PNHP Fact Sheet: Health Savings Accounts — No Savings

What is a Health Savings Account?
Health savings accounts (HSAs) are promoted by insurers as the “consumer-directed” solution to the health care crisis, and by some conservatives as a way to make individuals more “responsible for their health care choices.”
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By Steven Lewis
Winnipeg Free Press
August 21, 2005

The official voice of Canadian doctors has had it with single-tier medicare. Why? Because patients are suffering and dying waiting for care, according to the ineffable Dr. Victor Dirnfeld of British Columbia, with rhetoric unsupported by evidence.

Governments just don’t give Canada’s altruistic doctors the resources to do right by their patients. The solution: Give Canadians a choice to buy their way out of the public lineup.

Last Tuesday, CMA delegates timidly endorsed a private, parallel system by resorting to the convoluted vehicle of the double-negative (voting against a resolution that was against private medicine).

By Wednesday, they were braver. Sixty-four per cent voted in favour of this resolution: “The Canadian Medical Association supports the principle that when timely access to care cannot be provided in the public health-care system the patient should be able to utilize private health insurance to reimburse the cost of care obtained in the private sector.”

Good for the CMA. On Tuesday, the debate was muted, the proceedings oddly preoccupied with wording. No passion, no ringing discussions of principle. Not with a bang, but a whimper. The next day, more spirited to-and-fro. In the end, forced to take a stand, the 200 delegates took one.

It’s folly to blame an interest-group for pursuing its interests. The CMA does not exist to advance the public interest — it is the doctors’ lobby, pure and simple. And, like all sophisticated interest groups, it insists that it is solely preoccupied with the well-being of the public.

Ergo: When a bunch of us doctors set up private clinics for the well-to-do, all Canadians will get better and more timely care. That’s why we’re doing it — nothing to do with money. We deeply admire the public system; we just can’t pass a resolution that declares it to be the best option. We share its values, only it isn’t getting the job done.

Government’s fault — always is.

The CMA has traded the Hippocratic for the Hypocritic with a capital H. But it could show the public just a little respect. We’re quite prepared for your pursuit of self-interest.

You don’t have to pretend you’re doing it for us — you’ve been ambivalent about medicare since the beginning. It’s not about us having a choice, since, by the CMA’s own reckoning, most Canadians won’t be able to buy private insurance. It’s about you having a choice. We’re just fodder for the argument, and collateral damage when you get what you want.

So come clean. Celebrate the lucrative private options for doctors who want to make more money and restrict their practices to those in their own class. Tell us candidly that you favour a minimalist set of core services for the masses, reserving the high-quality diagnostics and fast access to care for successful people like you. That way, you’ll make more money. And, with a stripped-down public system, you’ll pay less tax, too.

And don’t be afraid to chide the thousands of physicians who are naïve enough to commit to the public system. Tell them that their labours are in vain, their system is second-rate, their Toyotas an embarrassment in the hospital parking lot.

Let’s assume that many doctors will want out, and the public system will be under more strain with its capacity temporarily reduced. What can governments and the public do to strengthen the public system and shore it up against further erosion?

There’s a lot that can be done. First, let’s get all the talent in the public system working at full capacity. Get other professionals involved more centrally in primary care. A team of nurses, rehabilitation therapists, psychologists and pharmacists is capable of providing excellent front-line care. If my physician clinic went private and I had the option of seeing a nurse practitioner in a comprehensive clinic, I’d go in a minute. I might go anyway.

Second, if the CMA and its followers want a private and parallel system, make sure it is truly private and parallel. Don’t subsidize it by training its personnel at huge public expense — charge them full tuition ($60,000 a year for physicians). Make them build their own hospitals so the complications from their surgical centres don’t end up taking our space in the public system.

Students at the swish private schools — you know, the ones that the CMA likes to refer to as benign analogies to private medicine — don’t get to use public-school facilities whenever it’s convenient. Let them and their investors put billions of dollars on the table and see if they can make a go of it. You want to be entrepreneurs? Go for it — assemble the capital, take the risk.

Third, regulate profiteering and over-servicing. Provinces can pass laws that opted-out physicians can charge no more per service than the rate in the public system. Some do so already. Require private clinics to undergo regular quality and utilization audits. The U.S. is full of horror stories of investor-driven excess. Examples: A northern California hospital was cracking open chests to perform unnecessary by-pass surgery in response to pressure from the head office to increase profit margins. A southern California outfit was flying in healthy patients from the East Coast to undergo a few days of diagnostic investigations to generate higher revenues.

Impossible here, you say? Think Enron. Think Vioxx. Hell, think Krispy Kreme. Profit is a harsh taskmaster.

Fourth, and importantly, make doctors choose — in or out. No hybrid public and private practices. Take away the safety net: You don’t get to maintain a part-time public practice, where the state pays your fees, while building up your private and parallel business.

You’re entitled to move out — and we’re entitled to change the locks.

But it’s not just governments that have to respond vigorously to the privatization challenge. It’s all of us. Citizens have to make medicare a political issue at both the provincial and federal level. Make parties declare where they stand. If governments get a democratic warrant to preside over the development of a private and parallel system, let it blossom. Canadians deserve a chance to vote on it, one way or the other.

Not everything has to be overtly political. Legions of doctors are philosophically committed to the values of public health care and do their best to make it work. We should support them, honour them, and let the world know who they are. Launch a sticker campaign that certifies medical offices and clinics as medicare-friendly. Voting with one’s feet is always a healthy signal to those who earn their living by serving us. Ask the embarrassing question when making an appointment: “Are you a medicare-friendly clinic? If not, why not?”

And every once in awhile, hit the streets. As the CMA drafts its report on how the public and private systems ought to interact, serenade it with the chants of tens of thousands of citizens in front of their Ottawa head office in support of single-tier health care. Demonstrations in front of provincial medical association offices would be similarly invigorating.

We owe a debt to the CMA for letting us know where it stands. Let’s reciprocate the favour by letting it know, loudly, where we stand. If, in the end, the public sides with the CMA, applaud them one more time.

All that is clear right now is that if medicare is to improve and thrive, it will be in spite of — not because of — the efforts of organized medicine.

Steven Lewis is president of Access Consulting Ltd. in Saskatoon and adjunct professor of health policy at the University of Calgary.

By Sheryl Ubelacker
Canadian Press
August 26, 2005

TORONTO (CP) – When Dr. Kellie Leitch returned to Canada from the United States a few years ago, she joined a growing number of Canadian physicians choosing to come back home to practise. And now, the country’s medical brain-drain has been reversed for the first time in 30 years.

For decades, Canada experienced more drain than gain when it came to doctors departing for so-called greener pastures in the United States or countries overseas. But last year, that trend was reversed for the first time, with more doctors returning home than waving bon voyage to the country’s shores, a new report shows.

The report by the Canadian Institute for Health Information (CIHI), released Wednesday, shows that 317 physicians returned to Canada last year compared to 262 who left.

The net surplus is the first since the institute began collecting this data in 1969, and is “a continuation in the trend we have seen since the mid-1990s of a decreasing number of doctors leaving Canada for opportunities in other countries,” said Steve Slade, co-author of the report.

“That’s not happened once on record with our database, and it’s a first, a historical year for Canada,” he said from Ottawa.

The number of doctors who left Canada stood at 420 in 2000; and in 1994, a whopping 771 physicians crossed the border south or left the country’s shores.

Meanwhile, a 24 per cent rise in the number of doctors returning home in 2004, compared with five years earlier, gave Canada’s physician workforce the net gain.

Leitch, who attended the University of Toronto’s medical school, went to California in 2001 to complete her training in pediatric orthopedic surgery.

There were lots of opportunities in the United States, but Leitch said she jumped at an offer from the University of Western Ontario and returned to Canada in late 2002. Since then, she has been named chair chief of pediatric surgery at the Children’s Hospital of Western Ontario.

“The primary reason I returned to Canada . . . is that the Canadian taxpayers paid for my education,” Leitch, 34, said from London. Ont. “There is a huge investment in educating, in particular specialist physicians . . . and it only made sense to me that the people who had made that huge investment should benefit from that specialty they’ve invested in.”

Leitch said there are only about 60 orthopedic surgeons for children in Canada, and even one leaving would have a huge impact on patient care.

But she doesn’t think returning home makes her unique.

“I think there are a lot of Canadian physicians who were trained in Canada who’ve gone to the United States and are looking for a reason to come home. I think it’s because we have a better quality of life in Canada, I think they see there are opportunities here that weren’t available to them in the United States or elsewhere abroad, and that we are a well-supported community.”

The report by the Canadian Institute for Health Information (CIHI), released Wednesday, shows that 317 physicians returned to Canada last year compared to 262 who left.

The net surplus is the first since the institute began collecting this data in 1969, and is “a continuation in the trend we have seen since the mid-1990s of a decreasing number of doctors leaving Canada for opportunities in other countries,” said Steve Slade, co-author of the report.

“That’s not happened once on record with our database, and it’s a first, a historical year for Canada,” he said from Ottawa.

The number of doctors who left Canada stood at 420 in 2000; and in 1994, a whopping 771 physicians crossed the border south or left the country’s shores.

Meanwhile, a 24 per cent rise in the number of doctors returning home in 2004, compared with five years earlier, gave Canada’s physician workforce the net gain.

Dr. Ruth Collins-Nakai, president of the Canadian Medical Association, said the return of some physicians may be related to Canada luring back doctors to head or staff high-profile research institutes at universities across the country.

“I guess we’re somewhat relieved to see there’s a net increase in physicians coming into Canada, although it doesn’t really help us in overall numbers,” lamented Collins-Nakai. “We are more or less treading water in terms of our overall physician supply.”

The CIHI report shows that the number of doctors across the country rose by five per cent between 2000 and 2004 – to 60,612 from 57,803.

But growth in the country’s population kept pace during that period, leaving the number of doctors per 100,000 residents relatively stable – a status quo that has not made it easier for Canadians to find a family physician or get access to a specialist.

Collins-Nakai said hundreds more medical school entry positions are needed – and professors to replace those retiring to teach them – if Canada is to even approach self-sufficiency in achieving a physician workforce large enough to serve all Canadians in a timely fashion.

“In order to accomplish that, the medical schools, which are currently bursting at their seams, are going to need increased resources,” the cardiologist said from Edmonton.

Complicating efforts to ramp up the number of doctors to meet an aging population’s growing demand for both family practitioners and specialists is the concurrent greying of health-care services.

Baldly put, Canada’s doctors are getting older. In 2000-2004, the average age of physicians increased by one year, to 49 from 48. During the same period, the proportion of physicians under age 40 dropped by 13 per cent.

“That’s like our window into the future, where we see a decrease in the number of really quite recent graduates in Canada,” said Slade.

The report also shows that the doctor supply is made up increasingly by women: in 2004, females accounted for almost one-third of physicians, a 10 per cent increase since 2000. Among doctors 40 and under, women made up nearly half in 2004.

But with more female doctors working shorter hours, access to care is not improving for patients, but declining, experts says.

Making matters worse for patients is the expected retirement of more than six per cent of physicians in the next two years, said Collins-Nakai. “And we expect up to one-third of all physicians to be decreasing hours of work.

“Many physicians over the past half or (full) decade have been doing excessive hours of work to provide access to patients,” she said. “And we know we’ve got increased burnout levels among physicians.”

– Here are some highlights from the CIHI report on doctors:

-In 2000, 420 Canadian physicians moved abroad compared to 262 in 2004, a 38 per cent decrease.

-In 2000, 256 physicians returned to Canada compared to 317 in 2004, a 24 per cent increase.

-For the first time since 1969, when statistics were first compiled, more physicians returned to Canada than left the country.

-Between 2000 and 2004, the number of doctors in Canada grew by five per cent, a rate that kept pace with population growth.

-Among the provinces, Alberta and P.E.I. had the largest percentage increase in the number of physicians in the five-year period – up by 19 per cent and 18 per cent, respectively.
-In 2000, there were 188 physicians per 100,000 population; in 2004, there were 189 per 100,000.

-The proportion of family physicians to population rose slightly, while the proportion of specialists dropped between 2000 and 2004.

-During 2000-2004, the number of international medical graduates in family medicine in Canada rose 12 per cent, while specialist graduates numbers fell 9.4 per cent.

-The average age of physicians increased by one year from 2000-2004, to 49.

State’s health insurance needs intensive care
By David Lazarus
San Francisco Chronicle
Sunday, August 21, 2005

The United States is spending billions of dollars a year — not including the roughly $60 billion annual tab for the war in Iraq — to fight terrorism.

We’re doing this because terrorists hurt people. The especially proficient ones kill people.

But if keeping people out of the hospital (or morgue) is a primary goal of this lavish spending, how do we explain the catastrophe that is the U. S. health care system?

An increasing number of Americans are going without health coverage as our company-sponsored insurance system continues to erode.

Those without insurance, in turn, are skipping visits to doctors and failing to take preventive measures that could keep an illness from becoming debilitating.

These are two of the findings from a report issued last week by the UCLA Center for Health Policy Research. It showed that the number of California adults covered by company-sponsored health plans is steadily falling.

Perhaps even more troubling, spouses and kids of California workers are increasingly losing health insurance as companies cut back on the scope of coverage.

This is California we’re talking about — the wealthiest state in the wealthiest nation on the planet. And our health care system is failing us.

“California’s problems are the problems of the nation,” said Richard Brown, director of the UCLA center and co-author of the newly released study.

“The cost of health care has continued to increase so rapidly it has outstripped by far workers’ increases in salary and the ability of employers to afford it.”

Indeed, companies that once provided health benefits as a routine matter of employee compensation are increasingly offloading costs on workers in the face of double-digit annual price increases.

Average workers, in turn, are increasingly finding it difficult to provide themselves and their families with the coverage they need to ensure well-being.

More than 6 million Californians now lack health insurance. At the national level, the number of uninsured is a staggering 45 million.

That number will only continue to climb as more companies step back from their traditional role as health-insurance provider.

Rick Wagoner, chief exec of General Motors, told shareholders earlier this summer that GM — the nation’s largest private purchaser of health insurance — will spend $5.6 billion this year on health benefits for workers and retirees.

That’s more than the company spends on steel for its vehicles, and translates to an extra cost of $1,500 for every car or truck produced.

“Our $1,500-per-unit health care expense represents a significant disadvantage versus our foreign-based competitors,” Wagoner said. “Left unaddressed, this will make a big difference in our ability to compete in investment, technology and other key contributors to our future success.”

He added: “It is crystal clear that we need to achieve a significant reduction in our health care cost disadvantage and to do so promptly.”

But how do we do that? If universal coverage for all Americans is our goal, and it must be, what’s the use of pouring more money and resources into a system that’s already out of reach of millions of people and breaking the economic backs of employers large and small?

The answer, obviously, is to admit that the employer-based insurance system that came into being during World War II is no longer capable of accommodating the nation’s health care needs.

“It’s time for employers to take a very close look at a single-payer health care system,” said state Sen. Sheila Kuehl, D-Santa Monica. “They need to see that there is a way to control costs while still providing high standards of health care for everyone.”

Kuehl has introduced legislation — SB840 — that would create such a system in California. The bill was approved by the state Senate in May and is now winding its way through the Assembly.

A single-payer system essentially provides health coverage for everyone, based on taxes collected from companies and individuals. There are no extra co- pays or premiums. Anyone can receive treatment from any doctor at any hospital.

“Single-payer is a really good system,” UCLA’s Brown said. “It’s the most effective way to ensure equity and to control health care spending and costs.”

The beauty of Kuehl’s plan is that it would allow California to serve as a proving ground for the rest of the country. Single payer could be introduced and tinkered with here, then rolled out elsewhere.

Canada adopted a similar approach in gradually expanding a single-payer system to all its provinces. It started with Saskatchewan in the 1940s.

The Canadian system isn’t perfect — far from it. Long waits for treatment are a constant complaint.

Nevertheless, nearly two-thirds of Canadians surveyed still give their health care system a grade of A or B, according to poll results released last week.

When was the last time you spoke with a working man or woman who gave similarly high marks to the U.S. health insurance system?

If anything, the experiences of Canada, Britain and other developed nations that have pursued single-payer systems can show the United States both what works and what doesn’t in shaping a program to meet this country’s needs.

Whatever else, the UCLA study shows that if we don’t do something soon to remedy things, more Americans will go without coverage with each passing year.

“I think we’re finally getting to a point where a significant portion of the business community will stand up and say that it can’t take it anymore,” said Brown. “Maybe that’s when we’ll see something get done.”

David Lazarus’ column appears Wednesdays, Fridays and Sundays. He also can be seen regularly on KTVU’s “Mornings on 2.” Send tips or feedback to dlazarus@sfchronicle.com.

Time for a healthy divorce from employment
By Dr. Susanne King
Berkshire Eagle
Tuesday, August 23, 2005

LENOX – “Employers bracing for health bills” cried the headline in The Berkshire Eagle earlier this month. For the past five years, employee health plan costs in Berkshire County and elsewhere have been rising at double digit rates, and the same is predicted for the coming year. For some small business owners, the rate of rise in health insurance prices has been even steeper. A friend who is a self-insured small business woman told me her insurance tripled over the past five years. She said if her premiums continue to rise, she will be unable to afford health insurance.

Cities and towns have also been struggling to pay for health care for municipal employees, which has led to conflict. Unable to afford the rising cost of health insurance, cities and towns are asking their employees to pay for a greater percentage of the cost of their health care. Property owners are affected as well, since property taxes must be increased to pay for health insurance for municipal employees.

The New York Times reported last year that “health premiums are sapping corporate balance sheets even more than the rising cost of energy.”

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Take the case of General Motors. In 2003, GM’s cost to build a midsize car in the United States included $1,400 for health insurance. However, in Canada, GM was able to manufacture a car for $1,400 less than in the U.S. because Canada has a single payer national health insurance program rather than private insurance tied to employment.

Single payer means that the government collects and dispenses health care funds. In other words, the government is the “single payer” and insurance companies are eliminated. Canada’s single payer, national health care system covers everyone regardless of employment. In a single payer system, huge savings occur because administrative expenses are approximately 3 percent compared to 39 percent when hundreds of American insurance companies are involved. Single payer health care would be like our current Medicare system, except everyone would be covered, regardless of age.

A joint letter signed by the top executives of the Big Three automakers (GM, Ford, and Daimler/ Chrysler) in Canada, said that in addition to providing “essential and affordable health services for all” single payer “significantly reduces total labor costs compared to the cost of equivalent private insurance services purchased by U.S. -based automakers,” and “has been an important ingredient in the success of Canada’s most important export industry (automobiles).”

Canadian national health insurance saved Canadian automakers $4 per hour per worker in 2003 (in U.S. dollars). “High health care costs have created a competitive gap that’s driving investment decisions away from the U.S.,” said the vice chairman at Ford.

Our economy is hurting. In 2003, General Motors spent $4.5 billion on health care, Ford spent $2.8 billion, and Daimler/Chrysler spent $1.4 billion. Every business, big or small, is hurting. Meanwhile, the number of workers insured by their employers is shrinking, and the remaining insured workers are being asked to contribute more to their health care costs, sharing premium costs and having higher deductibles and co-pays.

Employees are hurting. The employer-based private health insurance system in the United States is an unhealthy marriage between employers and private insurance companies. Our system was created after World War II, when wages were frozen, and health care benefits were provided instead of raising wages.

This system has lumbered along, getting more and more unwieldy and expensive, dragging down the competitiveness of our country in a global economy, while workers in every other industrialized nation have national health insurance administered by their governments.

Private health insurance companies are responsible for this unhealthy marriage in our country, which spends twice as much for health care as any country in the world, and yet has poorer health care outcomes than other industrialized countries. What has developed is a system in which our struggling businesses and towns subsidize the profits of insurance companies and drug companies.

In order to maintain their enormous profits, these companies raise the specter of “socialized medicine,” with visions of lines and inferior care. But single payer is not socialized medicine, because health care itself would be provided by privately-owned hospitals and doctors’ offices. The only change would be in the funding and administering of health care by a “single payer” (the government), rather than the current hundreds of insurance payers. The government already pays for more than 60 percent of health care, including Medicaid, Medicare, and the Veterans Administration health care system, as well as paying for public employees’ private health care coverage and giving tax subsidies to private insurance companies.

Government health care spending will increase with the boondoggle that is coming with the privatization of the prescription benefit for Medicare. Why not eliminate the middle men, and use the public funds that are now going through private insurers to actually fund public coverage? Massachusetts has everything to gain by embracing single payer health care.

If towns did not have to subsidize health insurance and drug company profits by paying for health care coverage for employees, they could focus on paying for education, which has suffered from cutbacks in funding because of rising health care costs. And how many business owners and employees matched the salary and benefits of the not-for-profit Massachusetts Blue Cross Blue Shield CEO in 2002, who made more than $3 million?

Automakers have moved manufacturing to Canada, where they take advantage of the single payer national health care system to increase their profits. If we were to have single payer health care in Massachusetts, our system would be an incentive for businesses to move to our state, where the costs of doing business would be lower. What would you save in your business if you did not have to pay for health care insurance premiums for your employees?

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Now is the time to legislate a new system that will divorce health insurance from employment. There are four bills addressing health care reform in the Massachusetts legislature. Only one bill, the single payer Massachusetts Health Care Trust, S. 755, would free businesses, workers and our economy from this tyrannical alliance of health care insurance and employment.

S. 755 is also the only universal and affordable bill. Now is the time to legislate a single payer health care system for our state.

Healthcare Is Migrating South of the Border
California employers are steering Latinos to Mexico, where care is less costly but uneven
By Richard Marosi, Times Staff Writer
Los Angeles Times

TIJUANA — Thousands of Latinos who live near the border are taking advantage of a benefit increasingly offered by their U.S. employers: cheaper healthcare in Mexico.

About 160,000 California workers — farm laborers as well as working–class Latinos employed at hotels, casinos, restaurants and local governments in San Diego and Imperial counties — are getting their annual checkkups and having surgeries through health networks south of the border, insurers say.

The arrangement is cheaper for both employers and employees. In Mexico, healthcare costs are about 40% to 50% lower than in California, freeing some employers to offer services that they couldn’t otherwise afford.

“It’s a win-win situation for me. I’m able to offer it to everybody, and my premiums went way down,” said Mark Holloway, part owner of a department store in Calexico, Calif., who said he couldn’t afford health insurance for his 50 employees until he enrolled them in a cross-border plan.

He said he can sign up several employees, each at about $100 monthly, for about the same price as one employee in a U.S. plan.

Employees enjoy lower premiums and co-payments, typically $5, and the comfort and convenience of describing their aches and pains in Spanish to doctors who, they say, tend to take more time with them.

“The rate is good, the service is good,” said David Ouzan, a city councilman in Calexico, where about a third of the city’s workers use dental and medical clinics in Mexicali, just across the border. “I myself have used dentists in Mexico.”

Still, the trend has generated some misgivings among doctors and consumer advocates north of the border.

Some worry about the quality of care in Mexico and limited regulatory control.

Others say the cross-border plans represent a sad commentary on the limited access that immigrants and the working poor have to treatment in California.

They represent a “positive turn of events for cross-border health coverage … but are another reminder about how sick our health system is in thhe U.S.,” said Dr. Robert K. Ross, president of the California Endowment, a healthcare philanthropy.

Mexico has long been a low-cost alternative for thousands of people — many of them uninsured — who price-hunt among clusters of storeffront clinics and small hospitals in Tijuana and Mexicali for treatment they can’t afford in the States.

And some cross-border health plans have operated since at least the 1950s, when Imperial Valley farmers started offering coverage to migrant workers.

But the emergence in the last five years of cross-border HMOs, which must be licensed by the state of California, signals the growing acceptance of Mexican doctor networks by mainstream employers and insurers in the United States.

HMOs Cover 36,000

So far, three HMOs, two in the U.S. and one in Mexico called SIMNSA, are providing coverage for employees of California companies, covering 36,000 workers and their dependents, according to statistics provided by the insurers. About two-thirds of those employees are covered by the U.S. insurers, Blue Shield of California and Health Net Inc. (Health Net enrollees can access clinics on either side of the border.)

Since 2000, the number of nonagricultural employers in California offering such health plans has jumped from 165 to about 700.

Employee enrollment in farming association-sponsored plans in Mexico is far greater, though, reaching about 124,000, according to the plans. Though these are not HMOs, they rely on networks of Mexican doctors and hospitals.

Enrollees are typically Mexican citizens legally employed at U.S. companies, either living in Mexico or in the U.S. Many earn only $5 to $7 an hour and could not afford U.S.-based plans. But others are Mexican Americans, some of them in executive-level positions.

“Employers are really surprised a bit by the quality, the cleanliness,” said Peter Duncan, a vice president at Blue Shield of California, whose cross-border program is called Access Baja. “Often they had visions of squalor. It isn’t Cedars-Sinai. But they find that the basic quality of care is really there.”

Mexican facilities that are part of HMO networks serving U.S. companies are audited by the HMOs themselves for sanitary conditions, infection control policies and staff training levels, as required by the California Department of Managed Health Care. They are not directly evaluated by state regulators. Physicians must be licensed in Mexico and maintain a good standing in the medical community.

Still, some medical experts are concerned about what they describe as a wide variation in quality south of the border.

Though comparing the two systems, with their differing standards and philosophies, is difficult, doctors on both sides of the border say the Mexican regulatory system is lax, and doctor training not as rigorous as in the U.S.

In Mexico, doctors typically need six years of schooling; in the U.S., a physician’s education can take eight to 11 years, including college, medical school and possibly a residency training program.

“High-quality [healthcare] does exist in many places,” said Dr. Michael Rodriguez, a UCLA professor familiar with the border region, but “sometimes there are places that you’d wonder whether you would want to take a dog for treatment, let alone a person…. My guess and my hope is that HMOs are veery [discriminating] who they work with.”

Some consumer advocates say the audits done by HMOs themselves potentially create a conflict of interest. And they note that when complaints surface, the state may not have the jurisdiction to thoroughly investigate them. Mexican doctors, for instance, are not subject to regulation by the Medical Board of California.

Medical care in Tijuana, however, has generally improved since 1991, when Mother Teresa fell ill there and had to be taken to San Diego for treatment, said Patricia Aubanel, a U.S.-trained cardiologist who has performed heart surgeries in both countries.

Disreputable clinics touting miracle cancer cures or cut-rate cosmetic surgery still draw thousands of Californians, but a cottage industry of modern clinics and hospitals has developed in recent years that treats ailments ranging from colds to heart disease.

Insurers, employers and many border medical experts insist that the Mexican plans offer an acceptable level of care to a population that prefers healthcare in Mexico, even when offered plans in California.

But for some Latinos along the border, any plan is an improvement.

They are more likely to lack heath insurance than any other demographic group, according to the National Hispanic Medical Assn., and one of the draws of these cross-border plans is that they are a bargain.

Monthly premiums average about $100 for individuals and $350 for families in Blue Shield of California’s Access Baja plan. By contrast, the average monthly premium for California HMO plans was $261 for singles and $721 for families, according to a 2004 survey of employers by the California Healthcare Foundation.

Cross-border programs “seem to be fulfilling an important need, providing quality … healthcare services for very specific populations,” said Evaa Moya, executive director of the U.S. section of the U.S.-Mexico Border Health Commission.

Most cross-border enterprises function like California healthcare plans. Enrollees choose a doctor in Mexico for routine care. In emergency or urgent-care situations they can go to the nearest hospital or clinic in California or Mexico.

Participating employers include San Diego County’s landmark Hotel del Coronado, several manufacturing companies and retailers, and local governments such as El Centro’s Central Union High School District.

In Mexico, some medical offices brim with state-of-the-art equipment. Hospital signs direct patients in English and Spanish. Physicians in those offices say many of their colleagues boast degrees and training from top universities in the U.S. and Mexico.

Tijuana’s rapid population growth has fueled a mini-boom in hospital construction, drawing well-trained doctors from Mexico City and the U.S., say experts in both countries.

Technology Compared

Many facilities’ technology is comparable to that in the U.S., said Dr. Jose Hernandez Fujigaki, a U.S.-trained cardiologist who has performed heart surgery in National City, near San Diego, and, for a fraction of the cost, at the hospital he owns in Tijuana, Centro Medico Excel.

“We’re catching up,” said Fujigaki, adding that the Tijuana hospital can handle almost any surgery except skin grafts and organ transplants.

At Excel’s classroom-size main operating room, a horse trainer was recently wheeled in for a hernia operation. Three nurses in crisply pressed hospital garb spent several minutes meticulously assembling the instrument tray.

The team of three doctors made a small incision, inserted a small scope connected to a special camera called a laparoscope and repaired the man’s abdominal wall. Several visitors watched the procedure on television monitors from the observation room overhead.

Dr. Ruben Flores Diaz said the surgery, along with open-heart and other complex procedures, have been performed hundreds of times at Excel.

“This afternoon, he will leave … and a week from now he’ll be back wwith his horses,” said Flores Diaz, a general surgeon.

Excel’s charges are a fraction of those at U.S. hospitals. The daily charge for room and care in Excel’s intensive care unit is about $1,200. At Scripps Clinic, a large hospital in San Diego, the cost is about $4,000.

Personal Touch

Part of what draws patients south of the border is the very different medical culture. In California, some Latino patients say, care takes longer to get and is not rendered with as personal a touch.

These enrollees, who have received healthcare in both countries, say the U.S. system is too bureaucratic and hurries them out the door.

“Over there [in San Diego], we wait for more than half an hour and they just give us a Tylenol,” said cross-border plan member Guadalupe Briseno, who accompanied her 15-year-old son, Jorge, to the Tijuana clinic of Dr. Teresa Figueroa Garcia.

Garcia, 52, a soft-spoken family practitioner, is one of about 73 doctors in Tijuana affiliated with Access Baja.

Garcia, who shares her suite of offices with her husband, an internist, consults with patients in her office before treating them in an adjoining examination room.

She said she sees about seven patients daily. American doctors, by comparison, may see several times that, according to doctors north of the border.

Rosalia Serratos of Brawley, Calif., couldn’t afford insurance before her husband was hired three years ago at an Imperial Valley farm.

In years past, the family would seek treatment only in emergency rooms.

Now, their Access Baja plan enables them to go to Mexicali doctors, and in emergencies, U.S. doctors. The family believes that it can take advantage of the best from both countries.

Earlier this year, Serratos’ 3-year-old son, Saul, almost drowned in a pool accident and had to be airlifted to San Diego.

U.S. doctors, she said, saved her son’s life.

But for routine care she prefers taking him and her 9-year-old daughter to Mexicali, 25 miles away, where she says the clinics have shorter waits and more attentive doctors.

“I like the way they treated my son in San Diego. They never left him alone,” said Serratos, referring to the near-drowning. But for regular care, she added, “I like going to Mexico.”

Jose Rangel, a San Diego construction worker, said finding a good doctor to treat his lower-back pain was a problem in both countries.

In California, he would wait weeks for an appointment that lasted just a few minutes, he said. The doctors, he said, prescribed an assortment of drugs that only temporarily eased the pain.

In Mexico, the first physician he saw took X-rays and recommended surgery, but Rangel didn’t trust him because he didn’t take time to explain why.

“In Mexico, there are bad doctors just like here,” said Rangel, whose wife and two children also visit Mexican physicians. “It’s like everything else. It’s all about getting a good recommendation.”

Rangel ended up seeing Dr. Felipe Tovar Vasquez, a slim, middle-age back specialist for the Access Baja plan who extracted Rangel’s herniated disc and fused two vertebral bones. The operation was so successful that Rangel recommended the same procedure and doctor to his brother.

“I ended up well, thank God. I was walking two days after the surgery,” said Rangel, who can now painlessly hoist cabinets at his current job.

Tovar, a graduate of Mexico City’s prestigious Universidad Nacional Autonoma de Mexico, said Rangel was one of hundreds of people he had helped. His training and skills, he said, are the equal of U.S. doctors’.

The only difference, he said, is “a lot of money.”