Introduction

Among current difficulties facing society, health care is of particular relevance. The provision of health care has become a problem for national governments due to the difficulties surrounding public health financing and the provision of a welfare policy. The legitimacy of the health sector in most countries is based on its ability to provide a satisfactory standard of health care for all citizens, regardless of their ability to pay. However, with demographic changes and advances in medical technology, the demand for health services is increasing. At the same time, globalization limits the public funds allocated for this purpose. As a result, there is an increasing need for reforms that limit costs while guaranteeing high-quality health services for the population (^{Rothgang et al., 2010}).

Comparative research in the 1990s indicated that the welfare state in advanced capitalism faces enormous pressures in an environment of globalization and permanent austerity. For many years the nation-state was able to exercise effective control over its institutions and social policy, but today several factors have reduced the capacity of the nation-state to finance and provide welfare state services at post-war levels (^{Hurrelmann et al., 2007}; ^{Leibfried & Zürn, 2005}).

Profound changes within the political and economic environment have led to a massive debate on the future of the welfare state and a plethora of cuts specific to the restructuring of that model (^{Pierson, 2001}). ^{Bommes and Geddes (2001}) question the social and political analysis discourses that take national welfare states as their reference point. They argue that states may remain key actors, but they are no longer the only actors. Institutions beyond the nation-state also suggest that the universalizing project of welfare states now possesses a dimension shaped by supra-national, transnational, and post-national developments.

In the context of limited resources to offer universal services and the insecurity of the population in search of a welfare state, there is a pressing need to study what happens in border cities. ^{Butler (2010}) articulates the border in a state of vulnerability and, through the concept of “precariousness”, designates that politically induced condition where certain populations suffer from failures in social and economic support networks; therefore, it is differentially exposed to injury, violence, and death. They also state that precarity is not constituted passively through the withdrawal of legal protection but is produced actively through the coercive exercise of state power freed from the constraints of the law. It is evident that globalization has facilitated the free flow of capital; in contrast, borders are increasingly constructed to rigidly channel the waves of humanity seeking freedom of movement (^{Wonders, 2006}).

To address the health obstacles in this context, many Mexican nationals living in the United States cross the border with Mexico in search of health care. Cultural and geographic proximity, quality of medical services, and lower costs are factors that explain the demand for cross-border health services (^{Vargas Bustamante, 2021}). Another of the main motivations for diaspora medical tourism can be visiting family and friends (^{Mathijsen, 2019}).

^{Moré (2011}) refers to Ciudad Juárez and El Paso as reciprocal cities on each side of the border, where social failure and one of the most unique monsters of inequality can be observed. They also mention that both are the same city, one and the same, on the front line of the problems, where each is a consequence of the other and part of the same process, except that one is poor, and one is rich.

On the other hand, ^{Whittaker (2015}) analyzes health equity, i.e., recognizing unfair and avoidable health differences between groups of people, and relates these differences to social, economic, or environmental disadvantages. The author considers that many of the economic benefits that would be obtained from trade in medical services for low- and middle-income countries are not being achieved. On the contrary, the growth of medical travel exacerbates already existing inequities within health systems.

This study aims to analyze the behavior of cross-border medical tourism in Ciudad Juárez, Chihuahua, Mexico, following the crisis generated by the COVID-19 pandemic. Ciudad Juárez has traditionally been a medical tourism destination for visitors of Mexican origin coming from nearby cities in the United States. In the context of the COVID-19 pandemic, patients who regularly visited the city in search of health care stopped crossing the border for several reasons, including fear of being infected and government guidelines requiring, among other things, lockdown, social distancing, and restrictions on border crossings between Ciudad Juárez and El Paso. This situation resulted in a reduction in the demand for health services for these patients of up to 80% during the first months of the pandemic.

This type of analysis corresponds to the trade-in health services, one of the approaches to studying medical tourism in this work. The second approach refers to patients’ vulnerability in cross-border mobility in the face of the limitations of the welfare state provided by the United States to Mexicans residing in that country.

It is necessary to know in greater depth what happens at the borders. There are large flows of people who seek health care in neighboring countries daily, which generates a series of imbalances in the health systems of both the sending and receiving countries. Despite the challenges identified in providing services to international patients, such as the language barrier, cultural aspects, and travel time, there are still other elements to consider. ^{Merrell et al. (2008}) state that legal and liability aspects, such as the follow-up of foreign patients, are elements needing improvement. They also identify continuity of care in terms of the doctor-patient relationship across borders as a barrier to medical tourism and state that this is an aspect that requires the attention of the actors involved.

It was necessary to consult a wide range of bibliographic resources and conduct 34 semi-structured interviews with medical tourists to carry out this study, and from whom important contributions were gathered that made it possible to deepen the understanding of cross-border medical tourism. The study has five sections. The first section deals with the background, highlighting the importance of medical tourism from two points of view: as a trade in health services and as a consequence of the failures of the welfare state that are worsening at the borders. The second section presents the methodology used, which discusses the process of preparing the manuscript. The third section presents the results, while the fourth section presents the discussion. Finally, the fifth section presents the conclusions.

The scope consisted of understanding the experiences of the 34 people interviewed and thus approaching the complex phenomenon of medical tourism in Ciudad Juárez during the COVID-19 pandemic. Furthermore, it made it possible to identify some characteristics that can be transferred to similar research in border cities, such as studies on medical tourism in the Baja California context (^{Vargas Bustamante, 2020}, 2021).

Medical tourism as a trade in health services

A study on market opportunities and prospects for health tourism in Mexico (^{Deloitte, 2019}) estimated that in 2018 medical tourism represented 5.6% of the industry globally, with revenues of close to USD 4 000 000 000. This amount could increase to USD 13 800 000 000 by 2030 if joint planning work is carried out and if there is collaboration between investors, government, and academia. It also states that about 77% of the medical tourists are border tourists and come from the southern states of the United States. It mentions that there are no precise data on the origin of the remaining 23%. However, Google Trends indicates that, in addition to the United States, Canada, the United Kingdom, India, and Malaysia are the countries that have the most searches for surgeries in Mexico.

Medical tourism refers to the use of medical and hospital services abroad (^{Connell, 2013}). More conservative figures from various empirical studies also include so-called diaspora medical tourism. However, they exclude from their estimates border medical crossings, welfare tourism, and medical care of retired foreigners who are already residents in the country (^{Connell, 2013}; ^{Merrell et al., 2008}).

This study defines medical tourism as the act of traveling abroad to receive medical care (^{Cormany & Baloglu, 2011}). It is important to know the behavior of medical tourism during the COVID-19 pandemic because, from the perspective of the health services industry, for Ciudad Juárez it represents the permanence in the market of many of the service providers in this field. However, it also implies the limitation of health care options for the local population and an increase in the price of services. On the other hand, it is also important to know the situation of Mexicans in the United States concerning health services in that country.

^{Lee et al. (2021}) state that after declaring COVID-19 a public health event of international concern (PHEIC) on January 30, 2020, the Emergency Committee of the International Health Regulations (IHR) initially recommended: “any travel or trade restrictions based on currently available information” (^{World Health Organization, 2020}). Some member states of the Committee mentioned above had already adopted travel-related restrictions prior to this declaration, while many more ignored the World Health Organization (WHO) recommendation, leading international legal scholars to criticize state parties for alleged non-compliance with the IHR (^{Habibi et al., 2020}; ^{Mason Meier et al., 2020}; ^{Von Tigerstrom & Wilson, 2020}).

Individuals and groups affected by the restrictions, such as the tourism sector (^{Organization for Economic Co-operation and Development [OECD], 2020}) and medical and humanitarian professionals responding to the pandemic (^{Devi, 2020}), urged governments to ease restrictions. As the pandemic worsened, others criticized governments for not enforcing cross-border health measures earlier or more stringently (^{Bollyky & Nuzzo, 2020}) or for reducing them prematurely. By March 2020, travel-related measures had become almost universal. However, implementation was uncoordinated and somewhat chaotic, as the adoption of cross-border health measures varied in form, duration, and scope worldwide (^{The need for coordinated international pandemic response, 2020}; ^{Wolfsteller, 2020}). The result has been a difficult process of trial and error (^{Kupferschmidt, 2020}).

Patients Beyond Borders’ global guide to medical tourism reported that Mexico and Costa Rica are the most popular destinations for dental care, cosmetic surgery, and prescription drugs. Meanwhile, Thailand, India, and South Korea lead in more complicated procedures such as orthopedics, cardiovascular, cancer, and fertility treatments (^{Ledsom, 2021}). ^{Deloitte (2019}) projects that the value of the aesthetic industry in Mexico is expected to quadruple by 2030. If so, it should grow at a rate of 10.7% annually until 2023 and increase to 13.3% between 2024 and 2030, a more than encouraging outlook for the country, which must also overcome its most important challenges: quality, safety, and certifications.

The high percentage of cross-border patients mentioned in the Deloitte study (2019) relates to the vulnerability that characterizes Mexican immigrants in the United States (^{Vargas Bustamante, 2021}), who face obstacles to access and use health services, and health insurance coverage. This includes their legal status, as approximately 50% are foreigners who have not regularized their stay in the country (^{Ortega et al., 2007}; ^{Pew Hispanic Center, 2013}).

Medical tourism as a consequence of the failures of the welfare state

The recent emergence of COVID-19 poses a serious threat to human health and is causing significant social and economic disruption globally (^{Chattu et al., 2020}). Long before COVID-19, the United States was at a disadvantage relative to other high-income nations regarding health and survival (^{National Research Council, 2011}; ^{Woolf & Aron, 2013}). Between 2018 and 2020, life expectancy in the United States declined by 3.88 years (4.7%), representing 2.9 times the decline in life expectancy for Caucasians. Notably, there was a greater reduction for men, with 4.58 years (5.8%), than for women, with 2.94 years (3.5%) (^{Woolf et al., 2021}).

Although the United States is a world power and a leading country in biomedical research, it does not have universal health coverage. According to the WHO (^{OMS, 2022}), universal health coverage “means that all people can access the health services they need, when, and where they need them, without being placed in financial hardship as a result”. In contrast, in the United States, one in three U.S. citizens have concerns about how they will be able to afford their health insurance, as a medical bill can leave them bankrupt (^{Hohman, 2020}). In 2019, 28 900 000 000 people in the United States were uninsured; this number has been rising over the past five years and is expected to rise with the pandemic; of those millions of uninsured people in the United States, about 20% are non-regularized migrants (^{Tolbert et al., 2020}).

In the United States, private companies administer most social security. Public insurance refers to Medicaid, an individual welfare program jointly sponsored by the federal and state governments, where eligibility depends on the family’s income and the individual and their minor dependents. There is also Medicare, a social entitlement granted by the federal government where eligibility depends on age, currently set at 65 years; therefore, it is a program to protect retirees. Finally, CHAMPVA (Civilian Health and Medical Program of the Department of Veterans Affairs) is a civilian health program for military retirees (^{Shi, 2001}).

Aliens with a non-legalized stay in the country are excluded from federal government programs that grant subsidized health insurance, such as Medicaid and Medicare, and from all stipulations of the Affordable Care Act (ACA), even when, after its implementation in 2011, it expanded health insurance coverage to approximately 70% of the previously uninsured population in the United States (^{Congressional Budget Office, 2012}).

The death tolls and vulnerability already existing in that country were exacerbated with COVID-19 in the United States. This reflects not only the country’s policy choices and poor management of the pandemic (^{Bollyky & Patrick, 2020}; ^{Parker, 2021}) but also entrenched factors that have put the country at a disadvantage concerning the health care system for decades (^{Beckfield & Bambra 2016}; ^{Preston & Vierboom, 2021}; ^{Woolf & Aron, 2013}; ^{Woolf & Schoomaker, 2019}).

For many critics, the pandemic itself drew attention to these long-standing conditions with increased social and economic injustices and inequities experienced by Black, Hispanic, Asian, and Indigenous populations and other systematically marginalized and excluded groups. In this regard, scholars on the topic reported that rates of COVID-19 infections, hospital admissions, and deaths are higher in Black and Hispanic populations compared to White populations due to greater exposure to the virus, higher prevalence of comorbidities, such as diabetes, and reduced access to healthcare and other protective resources (^{Bassett et al., 2021}; ^{Lopez et al., 2021}).

This framework highlights the vulnerability of immigrants and the importance of research on cross-border patient mobility, which exists due to geographic proximity, cultural affinity, migratory flows, price differentials, personalization and warmth in medical, dental, and pharmacological care (^{Connell, 2015}), and immediate attention, quality of health services, and trust in physicians in Mexico (^{Martínez-Almanza et al., 2019}).

However, ^{Dauvergne (2008}) states that, despite formal developments in the international protection of human rights, people with illegal immigration status have benefited little from them; therefore, they are still largely dependent on States for their legal status. Similarly, they state that “the gulf between those who have some form of immigration status and those who do not is of vital importance” (^{Dauvergne, 2008}, p. 21). The selectivity of borders is apparent since, to the extent that travelers are classified as “legal” or “illegal”, the border acts as a sieve (^{Wonders, 2006}) that separates legitimate from suspect mobility. This filtering produces transnational systems of social stratification based on mobility rights.

The intensity of cross-border relations and the degree of economic interdependence between neighbors is often greater than that of two countries separated by thousands of kilometers (^{Moré, 2011}); it also affects the confluence of people, states, and markets at the border, each with its own supply and demand, guided by greed and necessity, ambivalences that interact more strongly in unequal borders than elsewhere.

Methodology

This study conducted qualitative research with an inductive approach based on 34 semi-structured interviews with visitors to Ciudad Juárez for health reasons. It aimed to make theoretical contributions to the study of the phenomenon of medical tourism by exploring the experiences when interacting with the participating subjects. The methodological strategy is qualitative, given that the selection of cases that give typological representativeness to the phenomenon is not based on inferential statistics (^{Hernández-Sampieri & Mendoza Torres, 2018}) but descriptive inference (^{King et al., 1994}).

This study does not claim to be representative of medical tourism during the COVID-19 pandemic in Ciudad Juárez. However, it does seek to identify some characteristics of medical tourism in Ciudad Juárez following the COVID-19 pandemic crisis and explain them in a way that would be useful for similar research in border contexts. The sample comprises 34 cross-border patients seeking health care services in clinics, hospitals, and medical and dental offices in Ciudad Juárez. The requirements for determining this convenience sample were the following: the patients interviewed were persons living in the United States who had crossed the border to seek medical care.

The study used a semi-structured interview script for data collection, which consisted of 30 questions based on six features of interest: sociodemographic data, health status, habits and customs, travel tastes and preferences, health-related motivations for visiting Ciudad Juárez, and imaginaries about the supply of health products and services in Ciudad Juárez.

The difficulty in obtaining official information on this tourism segment makes quantitative analysis difficult. The lack of official statistics on cross-border mobility for health reasons in Ciudad Juárez is not unique to the locality nor to the Mexican government. Authors such as ^{Connell (2015}) point out that one of the notorious characteristics of medical tourism, in general, is the lack of clear statistics and the absence of standardization in the scarce data available around the world. Likewise, ^{Hall (2013}) mentions that the existing figures often come from private companies, such as travel agencies or healthcare corporations, which makes the origin and reliability of the data questionable.

The study chose a qualitative methodology based on semi-structured interviews for these reasons. The advantage of applying this type of instrument is that by using a pre-established script, the informant is guided to talk about the topics to be investigated but is given centrality and freedom to do so in the way they find most convenient (^{Denzin & Lincoln, 2012}). The time parameter of the study spans from October 2020 to July 2021.

This is a descriptive type of work because it aims to analyze the aspects that encourage people to visit Ciudad Juárez for health-related reasons, based on an in-depth understanding of each case, which implies describing the phenomenon and the context in which it manifests itself. According to ^{Hernández-Sampieri and Mendoza Torres (2018}), the aim is to collect information on the concepts or variables established by specifying the properties or characteristics of the phenomenon. Therefore, the study explores the independent variable on the health insurance coverage of medical tourists to see if this strengthens or incentivizes the presence of medical tourism, under the working hypothesis that the lack of health insurance in the United States is an incidence factor for medical tourism in Ciudad Juárez.

Data were obtained through semi-structured interviews with persons living in the United States who crossed the border into Ciudad Juárez in search of health care. It was also necessary to use documentary analysis of news reports related to the behavior of medical tourism during the COVID-19 pandemic and information obtained from the digital portal of the government of Chihuahua on the epidemiological traffic light related to the behavior of this disease. The data were then analyzed and interpreted thematically with inductive analysis through a constructivist lens. The findings reveal that the roles of gender, educational background, expectations, place of settlement, sociocultural and language affinity, and lack of health insurance were significant in the characterization of medical tourism in the health system of Ciudad Juárez. Future research or measures should consider a practical and dynamic approach to understand cross-border patients’ health needs and experiences comprehensively.

Next, the study presents the findings obtained through the working hypothesis and the variable proposed for the research work, making it possible to identify the characteristics of medical tourism in Ciudad Juárez, Chihuahua, Mexico, since the COVID-19 crisis.

Results

The geographic and demographic specifications of Ciudad Juárez, Chihuahua, Mexico, as a border with El Paso, Texas, in the United States, favor the mobility of large flows of people, with a codependent relationship between the two cities. This gives rise to the need to explore the behavior of this mobility of people to Ciudad Juárez since the COVID-19 pandemic crisis.

Before the COVID-19 pandemic, there was already a reduction in demand for health services from cross-border patients due to U.S. trade policy restrictions, which was influenced by migratory movements and insecurity in Ciudad Juárez: “during the last few days, medical tourism in Ciudad Juárez has been affected with a reduction of up to 60%, an activity that for years had been an attraction for many North Americans” (^{Telemundo 48 El Paso, 2019}). This report was confirmed early in the pandemic, when health care providers cited an 80% reduction in demand. However, as control of the pandemic improved, it made it possible to reduce infection risk. Consequently, there was a corresponding relationship between patient visits from neighboring cities to Juárez and the color of the epidemiological signal, since when the signal was red, that is, when sanitary protocols required remaining in lockdown, a reduction in patient visits was noted. On the contrary, as the epidemiological signal turned green, fear decreased, and patients began to return, even seeking care for COVID-19.

Table 1, based on data published by the Secretariat of Health of the State of Chihuahua in the media, presents the behavior of the epidemiological signal in Ciudad Juárez during the COVID-19 pandemic.

Patients from the neighboring country who had the opportunity to receive the vaccine against COVID-19 felt safer, thus reducing their fear of crossing the border and returning to seek medical care in Mexico. Particularly in Ciudad Juárez, Chihuahua, a significant change in demand for cross-border health services has been seen since July 2020, when patients were even seeking care for COVID-19.

Discussion

The findings of this research confirm the statements of ^{Rothgang et al. (2010}) regarding the difficult situation faced by U.S. citizens in the face of a health sector whose legitimacy is questioned because of its inability to provide a satisfactory standard of health care for citizens and non-citizens, regardless of their ability to pay for medical care. These findings correspond with Vargas Bustamante’s observations of the border in Baja California. This author points out that affordability, added to the quality of care and cultural affinity, will incentivize the search for medical services at the border, especially for patients of Latino origin, specifically Mexicans (2020).

The results of the study point to the lack of health insurance as one of the main reasons for seeking medical care in Ciudad Juárez. Insurance tends to have high deductibles and represents a high cost for patients. The presence of large insurance companies and their interests is one factor that reduces the nation-state’s capacity to finance and provide welfare state services at the post-war level, as argued by ^{Hurrelmann et al. (2007}) and ^{Leibfried and Zürn (2005}). Likewise, the findings are consistent with ^{Moré (2011}). The people interviewed expressed fear of contracting COVID-19 at the beginning of the pandemic and needed to go to Ciudad Juárez to receive medical attention.

One of the significant contributions of this work was the identification of cross-border patients who come to Ciudad Juárez in search of health care for COVID-19. Similarly, the participants’ search for care in public hospitals stood out, although the best private hospitals in the city were also mentioned for this purpose. Other important aspects were finding that patients also come to Ciudad Juárez to attend to the sequelae caused by COVID-19 and satisfaction with the follow-up, which ^{Merrell et al. (2008}) mentioned as one of the barriers to the development of medical tourism. As a final finding, it is noted that cross-border medical tourism does not represent a major difficulty, according to the people interviewed.

Conclusions

The findings of this work illustrate the approach to a cross-sectional problem involving the dynamics of cross-border mobility, known as medical tourism, and the lack of accessible medical care in their country of residence. The study indicates that the dynamics of cross-border mobility are due to a state of vulnerability of patients not receiving health care in their country of residence during the COVID-19 pandemic. Such vulnerability is normalized in the border environment, as people seek to resolve their health needs in Ciudad Juárez, where a sense of practicality converges in the notion of the functionality of borders. Crossing the border provides services that meet the population’s needs at an affordable cost. At the same time, this demand makes it possible to keep hospitals, clinics, doctors, and dentists that have historically had this type of patient in the health services market in Ciudad Juárez, which can be called an organic medical tourism typology.

This research may help health care providers in border destinations to appreciate the differences among the population seeking their services, as the types of treatments and the profile of patients seeking them differ greatly. There is a need for further research to determine whether the characteristics identified in this study are common in other mobile populations and whether they are found in other destinations popular with international cross-border migrants.

Despite the difficulties caused by the COVID-19 pandemic, this research demonstrates that Ciudad Juárez continues to have functional relevance for meeting the health needs of residents of neighboring cities in the United States. Therefore, it identified opportunities to boost health care delivery to cross-border patients, who continue to express a preference for health care in Ciudad Juárez. There is a clear need for planning the supply of cross-border health services and binational coordination of the actors involved in this health market, which would benefit those who lack health protection.