Two countries, one insurance plan: San Diego workers find medical care in Tijuana

San Diego Union-Tribune (CA)

Jan. 21--An electrician from San Diego, a hotel food services employee from Serra Mesa and a golf course groundskeeper from Oceanside all found themselves among the dozens of patients at the same Tijuana medical facility on a recent weekday morning.

One came for a therapeutic massage and to fill a prescription, another to see a nutritionist, the third to have his adolescent son's persistent cough checked out.

Although their jobs are in the United States, their health care is in Mexico. On this rainy January morning, the workers and their dependent family members have converged at an eight-story building just yards from the U.S. border.

Patients come to SIMNSA for everything from dental care to medical tests to physical therapy to consultations with specialists--all covered under SIMNSA'S cross-border health plan. Nobody here is complaining about crossing the border; in fact, many of them prefer it this way.

The co-pay for a doctor's visit is typically $7, a fraction of what they would pay in the United States, and there are no out-of-pocket deductibles on the plan. Many are Baja California residents, or have family members on the plan who live in Mexico.

Amid uncertainty over the future of U.S. healthcare, large numbers of U.S. patients continue to cross to Mexico for medical appointments. Mexico's lower costs have long offered alternatives for U.S. uninsured patients or those in search of elective procedures not covered by their plans.

A smaller but growing number of insured workers from San Diego and Imperial counties are also seeking health services in Baja California through two Mexican plans overseen by the state of California.

Geared to Mexican nationals and their dependents who live in San Diego and Imperial counties, the plans spell savings not only for patients, but employers: SIMNSA says its premiums are 60 to 70 percent lower than those of comparable U.S. health plans. Its network includes 400 physicians, 200 of them employed full time.

The aim is to "provide affordable, quality health care for the region," said Frank Carrillo, the 73-year-old founder of SIMNSA, the oldest and largest of two Mexican insurance providers that are licensed by the state of California. "You can make a doctor's appointment at 11 p.m., that's why people come over here. Not only for affordability, but for accessibility."

Among SIMNSA's subscribers is María Teresa Contreras, a 68-year-old Barrio Logan resident insured through her husband, who works setting up banquets at at a La Jolla hotel.

"Over there, the doctor just checks you, gives you medicine and it's time to go home," said Contreras, seated in a recliner as she received ozone therapy. The treatment was not offered by her former U.S. health plan, but is available at SIMNSA for patients diagnosed with ailments such as diabetes, rheumatism and arthritis.

Shara Shapiro, 40, who lives in Serra Mesa and works in food service at a hotel in La Jolla, said she paid $90 every two weeks for a U.S. health plan before switching to SIMNSA three years ago at the recommendation of a colleague.

Now, she's paying $20. "It's much cheaper, I get better service, and I don't have a huge co-pay to see a specialist," she said.

A plan limited to the California-Mexico border

California is the only state on the U.S.-Mexico border that allows such cross-border plans. Of the two HMO plans licensed by the Department of Managed Care, the smaller and newer plan is MediExcel, which started in 2012.

Based in Tijuana's Río Zone at the private Excel Hospital, MediExcel's plan last year saw its enrollment grow by 35 percent last year, and currently counts some 10,000 enrollees, said executive vice-president Jim Arriola.

He concedes these plans are not for everyone: "If somebody doesn't want to go to Mexico, it doesn't matter how much they're going to save, they're not going to pick a cross-border plan," Arriola said.

Since SIMNSA became licensed in 2000, the company says more than 500 U.S. employers have chosen to offer SIMNSA as one of the options for their workers. Among the plan's direct subscribers are employees of the Hotel del Coronado, General Dynamics in National City and Barona Casino.

Enrollees can receive care at five different SIMNSA outpatient centers in Mexicali, Tecate and Tijuana, with the largest facility within easy walking distance of the San Ysidro Port of Entry. The hours are 8 a.m. until midnight on weekdays, with shorter hours on weekends.

The plan provides for U.S. emergency and urgent care. For major surgeries and other procedures not offered directly by SIMNSA, the plan contracts with other Tijuana providers.

SIMNSA counts close to 50,000 direct enrollees, but has expanded its pool of potential patients by 80,000 through agreements with two U.S. plans -- HealthNet and Anthem Blue Cross -- that allow members access to medical care in Mexico through SIMNSA, said Christina Suggett, the chief operating officer. In addition, more than 10,000 people receive discounted care at SIMNSA through the purchase of a membership card, Mexsalud.

One of SIMNSA's oldest clients is Local 30, the hotel and hospitality workers' union in San Diego. Of 3,500 members on health plans, about a third are enrolled in SIMNSA, said president Brigette Cummings. Members who enroll in SIMNSA health plans pay no fee--the entire cost is covered by the employer.

"For people willing to cross the border, it's an excellent option," Cummings said. "The co-pay is cheaper, the medicine is cheaper." But there are other advantages as well, she said: the extended hours allow participants to make appointments without having to take off from their jobs and the location in Mexico allows care for dependents in Mexico who are unable to cross to San Diego for treatment.

From field workers to hotel workers

The founder and driving force behind SIMNSA is Frank Carrillo, a Mexican-born immigrant who as a boy helped support his family selling popsicles by the border in Tijuana--at the very spot where SIMNSA's medical building now rises.

He was 16 years when his family moved to the United States. While the others went to work in the fields, Carrillo stayed behind in Los Angeles, "painting cars, construction, whatever came along."

He earned a GED, joined the U.S. Army, and after receiving an honorable discharge returned to civilian life and found work in sales for a health plan. After rising through the ranks, Carrillo struck out on his own as a consultant, helping companies get HMO licenses in California.

From there, he went to work for the Teamsters, overseeing the union's agricultural worker health program in the state of California, setting up health care contracts with providers on both sides of the border, as some of the farm workers lived in Mexico.

He saw an opportunity in setting up cross-border healthcare networks for Mexicans who cross to work in San Diego. "I saw service workers living in Mexico and working in San Diego, and I said to myself, the same thing I did for farm workers, I can do for these workers."

His newest project is a 120-bed, $120-million bi-national hospital being planned around the medical tower. Carrillo expects the first phase consisting of an emergency room and 30 beds will be completed this year, with the finished project set for opening in 2020.

SIMNSA and Scripps Health in 2016 announced they would be joining forces on the project, with Scripps acting as consultant, but a final agreement was not reached. Carrillo said he is moving forward, undeterred in his vision.

"I'm one of those immigrants who realized the American Dream," said Carrillo, a dual U.S. and Mexican citizen who lives in Chula Vista's East Lake. "When people say, 'You can't do it,' I do it. My hunger comes from being an immigrant."

Limited enrollment

Though Americans for decades have come south for a broad range of medical medical care, the concept of a cross-border health plan sanctioned by authorities both in the United States and Mexico is relatively recent. The 1998 passage of an amendment to the Knox-Keene Health Care Service Plan Act, which regulates managed care in California, opened the door to "Mexican prepaid health plans." These are plans that are licensed in California to offer employer-sponsored group plan contracts to Mexican nationals legally employed in San Diego and Imperial counties and their dependents, no matter what the nationality.

The legislation's sponsor, Steve Peace, was then a Democratic state senator representing San Diego's South Bay, and says Hispanic staff members first put the issue on his radar. "They came to me and said, 'this is crazy, you have people living in Mexico and in some cases living in the South Bay, they are being forced to get medical care that is more expensive," north of the border.

The option for insured workers to receive care in Mexico came on the heels of the signing of North American Free Trade Agreement, a period when "there was a lot of expectation that economic relationships were going to strengthen on both sides," said Arturo Vargas Bustamante, a professor at University of California Los Angeles' Fielding School of Public Health and a former official in Mexico's health ministry.

But for all the flurry of initial interest, the expectations of high enrollment have fallen short, Vargas said. A 2008 article co-authored by Vargas cited "legal, cost and geographic limitations" as the main obstacles to expanding enrollment. The plans are limited to employers in San Diego and Imperial counties and exclude "self-employed people who might be interested in buying less costly coverage in Mexico," the article stated.

Today, the California Department of Managed Care licenses only two Mexican prepaid health plans: the SIMNSA Health Plan and the MediExcel Health Plan. Both say they are compliant with the standards of the Affordable Care Act, and both are reporting growth.

"Many of the new members we're getting were previously uninsured," said Arriola of MediExcel. A big issue for low-wage earners in California is obtaining coverage for dependents, he said, and by selecting lower-cost cross-border plans, workers are able to enroll family members who previously did not have coverage.

While many San Diego service workers have found low-cost insurance under these plans, they are not the only U.S. option available to those employees willing to cross to Mexico for medical care. The Western Growers Association offers one of the largest health plans to agricultural workers in California through its assurance trust plan; as port of the choices, enrollees can receive some or all of their care in Mexico through a proprietary network of contracted medical providers in Tijuana, Mexicali and Algodones in Baja California and San Luis Río Colorado in Sonora. According to the association, some 15,000 enrollees are receiving at least some of their treatment in Mexico.