When Veronica Merrill decided to undergo stomach surgery for weight loss, she found two options: pay $12,000 at home in the United States, or have it done in Mexico for $4,000.
She packed her suitcase.
Her insurance would only cover the operation if she was morbidly obese and suffering from diabetes and hypertension.
This was not the case for the 50-year-old, who weighs 210 pounds (95 kilos) but aspires to slim down to 160 -- precisely because she wants to avoid ending up with those medical conditions.
"It's sad that I have to come to another country" for the procedure, said Merrill, who drives a school bus in rural Arizona and is highly critical of the US health system -- the most expensive in the world.
"We shouldn't have to do that. That's crazy. And we're the only ones (with this system), and that is depressing."
After researching medical tourism options, she saved up the money and contacted a specialist agency to organize her trip over the border to Tijuana, where weight-loss operations and dental treatments are popular.
Others travel to the Mexican city for treatment of cardiovascular conditions or cancer, orthopedic work and fertility care, as well as to buy medications.
"If I only could have done it in the US... (but) I can't pay that much money," she told AFP. "I just want to be healthy."
No price regulation
Each year, an estimated 20 million "medical tourists" seek treatment around the world, according to Patients Beyond Borders.
About 1.9 million of those people are Americans.
Mexico and Colombia -- which many Americans associate more with drug trafficking than health care -- are among the most popular destinations, along with Costa Rica and the Dominican Republic.
They all offer lower costs and high-quality infrastructure.
Bernie Sanders and Elizabeth Warren, two prominent Democratic candidates for the 2020 presidential election, have proposed universal health coverage -- an idea that Merrill considers "logical."
For now, Merrill turned to a company called Medical Tourism Corporation to organize every detail of her trip -- including her flight from Phoenix to San Diego, the driver who took her across the border and a luxury hotel.
Altogether, the tickets, hotel and surgery -- at the Oasis of Hope hospital, right by the border -- cost her $3,880. She paid in cash.
"We do the coordination... (we) have a destination manager in those cities who would help a patient with the language, the local logistics and things like that," said Deepak Datta, who founded Medical Tourism Corporation 13 years ago.
The company sends 60-70 people abroad each month to countries around the world, mainly Mexico.
"I operate on two or more foreigners every day," said surgeon Luis Cazares, who removed 80 percent of Merrill's stomach.
He said his greatest flow of patients is during the tax refund season in the United States, after April.
According to Gerald Kominski, a professor of health policy at UCLA in Los Angeles, the US does "little to regulate prices, in contrast to all other high-income nations."
"Medical tourism from a high-income nation like the US is indicative of a problem with affordability, as opposed to quality," he added.
But even if "Medicare for All" were introduced as Sanders and Warren have urged, Americans likely would not stop seeking cheaper care abroad, says Medical Tourism Association CEO Jonathan Edelheit.
After President Barack Obama's health care reforms in 2010, which required all adults to have insurance plans whether through work or the government, medical tourism by Americans expanded, he said.
Some employers whose medical costs "almost doubled since Obamacare was in place" sent staff abroad, he said, citing a company that saved $20 million in five years by sending employees for orthopedic and weight-loss operations outside the US.
Under universal care proposals, the US would likely end up with a system where, like in Canada and Europe, non-urgent procedures such as stomach operations require years on a waiting list.
"Wait times... will push people to go for medical tourism" to get treatment earlier, he predicted.
Indeed, many of the foreign patients at Oasis of Hope hospital are Canadian.
Europe is a sought-after destination for US medical tourists, though it does little to attract them, unlike emerging economies such as Singapore, Thailand and the Philippines.
The United States itself receives health tourists -- its highly advanced health care system appeals to patients with massive purchasing power from Arab and Asian countries.
But that is a luxury Merrill cannot afford.