“The media loves to talk about the heroic heart transplant in Bangalore, but that's the exception,” says Josef Woodman, CEO of Patients Beyond Borders, an online and print resource for consumer information about international medical and health travel based in Chapel Hill, North Carolina. “There's a lot of medical tourism that's fairly unsexy and pedestrian. Fifty percent of medical tourism is for dental care. And it's mostly short-haul trips from the population centers in California, Texas and Arizona. Millions don't have dental insurance. It's not a rip-off but it doesn't do any good and for the average single employee or citizen it's not practical.

“When you get older, you start having trouble with your teeth. I was down in Costa Rica and a guy had been quoted $60,000 for new teeth,” he continues. “He got them in San Jose for $17,000. That is real money being saved. The second biggest reason is cosmetic surgery, which is not covered. That's 65–85 percent of all travel that is either for dental or cosmetic. The remainder is for elective surgeries — a patient isn't satisfied with the doctor or the claims processing, even the conditions. And by the time you add up all the copays, gotchas, ceilings and other costs, it's cheaper to travel for oncology, heart procedures and other procedures.”

But even in a span of health care upheaval, medical tourism has largely remained stable. While there have been areas of growth — in certain kinds of procedures and international medical capacity, for example — and increasing acceptance among consumers, industry observers say that PPACA's impact on medical tourism could mainly lie still in the days to come.

“In a lot of ways, it really hasn't yet and it's not likely to for a while,” Woodman says. “On the one hand, you've got millions of new uninsured patients entering the system, and those are folks who are not likely to be considering medical tourism as an option. On the other hand, you're going to start seeing longer waits for specialty care just like in Canada and the United Kingdom — especially for invasive procedures. There's a lack of specialists and there's triage — you can't support the best health care for everyone.”

A new boost?

But now that the linchpin year of 2014 has almost passed, and millions of new consumers have entered, or plan to enter, the health care marketplace, PPACA may unintentionally give medical tourism a boost.

“The next shoe to drop will be employers deciding to put employees on exchanges and thus making them more cost-focused — particularly people on high-deductible plans,” says David Vequist, founder and director of the Center for Medical Tourism Research at the University of the Incarnate Word in San Antonio, Texas. “Also, the demographics of the people signing up haven't helped reduce costs of health care because it hasn't increased the young and healthy as expected. And hospitals and physician practices have been merging, which leads to greater pricing power and consumer prices. The costs of health care will continue to rise at a greater rate than expected. Therefore, more self-funded employers will choose domestic medical tourism benefits plans such as Wal-Mart, Boeing, Pepsi and Lowe's have already done.”

Also, new health care consumers combined with an aging population could make medical tourism a more attractive option as costs continue to rise.

“Even if more people are insured under the Affordable Care Act, the combination of higher deductibles and increased out-of-pocket costs through private insurance plans, as well as Congressional budget cuts to hospitals and doctors mandated by Obamacare, will push consumers toward alternative means to stretch their health care dollars,” says Renee-Marie Stephano, president of the Medical Tourism Association in Palm Beach Gardens, Florida.

Enter medical tourism, “where cost-saving can be as much as 70 percent lower than offered for similar procedures in the United States,” she continues. “Overseas opportunities will be of particular interest to baby boomers, who will be seeking elective procedures most associated with aging — orthopedic, ophthalmology, dentistry, cancer and cardiovascular treatments, and comprehensive health screenings.”

For those reasons, optimism is running high in the medical tourism industry in the United States and internationally. The Medical Tourism Climate Survey, which was compiled and published in April by the International Medical Travel Journal in the United Kingdom, finds that health care professionals from across the globe predict medical tourism growth.

“Medical tourism is an important contributor to the health care economy of many countries,” says Keith Pollard, the journal's managing editor. “Growth is expected to be biggest in two very different areas — cosmetic surgery, which continues to be a very active area, and cancer treatment, with patients seeking treatments not available to them in their own countries.”

Vequist says there could be other reasons to expect growth in medical tourism.

“It has the potential to be a growth industry — for both inbound and outbound [patients],” Vequist says. “But this just might be a regression to the mean effect — in other words, for outbound, because many more people around the world travel across borders for health care, it's likely that the percentage of Americans that choose this will rise over time. The inbound effect will be because American health care facilities will continue to pursue higher margin medical travel patients as domestic revenues become less profitable.”

Woodman adds that international medical facilities continue to multiply, too, with some of the best medical facilities in the world showing up in places as far apart as Health City Cayman Islands and Bumrungrad International Hospital in Bangkok, Thailand, thanks to the international accrediting body that monitors health care standards and quality.

“You still have the continued growth of internationally accredited hospitals,” Woodman says. “[The Joint Commission International] is on a tear. Now there are between 600–700 hospitals. That gives patients more choice and comfort. There has been a lot of these JCI hospitals that were not at capacity and when they got JCI accreditation, they got international business but they also got people in their own country who were gaining in affluence. These hospitals are quickly filling up, but I haven't been at a JCI hospital that hasn't been at or over capacity in two-and-a-half-years.”

Climate change

The International Medical Tourism Journal's 2014 Climate Survey talked to medical professionals from 280 health care facilities and medical tourism companies around the world. Here are more of the survey's findings:

• 48 percent of clinics, hospitals and medical tourism agencies reported growth in international patient numbers over the last 12 months; 30 percent saw no increase and 11 percent experienced a decline.

• 76 percent expect their international patient numbers to grow over the next 12 months.

• More than half expect annual growth of more than 10 percent in the medical tourism market over the next five years.

• Over the next five years, cosmetic surgery is seen as the biggest growth area for medical travel—cited by 55 percent of respondents—with cancer treatment, infertility treatment and dental treatment also expected to experience significant growth.

• When asked to name the most popular destinations in terms of patient numbers, respondents selected Thailand, India and the United States.When asked to name the leading destinations in terms of quality and range of services provided to international patients, the respondents ranked the United States, Thailand and India the highest.