LOS ALGODONES, MEXICO — The first time Mike Negle walked across the U.S.-Mexico border to Los Algodones, near Yuma, Arizona, he was instantly surrounded by salesmen who screamed they had the best deal, the best offer or the best price. They reminded Negle of hawkers in open markets in the U.S. who sold tomatoes or knock-off designer sunglasses. But these men weren’t selling tomatoes or sunglasses.
They were selling root canals.
“There’s a guy standing right at the gate by the border,” Negle explained. “He says, ‘I got good dentistry, come with me,’ and he’ll actually walk you over to the dentist and then they’ll give you an estimate."
"And then when you walk out of that door, someone else will grab you up and take you to another dentist down the road, and then maybe they’ll knock 20 bucks off, maybe beat the price by some,” he said.
Tomato markets aside, Negle wasn’t used to doing business like this. Like most Americans, he’d always chosen his doctors and dentists not because of cost, but because of coverage — as in, did his insurance plan cover a provider or not?
Negle drives tractor-trailers. He has since 1984. Over the years, he admits to eating a lot of roadside food and not making a lot of trips to the dentist. So by the time he went to see his dentist in Fargo, North Dakota, he was told it would take $20,000 to quell his many toothaches. Instead, Negle looked for other options.
“Know where to find a good dentist in Mexico?” he asked someone he met on the road.
“Yes. Go to Los Algodones,” she said.
Which he did. Negle made eight trips in six months for a total of four root canals, four crowns, five fillings, a teeth cleaning, a deep cleaning, and laser whitening. He’s not done. Soon, he’ll also get two new implants and a permanent bridge.
This was going to cost $20,000 in the United States. In Mexico, it cost him $3,800. (Story continues below)
The reasons for this incredible discrepancy in price are many: It is cheaper to live in Mexico. Mexican dentists don’t have to buy malpractice insurance and they generally don’t have to track down reimbursements from insurance companies. Also, they don’t have as much student debt and don’t have as many regulations.
Essentially, the market sets the bottom line. Which means that along the border, it is a constant race to the bottom to lower and lower prices. One economist, Michael Ellis from New Mexico State University, calls this an example of a "medical maquila," not unlike the factories along the border that produce goods for the U.S. market.
“The medical maquila model has been talked about for the last decade,” Ellis said. “It’s just beginning to take hold, but I think the pressure will build as the boomers retire.”
From Cantinas To Cavities
In Los Algodones, the pressure has spawned a cycle like that in any competitive marketplace: New dentists arrive and do whatever they can to try to attract customers from other dentists. Then the more established dentists try to stop them. Perhaps there is no better example of this than Dr. Bernardo Magaña, a dentist who moved to Los Algodones in 1969.
At the time, Los Algodones was a dusty border town. Magaña remembers that there were no less than 48 cantinas. Still, he sensed that if he put his practice here, people would come, Americans would come. He started advertising on television in the U.S. He became mayor and shut down the cantinas and the brothels. He worked and worked and so they came — not only more American patients, but also more Mexican dentists. The dentists moved into the empty spaces the cantinas and brothels left behind.
And the Americans came; mostly retirees. Some of them were snowbirds wintering in the southwest, while others were U.S. residents who lived near the border. Another group drove down to the area, from as far as the Midwest, in search of cheaper medications, tequila and an economical way to fix their teeth if they lacked dental insurance.
All kinds of people started making money from this. Besides the Mexican dentists, there was also the American newspapers that suddenly had more advertisers, and the local Quechan Indians, who built a huge parking lot — akin to what you might find outside of a large stadium — so Americans can park right next to the border and walk into Mexico.
Everyone seemed to be making money — except, of course, American dentists. Dentist Howard Sorensen practices in Yuma, Arizona and resents the advertising strategy of his Mexican competitors.
“I almost see it as predatory,” he said. “You went across the border, you see how they almost grab you and pass out cards. And they come across to Arizona and they advertise in our phone books, on our T.V. and our radio.”
The problem with this, Sorensen said, is that Mexican dentists aren’t licensed to practice in the United States. And if they aren’t licensed here, they shouldn’t be able to advertise here.
“If you create an unethical system, people are going to be unethical,” Sorensen said. “It is just the nature of human nature. Really they are all trying to make a dollar and they are going to make dollar, that is the bottom line.”
To this, Magaña acknowledged: “We don’t mix. We don’t have anything to do with one another. There is a total wall between the dentists in Yuma and the dentists in Los Alogodenes.”
The tension has been there for decades. At various points, Mexican dentists have even threatened legal action when they considered the remarks made by American dentists against them to be libelous, Magaña said.
Fortunately, for Magaña, this did not deter patients from coming to Los Algodones. It also didn’t deter more dentists from doing the same. And these new dentists, hundreds of them, were there to compete for the same American tourists Magaña had worked so hard to attract. For years, Magaña had been undercutting American dentists. Now, new and cheaper Mexican dentists are undercutting him.
These new dentists hired hawkers, dressed them up in scrubs and sent them right to the border, near Magaña’s office. The hawkers call themselves promoters.
Jorge Cruz, who belongs to an elite professional dental association with Magaña, has another name for them — jaladores, which means pullers.
“It is just that they are not that honest,” Cruz said. “You can try it yourself. You can take one of my cards, and they are going to say they don’t know where I am, I don’t know him, he is dead, he killed a patient. But I’ve got a better doctor.”
This is a downside of a competitive system without much regulation. You get hawkers driving down prices and making up their own rules. One hawker tells tourists she has a dentist who studied at Harvard–which he did, but only for one week in the continuing education department.
Dentists like Cruz and Magaña are in fact so irked by this that they are trying to lobby the local government to regulate the promoters and prohibit them from hawking on the street. One promoter, Jesus Daniel, said they just can’t stand the competition.
“See the big guys — like Magaña — all these guys got the money, so they want to shut us down,” Daniel said.
The dentist he works for is far from the border — in Los Algodones terms, this might mean only four blocks — with little foot traffic.
“See [Magaña] wants to say, forget all these little guys,” Daniel said. “They want everything for themselves and that’s not right because everyone has got to eat.”
So far, competition for American patients in Los Algodones and Yuma has played out as small town dramas. But economist Michael Ellis said in the years to come, American medical workers should be prepared to compete even more with their Mexican counterparts along the border.
“The world has gotten small enough that there will be more and more global competition for healthcare,” Ellis said. “It is proximate competition right across this little demarcation that we call the U.S.- Mexico border.”
Already some American insurance providers have decided to expand their coverage into Mexico, offering in-network dentists and doctors whose rates for services are as much as 70 percent cheaper than those in the United States. For its part, some tourism officials in Mexico are working on an online and print directory, like one that lists certified doctors and dentists in Baja California, so that Americans can find Mexican providers easier.
Even Negle, the truck driver with the new root canals and fillings, wants a piece.
He recently persuaded the owner of his trucking company in Minnesota to send all 140 of their drivers down to Mexico. It might even be his next full-time business venture, exact business name still to be decided — maybe Happy Smiles Vacations.
“Or something like that,” he said recently in the courtyard of his dentists’ hotel.
Of course, he plans on taking a commission for every new American patient he brings to his favorite Los Algodones dentist. He’s asking for 20 percent.
American Insurance Policies Are Also Heading South
A few weeks ago, Kevin Earle was working quietly in his office at the Arizona Dental Association in Phoenix when a new message arrived in his email inbox. He found it both startling and upsetting. The message was from a dentist, also upset, all over an attached health insurance plan that covers school teachers and other public employees in Yuma.
As with many American insurance plans, the policy excludes coverage for dental services provided outside of the United States. But there was something else, which Earle has memorized by now.
“To my knowledge,” Earle said, “the statement in the benefit plan says that it excludes coverage for services provided outside the United States and in parentheses it says, ‘except in Mexico.’ Closed parentheses. That’s the way it reads.”
There are actually commas, not parentheses, in the benefits plan. But his point remains the same: public employees in Yuma are insured at the same rate whether they see a dentist in the U.S. or in Mexico.
To this, Earle said: “That concerns us. First of all we’re talking about public monies that are being expended to the benefit of public employees, for services that may be provided by a provider that doesn’t meet the same standards as that in the United States. And I question why that exception is in their provider directory.”
For years, dentists in Arizona have begrudgingly watched their patients leave, then go across the border for care that costs much less. Before they were ever unhappy about American taxpayer dollars doing the same thing, they were unhappy about this. So unhappy, in fact, that in 2008 they asked the biggest dental insurance provider in the state, Delta Dental of Arizona, to put together a brochure designed to inform the Americans in exodus. Why, the brochure asked, would you seek dental care in a country where you are afraid to drink the water?
The brochure -- “Trouble in Paradise: The untold story of Dental Tourism” -- was, predictably, poorly received in Mexico. In response, many Mexican dentists wrote letters to the insurance company’s chairman of the board, Dr. Wesley A. Harper, requesting that he “present a correcting statement and… immediately cease and desist the distribution of this pamphlet full of false allegations.” The letter closed with a threat of legal action. The brochure was removed from the website of Delta Dental of Arizona in early 2009.
“It was a bunch of lies they were just telling over there I know they are just losing their customers,” said Jorge Cruz, a dentist in Los Algodones. “But why don’t they compete with lowering their prices or by giving a better service? That is a better way to go.”
Furthermore, Cruz was struck by what seemed to him an incredible irony: At the same time Delta Dental of Arizona was circulating its brochure warning their American subscribers of Mexican dentists, they were reimbursing Cruz’s patients, at an out of network rate, for the care he provided in Mexico.
“Yes, isn’t it ironic?” asked Cruz. “Because Delta is paying me to see their patients, so it doesn’t make no sense because in the end they’re using us to provide them a service to their patients and they know they’re paying us less than they would pay to an American dentist.”
The American insurance industry remains somewhat divided on the issue of cross-border coverage.
Delta Dental of California, for example, includes dentists in at least six practices in Tijuana as part of their provider network. Their reaction to Arizona’s Delta brochure was to “disown it.” In addition, California Delta’s CEO, Gary Radine, sent a letter to the president of the Mexican Dental Association denouncing the actions of Arizona’s Delta Dental.
Part of the reason why these two insurance companies — and they are two, separate insurance companies — are on opposite sides of the debate has largely to do with who runs each company.
Dentists are eight of the 13 members of the Arizona Delta Dental board of directors. California’s Delta Dental is run by other stakeholders. They include the people who purchase insurance plans for large companies or consortium, like the one in Yuma for school teachers and other public employees.
One of the purchasers of the Yuma plan, Debra Hedrick, said that their plan lets employees choose for themselves. They can see a dentist in Mexico, often for less. Or, if they want, see a dentist in the U.S. that often costs more.
“A dentist is a dentist is a dentist,” she said.
Earle, from the Arizona Dental Association, does not think so. He has already contacted three state legislators who represent Yuma to ask them to introduce a bill that would prohibit any American public employee from using their benefits for care in Mexico.
