Above Photo:Illustration: Mark Wang
Orthopedic surgery would have bankrupted us in the United States. So we went to Mexico instead.
“Holy shit,” my husband said when he saw the doctor’s son pull over and park his car next to a small, concrete building in the neighborhood of Nueva Tijuana. The exterior paint of the clinic was peeling and there were bars on the windows. We parked and stared at the clinic silently without getting out of the truck. I’d hoped $2,000 for orthopedic surgery was going to buy us something a little nicer than this.
Five days earlier, Aaron and I drove the half-hour from our rental home in the Mexican beach community of Rosarito to Tijuana’s Zona Río to see what we could do about his ankle, which was broken in two places after a hard landing off of a step in the house. We pulled up to Hospital Angeles, which has a reputation among American tourists for being the best private hospital in the city. Valets greeted us in the parking lot. They let Aaron wait in our car by the entrance so he wouldn’t have to put any further strain on his injury. I hurried inside to see how soon I would be able to schedule an appointment with a doctor. Neither of us had health insurance.
We’d been living in Rosarito for two months. I was working as a freelance writer, and Aaron was an independent contractor in construction and roofing sales. For most of his adult life, Aaron didn’t have health insurance, instead paying cash when he got sick and using superglue to repair injuries that would have otherwise required stitches — a sort of DIY version of a procedure doctors actually do. The last time I shopped for health insurance was in 2017 when we were living in Texas. The cheapest plan I could find on the ACA marketplace cost around $700 a month — a significant bump from the $200 a month we’d paid when I’d had a staff job at a newspaper. The plan had poor reviews on HealthCare.gov and didn’t include the good hospital just a few miles from our home, where I would want to go in an emergency. I felt like I was about to set our money on fire. So we decided to go without insurance, especially since we were thinking about leaving Texas to take advantage of our flexible work situations.
That’s how we ended up living in northern Baja, joining the millions of people who commute between Tijuana and San Diego at the busiest international border crossing in the Western Hemisphere. Medical tourism is one of the leading industries connecting the two regions. Billboard ads for plastic surgeons tower over gridlocked traffic at the San Ysidro port of entry, where a doctor’s note has provided travelers access to a faster lane of traffic. Pharmacies advertising discounts on Viagra and other medications are strategically situated next to bars and restaurants on Tijuana’s tourist strip, Avenida Revolución. Chain pharmacies have doctors on duty who can perform basic checkups for the equivalent of a few dollars. Once, when I came down with a sinus infection, a pharmacist checked my throat and lungs for 50 pesos (around $3) and wrote a prescription for antibiotics that cost another $20. We did have vague plans to get on American insurance again, as soon as the right job opportunity opened up for either of us. In the meantime, Tijuana’s health care seemed like a solid, short-term backup plan.
Then Aaron broke his ankle in two places. A crowded public health clinic down the street from our house in Rosarito gave him an X-ray, put on a cast, and provided an extra copy of the scan on a disc, all for $15. The clinic didn’t have any crutches, but we found a pair at a grocery store nearby for only $30. Before we left, the nurses gave Aaron bad news: They could tell from the X-ray this break wasn’t going to heal by itself, and it would eventually require surgery. A nurse wrote down a list of hospitals we should visit in the area, marking the nicer ones with asterisks. I wasn’t exactly sure how getting major surgery without private insurance worked in Mexico, let alone in the United States. Between the two countries, I figured at least one of them would have a doctor who would be able to help us.
We pulled up to Hospital Angeles, which has a reputation among American tourists for being the best private hospital in the city. Valets greeted us in the parking lot.
Hurrying across the marble floor of Hospital Angeles, I approached a receptionist and explained that my husband needed ankle surgery. She gave me the names and office numbers of two different orthopedic specialists who happened to be in that day. I could just drop in, she said; a hospital staffer would get a wheelchair and bring my husband up once I made my selection. At that moment, I felt like we were part of the 1%, getting the best health care available in a country where we weren’t even citizens.
The first orthopedist’s office I scouted was empty, except for a receptionist who said the doctor would return in 20 minutes. The second office was busier, with around half a dozen patients and their families in the waiting room. The doctor was a middle-aged man dressed in worn cowboy boots and wearing a nice watch. He laughed with one of his patients about something. My Spanish wasn’t good enough to understand the joke, but what mattered to me is that they genuinely seemed to like each other. I called Aaron and told him I’d found his doctor.
Dr. Mario Armando Caloca sometimes strained to find the right words to say, but his English was much better than our Spanish. Pointing to the X-ray, he showed us exactly where he would use a metal plate and screws to reattach the bone. The procedure would cost us around $10,000. We sat in silence, disappointed. Armando Caloca explained that the Hospital Angeles charged higher fees than most, but that he also had admitting privileges somewhere else, where the total would only be $3,500. Still, we didn’t say anything. Finally, he said that there was yet another hospital where he could perform the surgery for a grand total of $2,000, his fee and the hospital’s fee included. We nodded in approval. The procedure was scheduled for a Saturday, five days later. He would send someone to meet us in the parking lot of Hospital Angeles and bring us over to the clinic on the day of surgery. In case we had any questions, he gave us his direct cellphone number.
While the United States government cracks down on people crossing from Mexico in the hope of a better life, a growing number of Americans are crossing the border for affordable health care. Most American politicians wouldn’t dare compare our health care system to Mexico’s, even as President Andrés Manuel López Obrador has promised to reform the country’s public system to make it as good as public healthcare in Europe. However, workers in Mexico’s public hospitals say they are currently experiencing catastrophic supply and staffing shortages; by one account, it’s the country’s worst public health care crisis in 40 years. But Mexico’s health care system also has a flourishing network of private doctors and hospitals that offer care at a fraction of the cost without insurance in Canada or the United States, which is how Mexico takes care of an untold number of uninsured and underinsured Americans.
Jessica Cisneros, a 26-year-old immigration attorney running for Congressin south Texas, is currently uninsured while she works full-time on the campaign, hoping it will pay off with an agenda to bring free, universal health care to the United States. Last July, back when she still had coverage, she needed a root canal, but her insurance didn’t cover dental. Cisneros crossed the border and underwent the procedure in Nuevo Laredo for about $200. (About 1 million Americans traveled abroad for dental care in 2018, according to the medical tourism guide Patients Beyond Borders.) Several weeks ago, Cisneros’ father came down with pneumonia and needed to stay in a hospital. He weighed the cost of using his American insurance against crossing to Nuevo Laredo. Because of his high deductible, he chose a hospital in Mexico.
“A lot of people feel that treatment over there is more effective than it is here,” Cisneros told me. “They feel U.S. insurance companies dictate what kind of treatment you need to receive, and that’s what the doctor follows. But in Mexico, it’s not like that.”
Last August, the New York Timesprofiled a Denver-based medical company called NASH, which pairs American patients with American doctors and sends them both to Cancún for surgery. The arrangement saves employers so much money on hospital costs that patients receive a check from their employer if they choose this option. In 2019, Utah began flying state workers to Tijuanato pick up prescriptions, paying for both the flight and a $500 bonus and still saving money. But perhaps the most visible American medical tourists in Tijuana are the Amish, who regularly come for a cancer hospital that is “considered cheaper, a lot cheaper, and just as good care or better than in the States,” a 25-year-old Amish father from western New York, who gave his name only as Daniel, told me.
Even with our surgery scheduled in Tijuana, I hoped I could still find a comparable cash deal in the United States, but the problem was figuring out the price. Doctors often don’t know how much something will cost or even what their own fee can be. When a hospital bills a patient $2,000 just for the anesthesiologist, for example, the anesthesiologist may only be receiving $500. Private health insurers “have a lot of money and time to devote towards lobbying, and doctors don’t,” explained Dr. Amy Shore, an anesthesiologist based in Los Angeles. While doctors in private practice may be able to work out cash deals with uninsured patients who need surgery, she says that’s a rarity: “With the hospital administration, and the insurance companies in there, it’s not really under our control anymore.”
Joanna Mayfield, who works as a real estate agent in New York City, saw her health insurance premiums skyrocket shortly after the Affordable Care Act went into effect in 2014, so she and her husband, also an independent contractor, stopped purchasing insurance for themselves and instead only covered their children. In July 2017, while riding her bike in Brooklyn, Mayfield flew over her handlebars and broke her collarbone. An emergency clinic warned her that she needed immediate surgery; Mayfield scheduled a consultation at NYU’s Langone Hospital, which cost $115.
Mexico’s health care system has a flourishing network of private doctors and hospitals, which is how the country takes care of an untold number of uninsured and underinsured Americans.
In his office, the doctor listed his qualifications and then told Mayfield she definitely needed surgery. However, he couldn’t give her a date for when he was available, claiming her injury actually wasn’t an emergency because it wasn’t yet “tenting” — the medical term for when a clavicle fracture nearly pokes through the skin. He also couldn’t tell her how much it would cost. Three days later, his office called and told Mayfield that she could have the surgery in a week, but they still didn’t know the cost. Mayfield asked if she should just leave the country.
“Most people do that,” she recalled the receptionist saying. So she hopped on a flight to Mexico City with her mother and got a cellphone number for an orthopedic surgeon from the cab driver who picked her up from the airport. Over the phone, the doctor asked if she had eaten; he was ready to perform the surgery that day. Before she made her decision, the NYU hospital did get back to her, quoting $27,000. They required the full amount and wouldn’t accept any payment plan, even if she offered to pay half up front. Mayfield went ahead with the surgery in Mexico. “I had my own room, I had my own nurse,” she said. “The whole thing was like $5,000.”
Before the surgery, I asked Dr. Armando Caloca for the name of the clinic where Aaron and I would be going; I became concerned after I couldn’t find any information about it on Google. I called a family member who is a surgeon and asked about a cash deal in the U.S. He looked at Aaron’s X-ray over text. My relative agreed with the doctor’s diagnosis but explained that American hospitals likely wouldn’t let us do the surgery without insurance — even if he waived his own fee, which he generously offered to do. And if a hospital somehow did decide to let an uninsured patient schedule this surgery, the hospital fees alone could run anywhere between several thousand and tens of thousands of dollars, all for that same metal plate and screws. He urged us to try to get on American insurance, warning us there was no way to judge how the Mexican doctor’s infection or success rate fared or whether he would even be using the correct-sized screws.
But Aaron was in pain and ready to be done with it. I texted Dr. Armando Caloca, peppering him with questions. He told me that he had a high success rate, a low infection rate, and that the clinic was safe. When I asked if the mid-priced clinic would be a better choice, I recalled him saying we should save our money because it was just a foot. I took this to mean a low-risk surgery, not that he was feeling blasé about Aaron’s appendage.
We saw the clinic in person for the first time on the morning of Aaron’s surgery. After feeling like millionaires in Hospital Angeles, the shabby appearance of the clinic that we could actually afford was a rude awakening. “You don’t have to do this,” I told Aaron. He paused for a few seconds. “Fuck it,” he finally said. He grabbed his crutches and hopped out of the truck.
Dr. Armando Caloca showed up a little late with a colleague and a large coffee in hand. They asked if Aaron was ready, exuding the calm, cocky presence doctors tend to have, easing my fears a bit. I signed the $2,000 check before they changed into their scrubs.
Alone with the anesthesiologist in the operating room, Aaron said he was ready for the countdown, expecting to be put to sleep. The anesthesiologist shook his head and told Aaron to lean over and cross his arms. He pulled out a needle. Aaron would be getting a shot in his spine, essentially an epidural, which would leave him numb below the waist but awake for the procedure.
The two surgeons entered the room, right around the time Aaron noticed that there was no air conditioning in the building. Dr. Armando Caloca picked up Aaron’s foot and asked if he could feel it. It was completely numb. “Great, you’re ready,” he said. They put a surgical sheet over his midsection to block the view. Aaron, trying to peek over the screen, made eye contact with the doctor, who walked over to the stereo and turned up the volume. Mexican dance music drowned out the sound of the surgical drill.
“If I had known I’d be awake, I would have Facebook-lived it,” Aaron told me a little over an hour later when I handed him back his phone. The surgery went well, we were told. Aaron seemed relieved, and Dr. Armando Caloca gave me a new X-ray of Aaron’s ankle, showing me where the plate and screws were holding it together. The doctors said Aaron needed to spend the night at the clinic. They also warned him not to get hooked on pain pills — a premature warning, I thought, but I appreciated the sentiment. We thanked them and called our parents to tell them the great news.
Aaron and I spent the afternoon streaming shows on his cellphone in the clinic’s cramped recovery room. I began to notice a foul smell. A nurse came by and said not to use the toilet directly across the hall because of a plumbing issue. I also could have sworn that a man waiting in the lobby with me during Aaron’s procedure had told me, in a conversation we had in broken English and Spanish, that his wife was there to have a baby. But I still hadn’t heard the sound of any baby crying in the small building, and I never saw him again. Both of these things were bothering me, but I tried not to think about them too much.
The doctor walked over to the stereo and turned up the volume. Dance music drowned out the sound of the surgical drill.
Late in the afternoon, Aaron mentioned his leg was starting to feel warm. Several nurses and a young doctor checked his IV and confirmed that Aaron was getting plenty of pain medication. Aaron insisted his leg was feeling warmer, as if the numbing agent were wearing off. We were working through a language barrier, but a nurse who knew English relayed to us that they would increase the dose. “I’m starting to feel everything,” Aaron said, the pain making him short of breath. “Why would they have me spend the night just to do this to me?”
After I explained that there was something seriously wrong, the clinic’s on-duty doctor, a woman who looked like she was in her twenties, came in to ask Aaron about his drug usage. She said his tolerance was unusually high, though she agreed to administer more medication. Aaron tried to remain calm, but I could see he was grimacing. He said the meds still weren’t working. He looked and sounded like he was in worse pain than when he first broke his ankle. At some point, I finally snuck a look at the label on the medication they were opening before placing it in his IV. It was tramadol, a drug that has about the same strength as Tylenol. I started to call and text Dr. Armando Caloca, trying again and again when I didn’t get an immediate response.
When I confronted the staff about the pain medication, the young doctor said that we were bothering the other patients. I threatened to pull Aaron out of his hospital bed and drag him somewhere else, making sure to disturb all the patients if they didn’t fix this. A nurse who knew English relayed my sentiments to his superior. They had a conversation among themselves. Listening in, I heard the nurse say no tenemos. Apparently, there was no morphine or other opiates anywhere in this building; the only way to get stronger pain meds would be a prescription from Dr. Armando Caloca. In the middle of this argument, someone from the clinic finally got through to him, and when they put him on the phone with me, he sounded angry. “You,” he huffed, “are the worst patients I ever had.”
Armando Caloca said he would prescribe buprenorphine, explaining it was the drug most like morphine, which is widely inaccessible in Mexico; but if we tried to pull Aaron out of the clinic before being formally discharged, he would refuse to help us further. I told Aaron I would have to leave him alone while I went to fill the prescription at a pharmacy down the street. “Just hurry,” he said. Driving over in the rain, I thought about how I actually had no idea where we would go if this didn’t work. At that moment, I wished more than anything that I was at an American hospital where I understood what people were saying and how things were supposed to work.
At the store, the pharmacist had the buprenorphine but said he needed to see my ID. I showed him my passport. He said no, he needed an ID with my address on it. I had only brought my passport with me. Standing in the pharmacy, I started to cry. Annoyed, or perhaps taking pity on me, the pharmacist finally gave me a break.
Aaron was still wincing in pain and breathing deeply when I returned. The buprenorphine kicked in quickly after the staff administered the shots, and he soon fell asleep. The next morning, another young-looking doctor was on duty. He asked Aaron a set of questions about his pain level and other symptoms and then, finally, gave us clearance to leave.
Back at our house in Rosarito, Aaron hobbled slowly ahead, struggling with each step, as I held the door open for him. He stopped to tell me something. “When you think of all the money we saved, I think that went pretty well.”
During our follow-up appointments at the Hospital Angeles, Dr. Armando Caloca and I never addressed the fact that he’d told us we were the worst patients he ever had. As I began working on this story in December, he agreed to an interview. He blamed the clinic for what went wrong, saying some clinics have uneducated staff and can be 20 years behind modern medicine. He tried to search for the words to describe the dynamic between American patients and Mexican caregivers. “We have two kinds of patients. One wants to feel well. The others are looking to blame the medical staff, to blame other people. They only want to get benefits,” he said. I asked him if Americans have a reputation for coming to Tijuana specifically to seek out opioids. “Yes,” he laughed.
The doctor recalled being “very mad” at us on the day of Aaron’s surgery. But when he got home, he sat down in front of the mirror and asked himself why he was so upset. “If you go to the patient, and you resolve the problem, it’s good for you because you resolve the problem for the patient,” he told me. He credited American health care as having better technology and well-regarded doctors but said the costs and long wait times are driving patients from the United States and Canada to his practice. “In Mexico, what I try to do, is faster, cheaper, and good medicine,” he said. While Dr. Armando Caloca said he treats all his patients equally, he acknowledged that clinics that cost more are generally linked to better health care. “All of the problem is money. You have money, you have the best quality of medicine — not just in Mexico, in the United States, too.”
Last summer, we finished the lease on our house in Rosarito and moved back to Texas temporarily for Aaron’s work. Less than a year after the surgery, he was climbing ladders and riding bicycles without any residual pain. At the end of January, we moved to Long Beach, signing a lease for a full year. I’m now applying for coverage on the California marketplace — a move counts as a qualifying coverage event — with the understanding that California has lower premiums than Texas. If our application doesn’t work, there are other options to hold us over. There’s an app called Heal, available in some cities, including the Los Angeles area, which arranges house calls between physicians and patients and charges the uninsured a flat $159 per visit. There are also plenty of stand-alone emergency clinics like MedPost, which start at around $100 per doctor consultation and add more fees for each medical test. And then there’s always the option of getting in our car and heading south on the freeway for about two hours and returning to Tijuana, the closest thing that America has to affordable health care.