Research Summary

32.5 percent of El Paso residents crossed into Mexico for healthcare services in a recent two-year period—and most of them had insurance.

For decades, healthcare policy discussions have centered on a simple binary: insured versus uninsured. Yet research along the Texas-Mexico border reveals a far more complex reality that challenges our understanding of healthcare access, patient behavior, and the sophisticated strategies people develop when traditional systems fail them.

Kelli Frias, whose groundbreaking research at American University's Kogod School of Business examines consumer behavior in healthcare markets, has uncovered something remarkable: communities facing healthcare exclusion don't simply accept their circumstances. Instead, they develop what researchers call "cultural health capital"—a sophisticated set of skills, resources, and capabilities that enable them to navigate multiple healthcare systems simultaneously in ways most Americans cannot.

The Strategic Healthcare Consumer We've Overlooked

When we think about healthcare consumers, we rarely consider them strategic. Most Americans go where their doctor tells them, choose the hospital closest to home, or simply use whatever their insurance covers. But border communities have developed an entirely different approach out of necessity.

These individuals possess an expert-level understanding of healthcare pricing, quality indicators, and system navigation that would make most healthcare administrators envious. They know medication costs to the penny across two countries. They understand wait times, provider availability, and quality trade-offs in ways that defy the traditional "uninformed patient" stereotype that dominates healthcare policy discussions.

The statistics tell a compelling story. Research on El Paso residents found that among those who crossed the border for care, 82 percent used Mexican pharmacies, 63.2 percent accessed dental services, and 27.1 percent utilized health services. But here's what challenges our assumptions: these weren't primarily uninsured individuals scrambling for any available care. Many held full-time jobs with benefits—teachers, police officers, transportation managers—yet still found the US system insufficient for their needs.

Trading Medicine: Innovation Born From Exclusion

One case study illustrates the sophisticated nature of this navigation particularly well. A patient regularly purchased medications in Mexico, then traded them with her US physician for sample medications he kept in his office. The physician knew she couldn't afford the expensive US prescriptions. He didn't want her taking Mexican medications without oversight. So they created an informal system: she'd cross the border, purchase the medications she could afford, then call him to arrange a trade for samples.

This wasn't desperation—it was strategic problem-solving. It represented a physician and patient collaboratively navigating regulatory boundaries, cost barriers, and quality concerns to achieve the best possible outcome within constrained resources.

These patterns appear consistently across border communities. Consumers maintain relationships with neurologists on both sides of the border, consulting both and making their own informed decisions about treatment. They use Mexican healthcare for immediate needs while maintaining US insurance for major procedures. They've created informal networks—including specialized Uber drivers who serve as healthcare guides, navigating patients through Mexican clinics, pharmacies, and back across the border in a single trip.

What Marketing Theory Reveals About Healthcare Behavior

From a consumer behavior perspective, what's happening along the border challenges fundamental assumptions about how people make healthcare decisions. In most product categories, consumers understand quality indicators. You know what an expensive birthday cake should taste like versus a grocery store cake. You have anchoring points for price and quality that guide decisions.

Healthcare breaks this model entirely. Most Americans cannot tell you what an MRI should cost, what constitutes good quality versus poor quality imaging, or how to evaluate whether a particular medical device represents good value. Yet border communities have developed these evaluative frameworks out of necessity, creating quality indicators that work across two distinct healthcare systems.

The research reveals sophisticated mental models at work. A crowded waiting room in a US clinic signals an overbooked, inattentive physician. The same crowded waiting room in Mexico signals a physician worth waiting for. Same environmental cue, completely different interpretation based on cultural context and market understanding. Consumers navigate these shifting frameworks regularly, often without consciously recognizing they're deploying specialized cultural capital.

This expertise extends beyond individual decision-making. Border communities have created information-sharing networks that rival formal healthcare navigation services. Facebook groups provide real-time updates on clinic wait times, pharmacy inventory, and even safety conditions for crossing. WhatsApp connects patients directly with Mexican physicians who respond within hours—a level of access that shames most US healthcare systems' patient communication protocols.

The Cost of Expertise: When Agency Becomes Burden

But this expertise comes at a significant cost. One research participant described feeling like "a ghost"—someone who would never have a complete medical record because her healthcare was split between two countries, multiple providers, and systems that don't communicate with each other.

This fragmentation creates real risks. Medications purchased in Mexico may not be recorded in US electronic health records. Diagnostic tests performed on one side of the border remain invisible to providers on the other. The continuity of care that represents best practice in medicine becomes impossible when patients must constantly move between disconnected systems.

The emotional burden compounds these practical challenges. Multiple participants described feelings of shame and guilt associated with cross-border healthcare utilization. They experienced what researchers call a "resilience-risk paradox"—constantly balancing between demonstrating remarkable adaptive capabilities while simultaneously managing risks that wealthier, better-insured populations never face.

One woman purchased insulin in Mexico to manage her diabetes while keeping the electricity on, and her daughter enrolled in softball. She reasoned that keeping her child active reduced future pre-diabetes risk—a sophisticated cost-benefit analysis most healthcare economists would respect. Yet after making the difficult trip across the border and purchasing the medication, she often didn't use it, paralyzed by uncertainty about integrating it into her existing care routine.

What This Means for Healthcare Policy and Business Strategy

The sophistication border communities demonstrate in navigating dual healthcare markets offers profound lessons for healthcare policy, business strategy, and our understanding of patient agency.

For healthcare systems, this research challenges the notion that giving consumers more choice automatically improves outcomes. Border residents have extraordinary choice—arguably more than most Americans—yet face worse health outcomes and higher stress. Choice without adequate information, support systems, and care coordination creates what researchers call "illusory agency"—the feeling of control without its benefits.

For policymakers, the border experience demonstrates that insurance alone cannot solve healthcare access challenges. Most cross-border healthcare users have insurance. They're employed in stable jobs with benefits. Yet they still find the US system inadequate for their needs due to cost-sharing, provider availability, wait times, and perceived quality of care.

For business leaders and healthcare executives, border communities offer a living laboratory for understanding how consumers behave when forced to become truly strategic healthcare shoppers. They demonstrate what happens when price transparency becomes real, when alternatives exist, and when consumers develop expertise in quality evaluation.

This bi-national healthcare economy is not theoretical or distant. Utah's public employee program pays state workers to travel to Mexico for prescriptions. About 1 million California adults use medical, dental, or prescription services in Mexico annually. Cross-border healthcare represents a $3-4 billion market—and it's growing as US healthcare costs continue rising faster than wages.

Moving Forward: Learning From Margin to Mainstream

Perhaps most importantly, border communities challenge deficit-based thinking about marginalized populations. These aren't disadvantaged communities lacking resources—they're innovative communities that have developed valuable strategies for managing exclusion that remain underrecognized by health scholars and policymakers.

The question isn't whether we should support or discourage cross-border healthcare utilization. That ship has sailed—32.5 percent of border residents already do it. The question is whether we'll learn from their expertise, support their innovative strategies, and work toward systems that leverage rather than ignore their cultural health capital.

What if healthcare systems treated patients as the strategic consumers they've become? What if we designed care coordination that acknowledged dual-market utilization rather than pretending it doesn't exist? What if we created binational health records that supported rather than fragmented care?

These aren't hypothetical questions. They represent real opportunities to improve care for millions of Americans who've already voted with their feet—and their healthcare dollars—for a different approach to accessing care.