UNIVERSITY OF CALIFORNIA RIVERSIDE Medical Migration: Strategies for Affordable Care in an Unaffordable System A Dissertation submitted in partial satisfaction of the requirements for the degree of Doctor of Philosophy in Anthropology by Jennifer Catherine Miller-Thayer December 2010 Dissertation Committee: Dr. Juliet McMullin, Co-Chairperson Dr. Carlos Velez-Ibanez, Co-Chairperson Dr. Thomas C. Patterson Dr. Christine Gailey Copyright by Jennifer Catherine Miller-Thayer 2010 The Dissertation of Jennifer Catherine Miller-Thayer is approved: Committee Co-Chairperson Committee Co-Chairperson University of California, Riverside AKNOWLEDGEMENTS I am grateful to UC-MEXUS, the Ernesto Galarza Applied Research Center (EGARC), the University of California, Riverside Humanities Grant, University of California, Riverside Anthropology Department and the Eugene Cota-Robles Fellowship for providing financial support through grants, fellowships and wages. I would like to thank Juliet McMullin, Carlos Velez-Ibanez, Thomas C. Patterson, Christine Gailey, Michael Kearney, Jim Bell, Joye Sage, Andrea Kaus, Martha Ponce, Kara Oswood, Professor Shea, Augustine J. Kposowa, Kathy Sorenson, Alison Lee, Darcy Wiewall, Alison and Ira Lipsky, Deanna Brewer, Carmen, Dr. Lopez, Dr. Mendez and Dra. Arreola, Dr. Quintero, Jorge Arrendondo, Dr. Valdez-Hernandez, Dr. Ceja, Loreen, Lisa, Joe, my husband Thomas Thayer Senior and our children, all of my family, and the Transnational Medical Consumers, community members, medical personnel and care providers in Los Algodones and Mexicali , Mexico and Calexico, California and Yuma, Arizona who generously shared their views, experience and knowledge with me. The text of this dissertation, in part or in full, is a reprint of the material as it appears in “Health Migration: Crossing Borders for Affordable Healthcare” in Field Action Science Reports (FACTS) , October 2010; and “Politics, Economics and Health: Survival Strategies at the U.S.-Mexican Border” in the textbook Cultures of the United States , editions 1 and 2, published in 2006 and 2009 respectively. iv DEDICATION This dissertation is lovingly dedicated to my family members and mentors who offered support, friendship and endless encouragement before they passed: my father Joe Guresky, my grandmother Emma Ovall, my Great Aunt Carrie Regnier and my mentors and friends Jim Bell, Michael Kearney and Ira Lipsky. v ABSTRACT OF THE DISSERTATION Medical Migration: Strategies for Affordable Care in an Unaffordable System by Jennifer Catherine Miller-Thayer Doctor of Philosophy, Graduate Program in Anthropology University of California, Riverside, December 2010 Dr. Juliet McMullin, Co-Chairperson Dr. Carlos Velez-Ibanez, Co-Chairperson Approximately 45.7 million people in the United States are uninsured and unknown numbers of this population are underinsured, severely limiting their access to medical care. To address this problem, people use innovative strategies to increase their access through cross-border care options. The U.S.-Mexico border provides unique challenges and opportunities for healthcare in this context. The lower cost of medical and dental procedures and medications in Mexico makes that country an attractive alternative for low-income populations in the United States. Thus segments of the U.S. population practice transnational medical consumerism in an attempt to optimize their health by using the resources available in both countries. This practice has economic benefits for the people who access healthcare at an affordable rate and for the medical markets of the country providing the care. Drawing on data collected in the field in 2002, 2004, and 2005, this dissertation presents some of the complexities and dynamics of medical pluralism occurring at the U.S.-Mexico border. vi TABLE OF CONTENTS Chapter 1: Introduction 1 Background: The U.S-Mexican Border and Health 3 Healthcare in Two Nations 6 Construction and Reconstruction of the Border since the 19th Century 9 Methodology 26 Organization of the Dissertation 30 Conclusion 32 Chapter 2: Articulation, Globalization and Critical Medical Anthropology 34 Introduction 34 Global Frameworks: Political Economy, Dependency, Articulation 37 The Political Economy of Health and Critical Medical Anthropology 53 Critical Medical Anthropology (CMA) 54 Transnationalism 64 Transnational Medical Pluralism 73 Conclusion 77 Chapter 3: Transnational Medical Consumers 79 Introduction 79 TMCs Defined 86 Demographics/Research Findings 87 Social Networks and Cross-Border Medical Access 89 Relationships with Providers: I am a person, not a number 98 vii Insurance Coverage: Exclusion and Access 101 Border policies (shift of value – world systems) 108 Why cross the border for care? 112 Better care: “They care about you here” 119 Access to Medical Resources 122 I don’t get healthcare in Mexico! 124 Economic Growth Industry for Mexico 129 Conclusion 134 Chapter 4: Three TMC case studies 136 Introduction 136 Participant Observation 137 Mexican Healthcare 138 My First Visit 139 Hearing Aid Bargains 145 The Perils of Summer Appointments 147 Hearing aids 153 Travis – a weekend crosser 161 Isaac and Maggie – a snowbird and his daughter 172 Medication Access 176 Mexico 177 Reflections and Impressions 184 Conclusion 186 viii Chapter 5: Risk: Contrived, Perceived, and Real 188 Introduction 188 Risk Constructed 194 Is it Safe? 201 Cautions and Concerns 204 Social Networking 207 Medical Authority and Quality 208 Media and Risk 213 Real Risk 215 Better System 220 Risk in the U.S. System 222 Conclusion 228 Chapter 6: Conclusion 231 Introduction 231 Structures of Access and Exclusion 232 States vs. Pharma 241 Future research 252 Policy Implications 255 Changing the U.S. System 257 References Cited 263 ix LIST OF TABLES 3.1: Interviewee Demographic Data 88 3.2: Cost Comparison of Medications in the United States and Mexico 110 3.3: Cost Comparison of Medications in the United States, Mexico, and Canada 111 5.1: Is it safe to get medications or care in Mexico? 202 5.2: Any difference between medication from the United States and Mexico? 202 6.1: Health Outcomes and Expenditures 261 x LIST OF IMAGES 1: TMCs waiting in line to cross back into the United States. 85 2: A transnational consumer getting dental work done in Mexico. 118 3: A sign welcomes snowbirds to a business in Los Algodones , Mexico 126 4: A main street in Los Algodones , Mexico. 127 5: A second main street in Los Algodones , Mexico. 128 6: Help wanted sign in dentist office window requesting a fluent English speaker in Los Algodones , Mexico. 131 7: “Hawkers” for the Purple Pharmacy in Los Algodones , Mexico. 132 8: Hearing aid office in Los Algodones , Mexico. 142 9: Hearing aid receptionist Maria and my family in front of the fountain in the courtyard behind the office. 143 10: Hearing aid receptionist, Maria, in the waiting area. 144 11: Me, my family and the dentists that worked on my friend’s teeth in front of the fountain in the courtyard behind their office. 159 12: Travis getting his teeth worked on by the dentist in Los Algodones , Mexico. 160 13: Front of card warning of possible risks for buying medication in Mexico. 192 14: Back of card warning of possible risks for buying medication in Mexico. 193 xi Chapter 1: Introduction “Was it hard to get people to talk to you since they were illegal? How did you get them to trust you and talk to you?” It was a warm breezy summer day in central California and two of my good friends were getting married at a nearby vineyard. The questions came up while my husband and I waited with another couple for transportation that was to take us to the wedding. Though we didn’t know each other, we passed the time chatting amiably about how we knew the bride and groom. When I explained that I went to graduate school with both of them, they asked where I did my research. I responded that my dissertation research was on cross-border healthcare access at the U.S.-Mexican border. They were both very interested in my work since she was a U.S. medical technician and he was a dentist. Eventually, she asked the above questions. With both husbands looking on, I cocked my head to the side and gave her a quizzical look and responded, “Crossing the border for healthcare isn’t illegal. People do it all the time. They were very willing to talk to me about it.” With the images of the populations that I worked with at the border in mind , I was initially puzzled by her questions. Then I had the dawning realization that she had assumed that the people I worked with while conducting my research were illegal immigrants from Mexico who were crossing the border into the United States in order to access presumed “better” healthcare here. These same assumptions and ideas were expressed in another conversation with a man who “married into a Mexican family.” When he found out the topic of my research, he shared the story of his sister who died while attempting to cross the border back into the United States after arranging her mother’s funeral in Mexico, ending with the statement that 1 “crossing the border is very difficult.” His immediate representation of the border and the context of my research was that of Mexicans migrating into the United States under difficult and illegal conditions. These questions and stories represent the essence of the issues that I was dealing with in my research. As Anglo citizens of the United States, they made several assumptions about my work that commonly shape how many people in the United States view immigration and healthcare at the U.S.-Mexican Border. They assumed that the people crossing the border for healthcare were only coming from Mexico into the United States; that they were crossing illegally and under difficult conditions; and that they believed that the U.S. medical system was better than their medical system was in Mexico (and thus worth the risk of crossing the border).