Covers Louisiana's Medicaid Dentistry

Medical tourism in the US-Mexico border area

Table of Contents


List of figures

List of tables

List of abbreviations

Part I Medical Tourism - A Worldwide Phenomenon
1 Introduction to the subject
1.1 Problem and objective of the work
1.2 Structure of the thesis
1.3 Approach and methodology
2 The history and development of medical tourism
2.1 The precursors - geomedicine and medical geography
2.2 The development of health tourism
2.3 The new forms - wellness tourism and medical tourism
3 Health systems at a glance
3.1 Types of health systems
3.2 The US health system
3.2.1 Structure and development of the US health insurance system
3.2.2 Need for reform and critical examination of the American health care system Criticism: health expenditure Criticism: The number of the uninsured population Criticism: Different regional and demographic distribution of health insurance cover Excursus: Health system in Mexico
4 Framework conditions for medical tourism
4.1 The forms of medical tourism
4.2 Factors influencing trends - Pro medical tourism
4.2.1 Differences in costs
4.2.2 Service / quality
4.2.3 Globalization
4.2.4 Demographic change
4.2.5 Changing values ​​in society - the sixth Kondratieff
4.3 Barriers to medical tourism
4.3.1 Lack of standardization
4.3.2 Inconsistent insurance bases
4.3.3 Unexplained follow-up care
4.3.4 Missing local economic and social effects Excursus: Inclusion of other tourism service providers
5 medical tourism destinations
5.1 Asia
5.2 Africa
5.3 Europe
5.4 America
6 Medical Tourism in the United States
6.1 Structures and forms of US medical tourism
6.1.1 Outbound Medical Tourism
6.1.2 Inbound Medical Tourism
6.1.3 Intrabound Medical Tourism
6.2 The typical American medical tourist
6.3 The most popular destinations for Americans

Part II Case Study: Dental Tourism on the US-Mexico Border
7 The Mexico-USA border area
7.1 The US-Mexico border area - containment and definition
7.1.1 The geography of the border
7.1.2 Tourism and the border
7.1.3 Population growth and demographic distribution in the border region
7.1.4 Economic basics
7.2 The urban history of the border towns
8 Mexico's Tourist Potential Excursus: Current Political Movements - Focus: The Situation During The Drug War
8.1 General tourist conditions or tourist offer in Mexico
8.2 Consideration of the economic importance of tourism to Mexico
8.3 Recent Developments - Focus: The Medical Tourism Market
8.3.1 The medical product
8.3.2 Demand groups and forms of tourism in Mexican medical tourism
8.3.3 Dental tourism
8.3.4 Acquisition of Pharmaceutical Products
8.3.5 Eye treatments Excursus: The medical Mecca on the border: Los Algodones
9 Evaluation and interpretation of the results of the empirical study
9.1 The methodological approach Digression: Status Quo - Dental Health Insurance in the USA
9.2 Evaluation of the results of the target group study of US patients
9.3 Evaluation of the results of the target group study of Mexican dentists
10 Conclusions and need for action
11 Conclusion




In times of changing values ​​in modern society in the 21st century, a move away from the material values ​​of an industrial society towards a greater importance of post-industrial values ​​can be perceived. Living a lifestyle, feeling active and being healthy are now more important than they have been in the past. So it is not surprising that health is already a paid service today.

Medicine has thus become an important economic factor and the healthcare industry a billion-dollar business. Health insurance companies, public health administration, medical practices, clinics, the pharmaceutical industry, medical technology industry, medical research, teaching and further training are only parts of the huge complex of the "health system" and its internal structure.

The US healthcare system is described by multiple sources as expensive and patchy. The need for reform cannot be denied, and the dissatisfaction of a large part of the population is well known. President Clinton's failure to introduce health insurance similar to the German system led to a further deterioration in the American health system. The private insurance system has become established in the USA, as a result of which a large part of the population is under or uninsured. Using the example of dental treatments, the limits of the system and the consequences for the population and the economy can be demonstrated: A transnational medical tourism movement has been evident for several years. Due to the unique position of the USA with regard to its current health organization and the structure of the system as well as its close proximity to its southern neighbor Mexico, framework conditions are created that enable US patients to pursue medical frontier tourism that is economically not insignificant.

The present work deals with numerous facets of the US health care system and creates a link to the phenomenon of medical tourism on the basis of the selected market. As an exemplary example, the USA-Mexico border region is subjected to an analysis as a medical tourism destination and the need for research is shown. I would like to thank everyone who has contributed to the success of this work. In particular, Professor Dr. Becker, who was always at my side at the beginning of my work, Prof. Dr. Kagermeier, who spoke out in favor of the final supervision of my work, and Prof. Dr. Wachowiak for taking over the second correction.

Trier, May 2009

List of figures

Fig. 1: Schematic structure of the research work

Fig. 2: Medical tourism in the context of geography

Fig. 3: The new spectrum of health tourism

Fig. 4: Outlines of the US health system

Fig. 5: Health expenditure in the industrialized nations in 2006

Fig. 6: Health expenditure per capita according to total and public expenditure in 2004

Fig. 7: Concerns of the population in the context of economic change in society

Fig. 8: Number of uninsured persons and the uninsured rate over time from 1987 to 2007

Fig. 9: Percentage of the population without insurance coverage (age group under 65 years) by US American counties (as of 2005)

Fig. 10: Main motives of the medical tourism customers to go on a trip

Fig. 11: The global flows of medical tourists

Fig. 12: Influence of globalization on health

Fig. 13: The long waves of the economy and their basic innovations

Fig. 14: Medical Tourism India website

Fig. 15: Dubai Healthcare City logo

Fig. 16: Outgoing medical tourism movement of Americans (10-year extrapolation)

Fig. 17: Types of demand in the US healthcare system

Fig. 18: US patients' medical tourism hotspots

Fig. 19: The Mexican and American districts along the US-Mexico border

Fig. 20: Characteristics of cross-border shopping

Fig. 21: Typifications of the relationship between a border and tourism

Fig. 22: The total population of Mexico and its distribution along the border (1950-2000)

Fig. 23: Proportion of Hispanics in the USA and the border region (1979-2000)

Fig. 24: Population densities of the Hispanics living in the USA

Fig. 25: Share of the urban population in Mexico and the border region (1950-2000)

Fig. 26: Sister cities on the US-Mexico border

Fig. 27: Sketch of a northern Mexican border town

Fig. 28: Number of international tourists visiting Mexico by type of tourism (1998-2008)

Fig. 29: Foreign exchange income from international tourism to Mexico 1998-2008 (in million US dollars)

Fig. 30: Development of tourism-promoting measures for Mexico 1979-2000

Fig. 31: Material, experience and trustworthy goods

Fig. 32: Typical internet presence of the dental practice

Fig. 33: Mexican dental practice Ciudad Juárez (June 2008)

Fig. 34: Location of tourist pharmacies according to a study by OBERLE / ARREOLA 2004

Fig. 35: Distribution of medical services in Algodones, Baja California (status: 2003)

Fig. 36: Los Algodones website

Fig. 37: Main reasons for visiting Mexico

Fig. 38: Type of treatment in Mexico

Fig. 39: Obtaining information about visiting a dentist in Mexico

Fig. 40: Main motivations to visit a dentist in Mexico

Fig. 41: Weighting of various aspects of the visit to the dentist and the treatment

Fig. 42: Activities perceived after a visit to the dentist in Mexico

Fig. 43: Probability of a repeated visit to the dentist in Mexico

Fig. 44: Advertising campaigns by Mexican dental practices

Fig. 45: Advertising campaigns by Mexican dental practices specifically for US patient acquisition

Fig. 46: Additional tourist services of the Mexican dental practices

Fig. 47: Assessment of your own dental practice compared to conventional practices

Fig. 48: Frequencies of the individual treatments

List of tables

Tab. 1: Forms of medical tourism

Tab. 2: Medical tourism nations

Tab. 3: Presentation of the cost differences of selected treatments in a country comparison

Tab. 4: Models of the interrelationships along the border

Tab. 5: US-Mexican twin cities along the border

Tab. 6: Definition of the different types of tourists according to the Mexican Ministry of Tourism SECTUR

Tab. 7: Demand groups for medical services

Tab. 8: Cost differences of selected dental tourism destinations worldwide

Tab. 9: The most common pharmaceuticals in Mexican tourist pharmacies

Tab. 10: Statistical data for data collection from dentists

Tab. 11: Statistical data for data collection from the patients

Tab. 12: Positive and negative experiences regarding visits to the dentist

Tab. 13: SWOT analysis of strengths and weaknesses (internal analysis)

Tab. 14: SWOT analysis of opportunities and risks (external analysis)

Tab. 15: Summary of the main points from the patient survey

Tab. 16: Summary of the main points from the survey of the dental practices

List of abbreviations

Figure not included in this excerpt

Part I Medical Tourism - A Worldwide Phenomenon

1 Introduction to the subject

"Phenomena come and phenomena go, of course. But the evidence is that medical tourism will be with us for a while. It has just begun. "(SCHULT 2006, p. 40)

The medical tourism trend is becoming global. Southeast Asian destinations, Eastern Europe, parts of Africa and Central and South America in particular are flourishing in various medical segments. In the present work, the border between the USA and Mexico is examined more closely, because here, too, medical tourism tendencies can be identified for a long time. US citizens cross the border into Mexico to undergo medical treatment there that they cannot or do not want to receive in their own country for various reasons.

1.1 Problem and objective of the work

Within a private-sector health system, health care and thus the product 'health' becomes a service that can be used for a fee. In times when social security systems are in need of reform and there is a constant shortage of public funds, the costs of health care are also skyrocketing. Especially within the US health care system, a holistic cost-containment program with regard to health care has been advocated for years. However, it was not until the 1980s that the managed care program (see Chapter 3.2) found a suitable way of controlling the increasing financial burdens. Despite all of this, a not inconsiderable portion of the US population currently has no access to primary health care in their own country and is considered "uninsured"[1][2]. A country in which the world's highest per capita expenditure on health care occurs as a percentage of gross domestic product, but where at the same time its own population cannot be provided with adequate health care should be viewed critically. In combination with the changing values ​​of society, increasing health awareness, demographic development and the increased mobility of the population, these conditions promote the recent emergence of medical tourism. Based on the US market, the peculiarities of the medical tourism movement of patients within the border area to Mexico are to be examined more closely.

The existing literature all too often places a strong emphasis on the health economic or medical component.

The topic of health and medicine is also dealt with from a geographical point of view, but there is often a lack of a touristic perspective. An additional difficulty in dealing theoretically with the topic is the fact that the present work focuses on the US-Mexican border area and not on transatlantic medical tourism holiday destinations as is the case with the relevant medical tourism primary literature. Medical tourism as a term that is not yet too well founded arises from an interdisciplinary background and should therefore also be treated accordingly in the following work.

The research interests focus on the following key questions, which define the objectives and the chapter structure of the thesis.

- How is the term medical tourism defined and how can its origin be explained? Which phases is it based on or what can be traced back to the development of the trend? (Chap. 2)
- Which health system fundamentals can be crystallized in the sending country (here: USA)? Is the criticism of the US healthcare system justified? (Chap. 3)
- Which framework conditions have to be particularly considered with regard to medical tourism? Are there promoting and limiting factors for the medical tourism trend? (Chap. 4)
- Which other transatlantic medical tourism destinations can be identified? Can you find certain main destinations? Are there 'old' and 'new' destinations? (Chap. 5)
- Focus on the USA: What are the characteristics of medical tourism in the USA? How does an American medical tourist define himself, what are his basic motives and motivations (push and pull factors of the patients in the sending and receiving countries) and preferred destinations? (Chap. 6)
- How can the border area between the USA and Mexico be defined, recorded and classified? Can certain structural features be identified? (Chapter 7)
- In what way is the current medical / dental tourism noticeable on the US-Mexico border? What development has it undergone and what facets does it currently show? (Chap. 8)
- How do US patients rate the dental offers in Mexico (demand)? How do Mexican dentists rate their business, especially with regard to their US patients (offer)? What future prospects can be identified? What alternative courses of action do the dental practices have to further increase dental tourism in the region? (Chapter 9)

1.2 Structure of the thesis

The overall structure of the research work can be shown schematically in a graphic as follows.

Fig. 1: Schematic structure of the research work

Figure not included in this excerpt

Three levels of work can be extracted. The first part gives an overview of the basics and concepts of work, medical tourism and basic knowledge for the structure of the US health system (Chapters 1 to 3). The first chapter presents the methodological structure of the present work. After a description of the problem, the exact objective and the schematic structure of the work, the procedure and methodology are explained. After the methodological basics of the present work have been clarified, the history or the background of medical tourism in the context of health tourism is processed and some terms necessary for the work are defined (Chapter 2). The thesis also deals with the systematic representation of the health system in the USA. The characteristic health care structures are explained and critically assessed (Chapter 3). The second section deals with medical tourism in detail. Framework conditions, transatlantic destinations and the medical tourism trend in the USA are dealt with here (Chapters 4 to 6). The fourth chapter focuses on the fundamentals of medical tourism, which represent basic knowledge for the further course of the work. The explanation of the fundamentals of medical tourism is followed by an explanation of the global medical tourism destinations (Chapter 5) and a further in-depth look at the medical tourism trend that has developed in the USA (Chapter 6). The third, empirical part of the thesis explains the medical tourism background of Mexico, i.e. it introduces a boundary observation as well as an analysis of the tourism development in Mexico (Chapters 7 and 8). There is a particular focus on the southern border region[3] the USA, the literature-based analysis of the border area (Chapter 7) is accompanied by an empirical case study which shows the research gap in the work based on the dental tourism trend along the US-Mexican border (Chapters 8 and 9). After a description of any alternative courses of action and a conclusion, the research work is concluded (Chapter 10).

1.3 Approach and methodology

In the preparatory phase of the work it became apparent early on that there was little specialist literature on the subject of medical tourism. The literature base on the German market is unsatisfactory, i.e. there is hardly any scientific German literature on the subject of medical and dental tourism that can be used. For this reason, English-language literature, journal articles and current articles from the daily press often had to be used. Furthermore, there is only an unsatisfactory data basis with regard to national and international official statistics for medical tourism and only a limited number of studies on the matter. On the one hand the topic is relatively new, on the other hand the area of ​​dental tourism and especially the destination border region Mexico is a rarely discussed topic. Reason enough to question the rather one-sided presentation of the research subject through various media.

In order to limit the research topic at the beginning and make it comprehensible, a secondary source analysis was carried out, which brought together a collection of various sources. In addition to national and mainly international literature, internet articles, texts from (specialist) journals and magazines and articles in the daily press as well as studies from various institutions also served as assistance.

This was followed by primary research in the field along the USA-Mexico border. Using a standardized online survey of medical tourists and US patients[4] an attempt was made to sound out voices from the region as well as development tendencies of the dental tourism trend. At the same time, another online questionnaire, designed for dentists working in Mexico, was launched[5]. The dentists were selected on the basis of extensive internet research, and there was also an entry in the Mexican Yellow Pages (seccion amarilla[6] ) a mandatory requirement for inclusion in the examination. With regard to the patients, the questionnaire was posted in internet forums and so-called medical tourism blogs[7]. This comprehensive quantitative online survey was carried out exclusively in English. The response rate for the two surveys can be classified as satisfactory. However, the results cannot necessarily be transferred to the general public and are therefore of limited validity. However, by considering the entirety of the information, well-founded tendencies can be identified.

2 The history and development of medical tourism

The interest in physical well-being and health is not new. People have always had a keen interest in healing and relaxation, triggered above all by the occurrence of natural mineral springs. After the pioneering considerations of the Greeks, especially Hippocrates, these healing springs were also discovered by the ancient Romans (200 BC), whereupon these springs were used for water healing methods in many regions of Europe, including France, Hungary, Croatia and Germany . The existence of a large number of different health resorts at an early stage implies that the trend towards well-being, health and getting healthy has been around for a long time and is currently only subject to a so-called modernization and character shift (cf. KUREN & HOLIDAY 2007, oS and cf. BENCZÚR-ÜRMÖSSY 2003, p . 5). Today a fertile branch of industry is developing from this fundamental motive, the growth of which currently seems unchecked. The following chapter covers the development of the form of tourism - health-motivated travel - to date. At the beginning, the two geographical sub-areas of geomedicine and medical geography are considered, as these can be described as pioneering disciplines that for the first time established the link between medical aspects and geographical content. Health tourism is based on these beginnings and has established itself to this day as a separate sub-area in human geography. Since then it has been subject to numerous modifications and has currently expanded to include the new forms of wellness tourism and medical tourism.

The present work shows a focus on geographical issues and is also considered from this point of view. Accordingly, the term medical tourism is first explained in its origin and placed in the context of human geography.

Medical geography is a sub-area of ​​physical anthropogeography, whereas traditional and new health tourism can be assigned to economic geography and here to tourism geography. Medical tourism can also be located here as a designated sub-area (cf. HEINEBERG 2003, p. 18 f.). According to TURGER, medical tourism can be located at the intersection of health tourism and health system research, which both represent sub-areas of economic and physical anthropogeography (cf. TURGER 2005, p. 10).

Fig. 2: Medical tourism in the context of geography

Figure not included in this excerpt

Source: Simplified own illustration based on HEINEBERG 2003, p. 18 f. And TURGER 2005, p. 10

2.1 The precursors - geomedicine and medical geography

Both terms are made up of the words geography and medicine. Geography is defined as "[...] the science of the earth and its structure, of the phenomena of the earth's surface, of the interaction between earth and man." (FARLEX INC. 2009, oS). Medicine, on the other hand, is "[.. .] defined as the science of healthy and sick people or animals. It includes research into the causes and manifestations of diseases (pathology), their detection (diagnosis) and treatment (therapy) as well as their prevention (prophylaxis). " (FEDERAL STATISTICS OFFICE 2009, no page). Both terms link the sciences to a new concept, geomedicine, a "branch of medicine that relates diseases and their distribution to geographical conditions." (BIBLIOGRAPHISCHES INSTITUT & FA BROCKHAUS AG 2009, oS). In the border area between medicine and geography it deals with the relationships that are formed between medical conditions in geographical areas and phenomena in the geosphere (see JUSATZ 1984, p. 11). Their therapy and preventive measures are placed in the foreground (cf. DIESFELD 1995b, p. 18). Areas such as medical geography, geomedicine, health system research (see Chapter 3) and environmental medicine are located at the intersection of the two disciplines[8]who have favourited Travel Medicine[9]who have favourited Medical Meteorology[10] etc. at.

JUSATZ was an important representative within German geomedicine and defined it as a sub-discipline of physical anthropogeography. However, the definition remains incomplete in that it cannot be explicitly differentiated from medical geography. Both sub-areas are blurred and cannot be clearly delimited from one another. Just the definition of the term was divided into two parts. If research was dominated by physicians, they tended to use the term 'geomedicine', whereas geographers preferred the term 'medical geography' (cf. DIESFELD 1995b, p. 18). It should also be mentioned that the individual research in medical geography is strongly influenced by national traditions with different focuses (cf. KISTEMANN / LEISCH / SCHWEIKART 1997, p. 199). Medical geography, on the other hand, was ascribed a more descriptive character, whereas the tasks of geomedicine were more analytical. Geomedical research thus examines the relationships between the geosphere and diseases as a function of space and time (cf. JUSATZ 1983, p. 56). Her research fields include in particular the analysis of the spatial distribution of diseases and their connections with socio-economic environmental influences or different structural features (cf. HEINEBERG 2003, p. 18).

The term Geography of Health (health geography) is increasingly being used, namely when one goes beyond a simple definition of medical geography, which not only shows how diseases are expressed in space and time, but also when the causes are also explored (cf. KISTEMANN / LEISCH / SCHWEIKART 1997, p. 198 and cf. DIESFELD 1995b, p. 21). A withdrawal from medical issues can be seen. Geography has thus developed as an independent sub-area and strictly rejects the medical component, "a medical geography released from the shadow of medicine and reinvented as geographies of health and healing." (PARR 2002, p. 241) Only medical questions emerge and the health problems are further examined in connection with social, economic, political and cultural influencing factors. Research moves at the interface between the two segments, whereby interdisciplinarity within these is a necessity (cf. KISTEMANN / LEISCH / SCHWEIKART 1997, p. 198).


Medical geography as a field of research can be dated back to the 4th century BC. Even then, Hippocrates (460-377 BC) dealt with the emergence of diseases as a result of environmental conditions and external circumstances in the European-Mediterranean cultural area (cf. GESUNDHEITSGEOGRAPHIE.DE 2008, n.s. and DIESFELD 1995a, p. 27). He recognized a connection between the seasons, climatic elements, the prevailing water quality as well as the eating habits of society and the resulting health of the population. His attention was directed to the task of sensitizing doctors to the characteristic regional differences between living conditions and the resulting predominant diseases (cf. DIESFELD 1995a, p. 27).

Almost all historical documents recognize the origin of all observations and studies of the environment in connection with health, in the Hippocratic essay "On Airs, Waters, and Places" which the scientist wrote with the medical school on the Greek island of Kos (cf. RUPKE 2000 , P. 7) Galenus of Pergamon (129 AD - 216 AD) further developed the scientific research of Hippocrates and identified four basic components, such as hot, cold, wet, dry, which were combined with the basic elements such as earth, Air, fire and water were connected. His work dominated and formed the basis for many of the subsequent western-influenced medical sciences (cf. RUPKE. 2000, p. 8). The expression "salubrity of the place" as well as the general designation of places under Medical aspects were shaped during the same period, for example the Greek doctor Galenus from Rome (129-199 AD) recommends the highlands and desert climate for lung patients (cf. DIESFELD 1995, p. 35 - In: KISTEMANN / LEISCH / SCHWEIKART 1997, p. 198). In the following centuries, this idea of ​​a connection between illness and the environment in its most general form remained almost unchanged (cf. KISTEMANN / LEISCH / SCHWEIKART 1997, p. 198).

Beginning of the 19th century

Disease mapping has been the most common way of working in medical geography. In the 19th century it was one of the most important instruments of research. A prime example is the map by the doctor J. SNOW (1813-1858) who analyzed the spread of cholera in London. Thus, contrary to all assumptions, after years of research around 1854 he was able to prove that the cholera diseases were connected to the drinking water supply (cf. DORRMANN 1995, p. 233 ff. - In:

KISTEMANN / LEISCH / SCHWEIKART 1997, p. 198). SNOW thus became the founder of modern epidemiology (cf. DIESFELD 1995b, p. 17).

Only after this time did geography actively deal with this subject area. The German geographer PETERMANN then mapped the great cholera epidemics in England (cf. DIESFELD 1995b, p. 17). SNOW and PETERMANN thus introduced a set of instruments in geography to explain the incidence of diseases (cf. DIESFELD 1995b, p. 17). This achievement formed the foundation for the interdisciplinary relationship between the two subjects of medicine and geography, which continues to this day (cf. KISTEMANN / LEISCH / SCHWEIKART 1997, p. 198). This period of research also triggered the discussion about the content and differences between the terms medical geography and geomedicine.

19th century until today

In addition to the findings of Hippocrates, in the middle of the 19th century came the view that social factors such as living environment and occupation also influence the occurrence of diseases. A massive turning point occurred towards the end of the 19th century, when the research branch of bacteriology showed that pathogens could be controlled with microbiological and cellular pathological methods. Geographical as well as geomedical perspectives continuously decreased. During the First World War, geographical medicine experienced a new boom, as there was hardly anything to counteract the emerging epidemics and epidemics. In order to get answers about the spread of the diseases, maps were created in which parasitological surveys and microbiological analyzes are shown. Epidemiological maps of the spread of Ebola and AIDS, in particular, achieved a great reputation in the following years, as did other cartographic elaborations on relevant medical criteria and disease distributions (see GESUNDHEITSGEOGRAPHIE.DE 2008, no page). Until the middle of the 20th century So the use of geography in the medical field was limited to recording the distribution and spread of diseases in space and their cartographic representation. Today, however, medical geography is also dedicated to solving social, economic, political and cultural health problems. This includes, for example, the accessibility, distribution and use of health care (cf. GEOMED 2008, above). Current contents of medical geography continue to deal with questions of the epidemiological transition, but obviously indicate a change of direction towards political, economic, social and cultural issues (cf. KISTEMANN / LEISCH / SCHWEIKART 1997, p. 200). It can be seen that medical geography has increasingly opened up to neighboring disciplines since the 1990s, including medical sociology, medical anthropology, public health or health system research (see BENTHAM et al. 1991, oS - In: KISTEMANN / LEISCH / SCHWEIKART 1997, P. 202).

2.2 The development of health tourism

The development of European health tourism began in Greece on the basis of the knowledge of Hippocrates (460-370 BC). He claimed that all diseases refer to the internal imbalance that can arise between the four basic elements water, fire, air and earth as well as the human body fluids (cf. RULLE 2003, p. 225 f.). The cure in particular has a long past, in which Hippocrates is considered the pioneer of today's modern cure and the father of medicine. Thus, spa tourism is one of the oldest forms of tourism (cf. BENCZÚR-ÜRM0SSY 2003, p. 5). The cure was the harmonization of lifestyle habits, including baths. The first small trips were made to these bathing facilities, followed by the development towards organized spa traffic (cf. RULLE 2003, p. 225 f.).

RULLE defines health tourism as follows: "Health tourism is a sub-area of ​​tourism whose special travel motive consists of restoring or maintaining well-being, both physically and mentally, through the use of certain health-related services in the destination." (RULLE 2003, p. 107) GOODRICH / GOODRICH go even further and in their definition focus on the tourism component: "We define health-care tourism as the attempt on the part of a tourist facility [...] or destination [...]. ] to attract tourists by deliberately promoting its health-care services and facilities, in addition to its regular tourist amenities. " (GOODRICH / GOODRICH 1991, p. 107).

The most comprehensive definition in this context is that of KASPAR 1996. This describes health tourism as:

"Totality of the relationships and phenomena that result from the change of location and the stay of people for the promotion, stabilization and, if necessary, restoration of physical, mental and social well-being with the use of health services for which the place of stay is neither the main nor permanent place of residence and work is. "(KASPAR 1996 - In: ILLING 2009, p. 4).

A significant change in values ​​can be seen in recent years. According to sociological studies, the aspects of work, family and tradition take a back seat to personal identification and fulfillment and are replaced by values ​​such as health, fitness and performance (cf. RICHTER 1993, p. 67).

HALL counts health tourism to the special interest travel segment. The travel motive to improve one's individual state of health during a trip has existed for a long time. In today's sport- and health-conscious, westernized society, however, health tourism developed as a rather small tourism segment, primarily in countries such as Austria, Switzerland, Hungary, France, Italy or Israel (cf. HALL 1992, p. 151). RICHTER defines the actual health vacation as "[...] a combination of vacation fun and individual, expertly supervised and scientifically based health programs." The contents of such a health trip are often sports, fitness and exercise programs or relaxation, nutrition and beauty offers (cf. . RICHTER 1993, p. 68). The people who take part in this tourism are called health tourists and pursue a travel motive that is defined by the execution of health-related activities. The choice of destination is determined by the presence of health tourism service providers ( see RULLE 2003, p. 227).

According to RULLE, the branches of health tourism consist of two segments

1) Traditional spa and spa tourism with rehabilitation

2) Preventive health care (including wellness) (see RULLE 2003, p. 228 f.).

In German spas and health resorts alone, 19.3 million arrivals were counted in 2008, an increase of 1.99% over the previous year (see GERMAN HEALING BATHS ASSOCIATION E.V. 2009a, o.S.). In Germany alone there are 300 rated spas and health resorts (see DEUTSCHER HEILBÄDERVERBAND E.V. 2009b, o.S.).

However, the entire European health tourism is subject to change, both on the demand side and on the supplier side, e.g. due to changing lifestyles, new market segments for health travel, etc. With market growth and the changed travel behavior of guests, the individual health destinations are slowly becoming global competitors (cf. RULLE 2003, p. 230 ff.).

2.3 The new forms - wellness tourism and medical tourism

The wellness tourism segment results from the change in the body, health and fitness market in the 1990s. At that time, the German health resort market was forced to move away from the classic health resort due to restrictions in the state-financed health resort sector and the subsequent health resort crisis (cf. KÖRBER 2001, p. 1). A precise definition of the term wellness seems problematic, since hardly two authors define the term the same. There are two different approaches to explaining the origin of the word wellness. On the one hand, the original term from 1961 DUNN was introduced by developing a new word from the terms wellbeing and fitness. Health defines a state of holistic well-being and is not just constituted by the simple absence of illness[11] (cf. BERG 2008, p. 8 and cf. ILLING 2009, p. 7). "Health is a state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity." (DUNN 1959, p. 786). His other publications form the conceptual basis of the wellness movement that has been going on since the 1970s (cf. KÖRBER 2001, p. 6). At this time, leisure and tourism geography developed within human geography, which is an important pioneer in the context of wellness and medical tourism and has existed as an independent sub-discipline since the 1960s (cf. . HOPFINGER 2003, p. 1). On the other hand, there is a source in the Oxford Dictionary from 1654, in which an improving state of health is described as wealnesse. Thus, the theory of the reinvention of the artificial word wellness in the 20th century can be contradicted. because the term was thus only modified (see ILLING 2009, p. 17).

It can be said that comprehensive health has both a physical and a mental component. The mental is addressed by the term wellness. MÜLLER / LANZ KAUFMANN defines wellness tourism as a sub-category of health tourism as follows.

"Wellness tourism is the sum of all the relationships and phenomena resulting from a journey and residence by people whose main motive is to preserve or promote their health. They stay in a specialized hotel which provides the appropriate professional know-how and individual care. They require a comprehensive service package comprising physical fitness / beauty care, healthy nutrition / diet, relaxation / meditation and mental activity / education. "(MÜLLER / LANZ KAUFMANN 2001, p. 7).

The following figure shows a compilation of various health and wellness tourism sub-areas in recent years, into which medical health tourism can also be classified. There are two different concentrations within medical health tourism: Health-motivated tourism with more therapeutic or surgical elements. With regard to the focus of the present work, attention is given above all to medical-surgical health tourism.

Fig. 3: The new spectrum of health tourism

Figure not included in this excerpt

Source: Own illustration based on SMITH / PUCZKÓ 2009, p. 7

Medical health tourism, also known as medical tourism, is a variant of health tourism and does not stand next to the term health tourism, but is a sub-area under it (cf. ILLING 2009, p. 4). JAGYASI derives the definition of medical tourism as follows: If a person travels across a border or outside their natural environment with the motive to seek medical treatment, then that part of the journey is defined as medical travel. Upon arrival, the person is a so-called medical tourist. The activities that involve the use of medical services by the medical tourist, whether direct or indirect, are called medical tourism.

In general, however, the term medical tourism can be defined as follows. "The Medical Tourism is the set of activities in which a person travels often long distance or across the border, to avail medical services with direct or indirect engagement in leisure, business or other purposes. "(JAGYASI 2008, p. 10). The MEDICAL TOURISM CORPORATION defines the term medical tourism exclusively as a transatlantic phenomenon." Medical tourism is a term that describes overseas travel for medical, cosmetic or dental health care. Medical outsourcing, health tourism, medical travel or health travel are all terms used to describe this phenomenon. " (MEDICAL TOURISM CORPORATION 2009, no page). The definition of medical tourism should, however, be handled with care, as there is no uniform definition in the literature. In a McKinsey & Company study on the medical travel market from 2008, for example, the following patient groups are excluded from the definition. Those who show wellness motives in their trip, who have emergency treatment carried out, emigrants who return to their home country and travelers who travel to neighboring regions or countries in order to be treated because of the high price difference (cf. MCKINSEY & COMPANY 2008, n.p.). However, this statement is to be viewed critically, since under the present topic both border tourism and the motive of the cost factor define a medical tourism-motivated trip and the definition is therefore broader.

The term medical tourism is not always used with pleasure. Doctors in particular only occasionally comply with this designation, since surgical interventions can hardly be ascribed a tourist aspect. Nevertheless, the patients are tourists on a basic level (cf. COOK 2008, p. 50).

In the present work, the further use of the term is based on Figure 3 and the following definition.

“Medical tourism, as a sub-area of ​​health tourism, describes the change of location of a person who undergoes surgical medical, cosmetic or dental treatment at the place of residence, which is neither a place of residence nor a place of work. This motivation can be disease-oriented or not disease-oriented. "(Own illustration)

Is medical tourism really tourism? Above all, the medical tourism offers emphasize the connection between surgical intervention and tourism, mainly in the postoperative recovery phase. However, it is questionable to what extent the patients can take part in tourist activities during this time. So is the country's tourist attraction only a marketing-related attractant for patients or can tourism really be pursued? Tourism is certainly a component of medical tourism. If tourism is about traveling and experiencing other cultures, then medical tourism can be identified as tourism. Most visitors actually find time to take advantage of tourist offers, and if the patients themselves have not yet recovered, the accompanying persons usually take part in tourism (cf. CONNELL 2008, p. 240 f.).

The inner attitudes and motivations of patients with regard to participating in medical tourism-motivated trips have changed in recent years. "Patients in a sense are both outsourcing and globalizing themselves." (CONNELL 2008, p. 238). The claim to return from vacation recovered and healthier has been raised to a whole new level with the niche of medical tourism and is currently a relatively new sector in the tourism industry (see CONNELL 2008, p. 233).

3 Health systems at a glance

Health care[12][13] is one of the major economic sectors in terms of its economic activities and contributes significantly to the gross domestic product in all industrialized countries. Healthcare providers offer the highest employment opportunities in most regions of the country. In some countries, up to 10% of all employees work in the health sector (cf. LASSEY et al. 1997, p. 1). At present, changes in the requirements for the health care system in general can be identified, because from a demographic point of view, an increased life expectancy can be seen in the western industrialized countries with a simultaneous drop in the birth rate. This means that the older generations are increasing in their share, whereas the younger population groups can gradually be called a minority (cf. HURRELMANN / LAASER o.J., p. 17). The medical care system is faced with new requirements insofar as this larger number of elderly people will make use of medical and psychosocial care services, and as a result the financial leeway of the patients will become ever narrower. In addition, as society ages, the number of inactive people is steadily increasing, with the working population consequently shrinking. A combination of these factors leads to an enormous burden on the social security systems (see HURRELMANN / LAASER o.J., p. 17).

In order to be able to assess health systems, one uses the central concepts of efficiency and effectiveness. Effectiveness measures the achievement of goals in medicine under the given circumstances, whereas efficiency makes a statement about the relationship between effort and the degree of goal achievement. Since a free market economy is largely rejected in the health care system, the efficiency is mainly based on detailed regulations that stipulate the amount of expenditure as well as its use, etc. Health systems research[14] accordingly concentrates on the clarification of the efficiency of the respective supply system (see ARNOLD o.J., p. 853).

The following chapter introduces the various organizational structures of health systems around the world, followed by a description of the systematic structure and an analysis of the need for reform in the US health system. This is intended to serve as a basis for a better understanding of the incidence of outbound medical tourism by US patients.

3.1 Types of health systems

In order to summarize different health systems into a few types, two system-forming delimitation criteria are used: the type of financing of health services and the degree of state intervention. When comparing health systems, a distinction is usually made between three ideal types.

- The competitive health system. This is mainly based on the willingness of individual individuals to want to protect themselves against the risk of illness. The enquirer determines the scope and type of health service that he would like to use. The insurance is provided on a voluntary basis and the financing consists of risk-specific premiums and self-financing. The resources of the health system are owned by non-profit organizations or privately owned and are controlled through market processes. There is freedom of choice and competition (pluralistic system) among the range of services and the various forms of care. This system is not distributable, but it is economically efficient and innovative. A tendency towards excessive expenditure in this system can usually always be recognized, since the service providers of the health goods can dominate the markets.

E.g. USA, Switzerland.

- The state health system. This system is fully tax financed. State institutions set a catalog of services for the health sector, decide on the prices of health services, take care of supply planning and ensure a certain level of quality. The resources of the system are mainly owned by the state. Spending is limited in that certain budgets are specified and service providers are subject to flat-rate remuneration systems. A free choice of doctor, on the other hand, is only possible to a limited extent (primary doctor system) and state-organized health systems are regarded as not very innovative, but as cost-saving and distributive.

E.g. Great Britain, Italy, Greece, Sweden, Spain.

- The corporate social security system. It is financed by wage-related contributions that are collected by the self-administered health insurance companies. In most cases, there is a risk balance between the insurance companies. The prices of the services, the quality and their scope are determined through cooperation and collective bargaining. The health system's resources are mainly non-profit or privately owned. The service providers are remunerated according to daily flat rates or individual services. Since there is also a tendency towards excessive expenditure here, budgets are set in advance for each sector. In this system, the interests of the supplier and the customer should be considered equally, but this rarely happens in reality. There is either an insurance dominance (state system) or a provider dominance (competitive system).

For example Germany, the Netherlands, Belgium, France, Japan (cf. HAJEN et al. 2006, p. 245 ff. And own considerations).

In reality, mixed forms usually occur, so that new system types can be distinguished (cf. HAJEN et al. 2006, p. 246).

Factors that essentially influence the structures, i.e. the forms of offer on the service provision side, include:

the historical origins,

the goals of social policy in a country and the image of people on which social policy is based (from which, for example, the relationship between subsidiarity and solidarity results),

the importance of health depending on the extent of the

Secularization in a country

the state of medical science,

the patient's needs,

the available resources,

the social position of the service provider.

(ARNOLD, M. o.J. - In: HURRELMANN, K./LAASER, U. 1998, p. 856).

These factors have played a role with varying degrees of importance in all supply systems worldwide (cf. ARNOLD n.d., p. 856).

3.2 The US health system

On the side of the service financiers as well as on the side of the service providers, the American health system differs significantly from the European structures. According to AMELUNG / SCHUMACHER, it should be taken into account at the beginning that the American health system does not exist as such, but that in reality several systems can be found in parallel. The structure of the health system in California differs from the New York health system, like Germany and the Netherlands in their health organization. What can be compared in the USA are the individual market segments (cf. AMELUNG / SCHUMACHER 2004, p. 14).

The European state of the welfare state is very different in its views from the American social benefit system, because this is still today based on American values ​​such as freedom and equality. These values ​​are, so to speak, at the same time a political creed of the Americans, which supports the liberal values. Everyone has the right to live their life according to their own rules and according to their own will (The land of the free), in addition each individual can shape their own happiness with the Protestant values ​​of diligence, thrift and initiative - this is the widespread belief (The Land of opportunity). These moral concepts proved and still prove to be persistent, which meant that it was hardly possible to introduce state social benefits (cf. ERDMANN 1995, p. 17).

The old US health system actually seemed like a customer-friendly system. The only downside was the lack of cost control. It was normal for insurance premiums to rise 15-20% a year. As a result, employers could not raise wages when health insurance expenses that employers provide for their employees grew at such a rapid pace. In conclusion, more and more US citizens decided not to have any insurance cover (cf. ZELMAN / BERENSON 1998, p. 1). The health model was only called into question with the onset of the global economic crisis in 1929, as high unemployment and increased political pressure caused those affected to rethink. For the first time in the USA it was seen as absolutely necessary to implement a nationwide social policy with state social benefits (cf. ORLOFF 1988 - In: ERDMANN 1995, p. 18).

Only a few years later, after an insignificant revolution in the old health system, managed care became the dominant form in insurance cover and in the provision of services (cf. ZELMAN / BERENSON 1998, p. 2). It should be noted, however, that the managed care concept has not developed evenly in the USA, partly due to legal framework conditions, but that some federal states are largely free of managed care (see AMELUNG / SCHUMACHER 2004, p. 14).

Fig. 4: Outlines of the US health system

Figure not included in this excerpt

“The US health system is a poorly regulated, strongly market-oriented and highly competitive system. Despite intense competition, it is also one of the most expensive health systems in the world. "(WIECHMANN 2003, p. 32). The health system in the United States is made up of a large number of private-sector and state sub-systems. The main difference to other health systems is that they do not exist general compulsory insurance (cf. HAJEN et al. 2006, p. 247). However, there is only limited talk of a privately organized US health system, since the two state health programs Medicare and Medicaid cover almost half of the health expenditure (cf. OECD 2001, p. 45 - In: HAJEN et al. 2006, p. 247) In addition to the state, employers are the most important financiers of medical health services. Two types can be distinguished: those who take on the insurance function for their employees themselves and those who have health insurances as company social offer service (cf. AMELUNG / SCHUMACHER 2004, p. 16.). The individuals who act as service financiers make up the smallest share of health expenditure and only play a subordinate role in the demand for health services (cf. AMELUNG / SCHUMACHER 2004, p. 17).

The evaluation and international comparison of the American health system reveal many disadvantages of the system. In a free market economy there is inevitably a lack of government intervention, which the population would benefit from in the form of comprehensive health care. "The American health care system has been called a 'paradox of excess and deprivation', because it is characterized by both very high costs and inaccessibility to health care of good quality for a substantial segment of the population. This is difficult to understand because the United States is the most powerful country in the world [...]. "(GRAIG 1993 p. 20 and MEMMOTT 1995 - In: LASSEY et al. 1997, p. 27) Industrialized nations, the United States of America is the only country that does not have a universal social security system for the health care of society. There is neither a generally accessible, solidarity, tax-financed health care system for citizens, nor a generally accessible social health insurance (cf. WIECHMANN 2003, p. 36). The health insurance in the USA also only grants a limited entitlement to benefits for some medical measures and products, for example drugs are often not covered (cf. ARNOLD, nd, p. 861). The most serious effect of this system is that a significant part of the population has inadequate or no insurance coverage or is getting one simply cannot afford adequate health care. The positive developments in the system include the high level of transparency in the provision of services, the use of regular quality management procedures and the recent development of managed care concepts (cf. WIECHMANN 2003, p. 36).

Industry observers believe that the US health care system is in the midst of a transition towards a consumerism movement. "Consumerism" means the greater involvement of the customer in the selection and purchase decisions of the health services they use (cf. DELOITTE LLP 2008e, p. 2). The patient is no longer just a patient, he is a consumer and is based on this more active, more committed, more critical and more individually thinking (cf. DELOITTE LLP 2008e, p. 4).

The emergence of managed care models

The American healthcare system has seen worrying increases in spending since the 1970s, which needed remedial action. A new form of care should guarantee a reduction in costs while maintaining quality. One possible solution was the reform towards managed care. With traditional care, the individual services provided by the doctors were reimbursed by the health insurance companies. The managed care model is based on a flat-rate form of remuneration, for example flat-rate or per capita flat-rate payments. Since 1973 there has been competition between traditional health insurances and managed care providers in terms of price and quality with regard to the medical services offered. However, large market shares of traditional health insurance companies have already switched to managed care models (cf. WIECHMANN 2003, p. 29). The idea behind the managed care concept is, on the part of an association of doctors, to take over the entire health care of a patient. There is therefore no free choice of doctors and only selected doctors in the network can be visited (cf. WIECHMANN 2003, p. 35). “Managed Care is an integrated system for controlling medical care with the aim of improving both quality and profitability. In order to achieve this goal, the health insurances establish contractual relationships with the service providers selected by them and exercise various forms of influencing the service providers and the insured [...]. "(WIECHMANN 2003, p. 51).

It is important to recognize that, with the emergence of the trend towards managed care concepts, medical work can be classified as "operationalization", so to speak. The tendency is the commercialization trend, in which the direct medical care becomes "an attractive investment sphere for private capital" (cf. KÜHN 1997, p. 2). It should be noted here that in the USA the health care system is seen from a mainly economic point of view (health care industry) and represents an economic sector like any other (cf. ARNOLD / LAUTERBACH / PREUß 1997, p. 3). (SEITZ / KÖNIG / VON STILLFRIED 1997 - In: ARNOLD / LAUTERBACH / PREUß 1997, p. 6). In other western industrial nations, the health care system of the respective country is defined as a social care system that is responsible for peace and the existence of the population (cf. ARNOLD / LAUTERBACH / PREUß 1997, p. 3).

In summary, it can be emphasized that the maxim of freedom of trade prevails in the USA, i.e. the medical service providers are only dependent on a few state regulations. Usually the treatments are billed according to the fee for service principle. An alternative option is for the enquirer to be a member of one of the Managed

Core organizations and a limited selection of doctors are paid on a flat rate basis. The restricted choice of doctor harbors financial advantages such as cheaper insurance premiums (cf. WIECHMANN 2003, p. 32).

For the USA it can therefore be shown that the best possible results are achieved through the managed core concept in health care. Medically, better care is guaranteed and the needs of the population are addressed, and uniform control in the health system is achieved. From an economic point of view, a more efficient supply of the population with regard to the optimization of transport costs, the improvement of allocation and the improvement of infrastructure planning etc. is guaranteed (cf. GEOMED 2008, no p.).

3.2.1 Structure and development of the US health insurance system

The possible types of insurance coverage can be determined according to the U.S. Divide CENSUS BUREAU into private and state insurance coverage. In the case of private insurance, an insurance draft is provided by the employer or a trade union, obtained from a private company, e.g. in the case of self-employment, or purchased individually from an insurance company. State insurance coverage includes the federal programs Medicare, Medicaid and the health care of the veterans, the State Children's Health Insurance Program (SCHIP), health plans for Indian population groups (Indian Health Plans) as well as individual health plans within the states (see US CENSUS BUREAU 2008a, p . 18 and US CENSUS BUREAU 2009, oS).

The health insurance system in the USA can be roughly compared with the private health insurance companies in Germany. The difference, however, can be seen primarily in the range of variation between the various health insurance companies. The choice is much greater in the US, as there are around 1,700 options available to a potential policyholder. As a result, many health insurance contracts differ greatly from one another. Most Americans are insured as follows: either they are covered by a basic insurance plan or they have major medical insurance, which is an insurance policy that covers most of the medical services. A combination of both types is often chosen (see FARLEY 1986 - In: ERDMANN 1995, p. 39). But these contracts are also designed for the insured in such a way that they hardly incur any costs for the insurance companies, for example only selected outpatient services are reimbursed and many preventive treatments and home care services are completely excluded from the insurance cover. Insurance to cover the cost of dental treatment

(dental expense insurances), ear treatment (hearing) or ophthalmological treatment (vision) must be concluded separately (see FARLEY 1986 / HIAA 1991 - In: ERDMANN 1995, p. 41 f.).

With regard to the research topic at hand, it should be mentioned that almost all health insurance companies offer their customers dental insurance. The only criterion when applying is that you include preventive measures at the time of the application. In most cases, these are also insurance policies with a high financial deductible rate, which explains the very low demand until the 1970s. Since then, however, the number of members has grown steadily and has the highest growth rates compared to other types of health insurance. The insurance cover includes simple services such as preventive examinations, tooth fillings or tooth extractions. As a rule, 50% of the costs for dental crowns and bridges are covered by the insurance. However, orthodontic measures are not included in the insurance cover (cf. FARLEY 1986 - In: ERDMANN 1995, p. 42 f.).

The United States of America has not yet managed to introduce a state health insurance system. During the past individual periods of government, the reform proposals relating to health insurance have mostly been postponed in order to give priority to old-age and unemployment insurance problems. Even at the beginning of the Second World War, the representatives of the nationalization of health services were not listened to, because the lobby of the advocates of / ee / or-service health security positioned itself in the foreground (see ERDMANN 1995, p. 18 f.). Until the 1940s, the majority of Americans had the only choice between not receiving medical attention or paying for treatment individually. There were only a few prepaid group practices14 or social institutions that treated the sick free of charge (cf. SIGERIST 1944 / ILSE 1953 - In: ERDMANN 1995, p. 27). The number of people with health insurance only rose again when the newly introduced tax and economic policy gave an incentive to take out insurance during the Second World War: in 1942 employers were exempted from tax burdens through the Revenue Act, which revolutionized tax policy that they had to spend on health insurance expenses for their employees. A so-called win-win situation, as the employer was given the opportunity to reduce taxes and at the same time, “the employee benefited from a positive expansion of company social benefits (cf. STEVENS o.J./HIAA 1991 - In: ERDMANN 1995, p. 28). As a result, the importance of insurance protection rose sharply in the coming years, and so did the[15] Company payments of so-called fringe benefits15 increased. In 1949, the Supreme Court also confirmed that the health insurance payments made by the companies for their employees are an integral part of the collective bargaining agreements. Alongside the state, the employers are currently the most important financiers of health services (cf. HAJEN et al. 2006, p. 249). It should be noted, however, that employers are not obliged to take out insurance (cf. WIECHMANN 2003, p. 30). As a result, however, it seems logical that the mobility of employees to change their job decreases, since this change can mean a loss of insurance cover (cf. COOPER 1992 - In: ERDMANN 1995, p. 29). This development naturally influenced the idea of ​​a state health insurance in the sense that in the following decades the nationalization of health care lost more and more conviction and plausibility (cf. STEVENS 1988 / PIACENTINI 1990 - In: ERDMANN 1995, p. 28 et seq. And cf. . WIECHMANN 2003, p. 27). In the meantime, however, the unemployed population such as pensioners, low-income people, families with children and the disabled have been excluded from insurance cover. To provide relief and support, health insurance was introduced in 1965 specifically for these population groups: Medicaid16. The Medicare17 program was developed especially for medical care and financial support for pensioners (cf. WIECHMANN 2003, p. 28 and cf. HEALTH CARE FINANCING REVIEW 2005, n.p.). The state health insurance programs also include health insurance for the military and veterans, as well as the State Children's Health Insurance Program (SCHIP) for children from low-income families and individual state health programs (see U.S. CENSUS BUREAU 2007, p. 19).

The lack of comprehensive state funding, however, is primarily due to historical reasons. In Europe the social security system and the state health insurance went back to the demands of the united working class, which with the help of their parties political[16][17][18]

Taking commitment for granted. This socio-economic basis was lacking in the USA because the working class did not form either in strong unions or in parties (cf. ERDMANN 1995, p. 16).

The main points that can be criticized about the US health care system and which may indirectly push factors for alternative options in health care for the population are explained below.

3.2.2 Need for reform and critical examination of the American health care system

"My experience lends me to believe that the only long-term solution to the healthcare crisis in America is to take the industry globally. By bringing a more affordable, first-class supply of health care providers together with the demand market that needs those services, the resulting global industry will reach a much needed balance of supply and demand. "(PIPER 2008, p. 6 f.) .

Factors that speak in favor of a reshaping of the US healthcare system are discussed in more detail below. Not insignificant are the weaknesses of the health system, which have a major impact on the mood of society with regard to health care and on the motivation of Americans to participate in medical tourism. The listing of the gaps in the American health system forms the basis or a so-called push factor for the American patient to consider a medical tourism trip if necessary. "America's misfortune is opportunity for Medical Tourism and foreign hospitals." (EDELHEIT 2008, p. 29). Criticism: health expenditure

Even after the structural reforms of the 1980s, the American health system has hardly been modified in terms of its health care expenditure. In terms of the share of health expenditure in gross domestic product, it is even one of the most expensive in the world (cf. WIECHMANN 2003, p. 33 and cf. HAJEN et al. 2006, p. 250).

The reasons for the high costs of the American health system are:

- High level of supply in hospitals and medical practices with expensive medical technology, i.e. higher technology expenditure
- Conducting defensive medicine with double diagnostic coverage to reduce the risk of malpractice and liability litigation
- Expensive liability and procedural law
- No general compulsory insurance
- Increase in the amount and scope of hospital services
- High administrative costs for health insurance companies
- High incomes of service providers (wage increases for medical professionals) and an increase in the number of practicing doctors
- General inflation in the economy as well as in health care
- Demographic change
- Higher grants for health insurance packages
- Expensive emergency care for uninsured people in hospital outpatient departments (cf. WIECHMANN 2003, p. 34 and cf. LASSEY et al. 1997, p. 55 and cf. HAJEN et al. 2006, p. 250).

But why are there such remarkable differences in the level of health expenditure in a country? These deviations are justified by the different value systems of a nation and its organizational structures. However, a high level of expenditure does not allow the logical conclusion that the healthcare system is characterized by inefficient supply and demand structures. Meanwhile, medical advances in the interest of the patient can lead to increases in prices and thus expenses. It can thus be stated that medical progress and the demographic development of the population are essentially contributing to an increase in expenditure on health services. A main factor in the increase in expenditure in the past was also the weak position of the patients or the payers, i.e. the health insurance companies, which were mainly seen as payers compared to the dominant position of the medical service providers (see SEITZ / KÖNIG / VON STILLFRIED 1997 - In: ARNOLD / LAUTERBACH / PREUß 1997, p. 4). It can therefore be stated that the American population pays higher prices for the same medical treatments compared to other industrialized nations (cf. ANDERSON et al. 2003, p. 90).

In a survey by the Organization for Economic Co-operation and Development (OECD), health expenditure in industrialized countries is compared with one another. This clearly shows that the United States of America has the highest health expenditure of all industrialized nations with a share of 15.3% of the gross domestic product. The OECD average, on the other hand, is 8.9%, i.e. 6% below the American expenditure value (cf. ORGANIZATION FOR ECONOMIC CO-OPERATION AND DEVELOPMENT 2008, p. 1).

Fig. 5: Health expenditure in the industrialized nations in 2006

Figure not included in this excerpt

Source: Own illustration based on data from ORGANIZATION FOR ECONOMIC CO-OPERATION AND DEVELOPMENT 2008, p. 1

It is also interesting to compare the private and public health expenditure per capita within the individual countries. Here, too, the USA is one of the countries with the highest private spending on medical services. More than half of the expenditures are repaid privately (54%) and 46% are publicly subsidized, whereas the average ratio for the other countries is one (private) to three (public) (OECD average: 73%). The public sector has, on average, the highest level of funding in any OECD country; the exceptions are Mexico and the United States of America. Canada and France also have a high share of private health expenditure alongside the USA (> 12%) (cf. ORGANIZATION FOR ECONOMIC CO-OPERATION AND DEVELOPMENT 2008, p. 1 f.).


[1] People are considered uninsured if they cannot show any health insurance coverage. The terms 'not insured' and 'uninsured' have the same meaning in the following work.


[3] Definition of border region: "Border regions are areas in the immediate vicinity of international boundaries whose economic and social life is directly affected by proximity to a border." (HANSEN 1981 - In: TIMOTHY 2001, p. 56)

[4] See Appendix 9

[5] See appendix 7 and 10

[6] The Yellow Pages of Mexico, see also SECCION AMARILLA at

[7] See Appendix 8

[8] ".. deals with the effects of environmental factors on human health." (MEDIZINFO 2009, o.S.)

[9] "Travel and tourism medicine includes the prevention, diagnosis and therapy of health disorders before, during and after the trip to countries with particular climatic or health problems." (STROTT 2005, p. 4 according to the Deutscher Fachverband Reisemedizin e.V.)

[10] "Medical meteorology is about the influences of atmospheric environmental conditions (weather, climate including climate changes, air quality) on human health." (FREIBURG WIRTSCHAFT TOURISTIK UND MESSE GMBH & CO. KG 2009, no page)

[11] The internationally recognized definition of health of the WHO from 1946 reads, for example: "Health is a state of complete physical, mental and social well-being and not just the absence of illnesses or ailments." (ILLING 2009, p. 7).

1 The health system is a "[...] system of facilities and health-related services such as medical and non-medical care, outpatient and inpatient care, and the supply of medicines, therapeutic aids and aids. Essential aspects of the health system are its organization into a statutory health insurance and private health insurance, financing and service provision. "(STATISTISCHES BUNDESAMT 2008a, o.S.).

[13] The health system describes: "The entirety of the institutions created by the state to maintain and promote or restore the health of the population." (WISSEN.DE GMBH 2008, n.p.).

[14] In connection with economic geography, the topic of health care has gained increasing importance in recent decades, from which health system research, which is closely related to medicine, has developed. Health system research focuses on analyzing new models in the health care system and researching their costs and affordability (see GESUNDHEITSGEOGRAPHIE.DE 2008, no page).

[15] "Prepaid group practices (PGPs) are complex organizations that directly combine prepayment for health care with a comprehensive health care delivery system. They conjoin a health care delivery system that provides comprehensive clinical services with an insurance / prepayment mechanism." (SCHOENBAUM 2004, oS ).

[16] "Additional services from companies to employees, such as grants for (health, accident, life, disability) insurance, use of a company car, payment of fares, discounted delivery of goods, etc." (TRADING-HOUSE.NET AKTIENGESELLSCHAFT 2009, oS)

[17] The Medicaid program is available as an insurance system for health services for populations in need. Half of this is financed by tax revenue from the states and the federal government (cf. WIECHMANN 2003, p. 30). The Medicaid program is not open to the general public compared to the Medicare program. There is therefore no legal entitlement to his services. Financial aid is distributed if the need has been checked beforehand, which can vary within the federal states (cf. ERDMANN 1995, p. 32 and cf. HAJEN et al. 2006, p. 248). Both programs should reduce the undersupply of the needy (cf. HAJEN et al. 2006, p. 248).

[18] Medicare coverage mainly covers the retired population, i.e. over 65 years of age, and their dependents. The program can be divided into two parts. Part A is compulsory insurance coverage that covers the cost of inpatient hospital care. This is financed by the social security contributions of the employed. Part B is voluntary and includes outpatient treatment and prevention services. This is subsidized by private insurance contributions and from tax revenues (3/4) or deducted from the pension of the insured person (1/4) (cf. WIECHMANN 2003, p. 29 f. And cf. HAJEN et al. 2006, p. 247 f.)

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