Barrett Newkirk

The Desert Sun

When Vic Yepello has a toothache he doesn't call any of the dentists listed in page after page of the phone book. He calls Mexico.

When the day of the appointment comes, he hops in his car and drives east, going far beyond any of the dental offices within a few miles of his Palm Springs home. He heads south and eventually farther east. About three hours and 165 miles later, he parks in a lot that costs him $6 a day and then walks the final 300 feet across the U.S.-Mexico border.

Yepello, a 70-year-old real-estate agent and cycling nut, has made the journey to Los Algodones four times in the last 15 months. The village, wedged up where Mexico meets California and Arizona, has earned the nickname "Molar City" by catering to thousands of foreigners a year — mostly Americans — who come seeking deals on fillings, crowns and false teeth. While they're there, many also stock up on cheap prescription drugs and eyeglasses.

PART 2: Mexico fills health needs for many Latino Americans

For an appointment last May, Yepello left home before 7 a.m. Including one pit stop on the way, he arrived in Los Algodones with plans to have his teeth cleaned, shop for glasses and buy some heavy-duty ibuprofen.

The trip was a follow-up to a root canal and a crown he had gotten six months earlier. Lately, a tooth above that dental work had begun to feel sore.

“So I’m just going to have them X-ray that, take a look and it and see if there’s something going on there,” Yepello said during the morning drive.

After a relatively brief stint in the exam chair, some time spent popping into the eyeglass shop and pharmacy, and a break for lunch in the village, he made it back home in time for dinner with his husband.

It's hard to say how many people make similar trips each year, but the number from California alone is easily in the hundreds of thousands if not millions. More than 6 million private vehicles (a number that excludes buses) entered Mexico from the U.S. in 2015, but border authorities aren't counting how many people in all of those cars and trucks are making the trip for medical reasons.

In Southern California, if people haven't gone to Mexico for health care, they probably know someone who has. People overburdened by the price of getting what's supposed to be some of the best health care in the world are willing to seek out options that would have seemed overly risky not long ago. And while more Americans now have health insurance than ever before, the high price of seeing a doctor, dentist or filling a prescription have not slowed the annual growth in the amount of money Americans spend on health care in foreign countries.

Josef Woodman, the author of the medical tourism guide Patients Beyond Borders, estimated that 900,000 Americans left the country for medical care in 2013, but Woodman is not counting people traveling for prescription drugs, a big draw to Mexico. Another estimate for California only based on a 2001 survey put the number at 952,000 adults heading to Mexico annually for medical care, dental work and prescription drugs.

In the Coachella Valley, the nine-city region that includes Palm Springs, one in 10 adults, or more than 36,000 people traveled to Mexico in the previous year for health care and prescription drugs, according to a 2013 survey.

Americans are spending more money every year on health care in foreign countries. In 2015, the total climbed to $1.8 billion, according to the federal Bureau of Economic Analysis, up from $585 million in 2006.

Many people who have gone say price was their motivating factor.

Ingrid Joyal, 69, of Sun City Palm Desert went to Mexico and paid $300 for porcelain crowns, a third of what she would have expected to pay at home.

Three years later, Joyal has no regrets.

“It hasn’t fallen out, and it’s fine,” she said.

Yepello hadn't considered Mexico for dental work until getting the suggestion from a trainer at his gym. His Medicare doesn't cover most dental work, and Yepello knew he couldn't afford more than $2,000 to bring relief to his increasingly sore mouth with a new crown and root canal.

The trainer gave him the name of a trusted dental office in Los Algodones. Yepello called and the woman on the phone said everything would cost $550.

“And my jaw just dropped. I couldn’t believe that it could be that little,” he said.

Making the journey alone each time has made Yepello an expert on where to park, where to walk across the border and how to navigate around the village. There's typically no wait to cross the border in either direction. Only once was he asked to show a passport, and even though it had expired, he was allowed to enter Mexico.

On the U.S. side of the border, the Quechan Tribe of American Indians runs a parking lot where short-term visitors can keep their cars while in Los Algodones. The lot can be crowded in the winter months when more people are making the trip, but on a Wednesday morning in May, Yepello had his pick of hundreds of spots.

The Quechan also run a casino and hotel off of nearby Interstate 8 that attracts people who need to stay overnight while visiting Los Algodones. Yepello has stayed there once, and while he thought the hotel was perfectly nice, anyone wanting decent food should drive a little further east to Yuma.

Los Algodones is a touristy border town styled on a medical theme. The buildings are old but brightly painted. Just across the border, pharmacies dominate every block. Mixed in are the eyeglass shops and souvenir stands. Men and women stand outside doorways hawking deals on pills. Sidewalk signs next to them list prices for Retin-A, Voltaren, Spiriva and other drugs that require a prescription in the U.S.

Medications that can be legally prescribed in the U.S. can be brought back from Mexico for personal use, but in some cases a prescription is needed for the drugs to be allowed over. U.S. Customs and Border Protection has highlighted the painkiller Tramadol and anti-anxiety drug Xanax as two medications commonly seen at the border that, because they are Schedule IV drugs, require prescriptions.

The law still allows U.S. residents without a prescription for those drugs to import no more than 50 doses.

The Food and Drug Administration cautions Americans against buying prescription drugs in foreign countries. Officials with the agency have said that in their experience, many drugs coming from foreign sources and claiming to be the same as U.S.-approved drugs are of unknown quality.

Before Yepello can compare prices on Mexican ibuprofen, he must sit in the dentist's chair. He walks the short distance from the border crossing to the dentist office and then into a narrow waiting room fitted with modern furniture. Beyond a reception window and doorway are the exam rooms. Mounted on the wall outside one is a small dry-erase board listing the morning's appointments and the names of the patients. One at 9 a.m., Yepello at 10:30, then another at 11:30.

The exam room equipment looks new but simpler than the padded chairs and machines seen in American dental offices. Instead of giving Yepello water from a tube inserted into his mouth, the dentist hands him a small plastic bottle of water. Lined up neatly on a counter top are a can of disinfectant spray, a jar of cotton swabs, scotch tape and a decorated metal can holding pens and a pair of scissors.

“Some of their equipment might be a little bit standard technology,” Yepello said. “But it still does the job.”

Dr. Marco Raya displays his dental degrees on the exam room wall, including one from the Autonomous University of Baja California, a large public university.

Speaking in Spanish while his assistant translates, Raya said most of his patients find him through word of mouth. He said with so many dentists in the same town, the competition means he can't afford to achieve less than excellent results.

Yepello's experience has convinced him it's possible to get dental care in Mexico as good as what's found in the U.S. The risk of complications is no different, he said.

“If something went wrong, yea I’d have to get back in my car and go down there,” he said. “But again it gets down to the affordability of it all. I don’t have to borrow money. I don’t have to do anything. I can just go do it.”

At least twice a month, Dr. Ayman Elraheb talks to one of his dental patients in the Palm Springs area who has decided to go with a Mexican dentist over him, or who recently made the trip. He estimated the loss his Coachella Valley practice sees from patients going to Mexico at around $100,000 every year.

Elraheb, who went to dental school in his native Egypt before moving to the U.S. and taking additional classes to get licensed here, said there’s no competing with Mexico on price but called the quality of work “unpredictable.”

He figured 20 percent of the work he sees done in Mexico isn’t up to U.S. standards, and he's often paid to fix it.

“If you really don’t care about the outcome, OK, you have nothing to lose,” he said. “But you’re not getting another set of teeth.”

From 2009 through 2014, Americans’ dental care costs rose 2.1 percent on average to $113.5 billion, or a per capita increase from $334 annually to $357. Insurance covered about $6 for every $10, leaving $4 for people to pay out-of-pocket, according to the Centers for Medicare and Medicaid Services, which tracks national health care spending.

Looking into the future, the agency is predicting that in 2025 the nation’s dental care will cost just under $200 billion, or $566 per capita,

Elraheb said his prices are a reflection of overhead costs with a little worked in for profit after his expenses are covered.

In a statement posted to its website, the California Dental Association says it understands the allure of cheaper dental care abroad before telling patients they should do their homework before getting any work done. Without highlighting specific destinations, the CDA suggests patients research infection controls and safety standards in the foreign country and their legal rights if something goes wrong. Questions to ask include: Can I get a refund if problems arise? Are the costs of any unplanned follow-ups covered? Does the dentist have malpractice insurance or is a civil lawsuit possible?

“CDA suggests that consumers considering this option proceed with caution and with a full understanding of the potential health, safety and legal risks,” the statement concludes.

Patients interviewed said they knew they accepted some risk by choosing Mexico. If something were to go drastically wrong, they acknowledged filing a malpractice lawsuit in Mexico seemed like an almost impossible process.

Phil York of Rancho Mirage has spent months trying to correct some of the dental work he had done in Los Algodones. Over two trips there in 2015, a clinic gave York, 49, five crowns. His insurance company even agreed to reimburse him for half of the $870 total price. At home, York was prepared to pay up to $700 per crown even after his insurance helped.

“The dental group was very clean and very professional,” York said. “Obviously, the prep work was not very fun. Getting five crowns done at one time is not an experience I would recommend.”

York was told he would experience some pain and discomfort in his mouth for one or two weeks. But more than eight weeks later, he was still feeling pain he described as “pretty intense.”

York followed up with Dr. Elraheb, who performed X-rays and examined York’s bite before determining four of the five crowns likely needed to be replaced.

One crown was repaired soon after, and York is talking to his insurance company to see if they can help cover the other costs. He has not reached out to the Los Algodones clinic.

“It clearly states on their contract that for any complaints or difficulties, you must return to them. You have to give them an opportunity to fix it,” he said. “When it’s a few hundred miles away and means going outside of the country and all that jazz, it’s a lot easier said than done.”

Mexico encourages patients and doctors to resolve disputes outside of court by offering arbitration services through an agency within the Ministry of Health known as Conamed, or the National Commission of Medical Arbitration. A 2005 study funded by the agency found the system was well liked by doctors and complaint filers and that the arbitration process tends to be faster and cheaper than court. Still, many cases still wound up in court.

A 2010 study published in the Yale Journal of Health Policy, Law, and Ethics examined the legal options for U.S. residents seeking compensation for inadequate medical care in various foreign countries and found it’s often a struggle. Building a case in U.S. courts against foreign doctors or clinics poses logistical challenges, while going through foreign systems can lead to drawn out processes for limited compensation.

In Mexico, the arbitration system resulted in an average recovery of $4,800, an amount that would not satisfy most American patients, the report said.

“In short, U.S. patients traveling to Mexico for medical care should not assume that its legal or arbitration systems will provide satisfactory recourse,” the study found.

To avoid future arbitration or lawsuits, Americans should research their options before heading to Mexico, said Woodman of Patients Beyond Borders.

“There’s care out there in some 20 destinations around the world, including Mexico, that’s as good or better than in the United States, but you got to look for it,” he said. “You’ve got to do your homework, and that’s especially true for the border towns and resort towns.”

In Woodman’s experience, half of the travelers think it is more important to research the doctor’s credentials while the other half will research the hospital or clinic. He recommended looking up international accreditation and paying attention to legal claims. Reviews on sites like Yelp can steer people toward quality, but only if there's a long history of positive feedback.

Any place that doesn’t respond to emails within 40 hours is giving you a warning sign to look elsewhere, he said.

“If they don’t feel good when they get there, they can always back out,” he said. “They don’t have to sign those admission papers.”

Yepello has now made four trips to Los Algodones, and his husband is considering going for new glasses. His Facebook posts about his experience have prompted at least two of his friends to go.

Part of the glowing review he wrote online immediately after returning from that first trip summed up his feelings. “Our system here is so broken...... this is really a no brainer."

PART 2: Mexico fills health needs for many Latino Americans

Barrett Newkirk's reporting on cross-border health care was undertaken as a USC Center for Health Journalism Fellow. He can be reached at (760)778-4767, barrett.newkirk@desertsun.com or on Twitter @barrettnewkirk.