paso-Las Cruces on April 12. Suarez said the cities were selected mainly due to their easy connections to the El Paso airport, a place he and other Juárez cluster boosters wager will see more passengers deplaning for health care trips across the border in the near future.

“We are moving slowly, step by step so we don’t make mistakes,” Berumen mulled. “This is an ambitious plan that we are carrying out in stages.”

Kent Paterson is an independent journalist who covers issues in the U.S./Mexico border region and a fellow in the 2017 Journalist in Aging Fellowship Program. Enlisting a diverse cross-section of journalists from across the United States, the program is sponsored by the Gerontological Society of America and San Francisco-based New America Media. This article was written with the support of New America Media, the Gerontological Society of America and the Silver Century Foundation.

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