The list of Minnesota brokers who are certified to arrange international medical tourism is a short one.

It’s Maria Maldonado.

The owner of Trip4Care in Minneapolis, Maldonado specializes in sending people to Spain, Portugal, Mexico, Costa Rica and Colombia for surgeries, dental care and fertility treatments.

Maldonado’s lonely position in the market reflects the struggles of medical tourism, despite predictions a decade ago that it would become a major alternative to America’s increasingly unaffordable health care. While procedures such as hip replacements still can be obtained cheaply in India, Thailand and other countries, that advantage has been eroded by federal changes that expanded health insurance to millions of Americans, and by large U.S. hospitals muscling into the business with their own domestic tourism services.

Maldonado has nonetheless parlayed her knowledge of health care in mostly Spanish-speaking countries, along with the high and rising costs of U.S. medicine, into a niche business. Many of her clients are insured, but find that they can’t afford the copays or are denied coverage for procedures that insurers deem elective.

“It’s so unfortunate in this country, in this wonderful country with these wonderful resources that we have here,” Maldonado said, “that people going to regular American hospitals pay such a high price.”

To Colombia for knees

Consider Ed Janssen. He couldn’t afford $40,000 in payments, even with his construction company’s insurance, to replace two gimpy knees, so the Windom, Minn., native worked in pain for years. Then Maldonado set up a trip to Cali, Colombia, this January that provided surgery, rehabilitation and a little fun in the sun for Janssen and his wife for $26,000.

“I’m 58. We’ve got everything paid for,” said Janssen, who now lives in Kansas. “I’m not going to go $20,000 in debt at this point in my life. I would have just dealt with the pain.”

Orthopedic procedures remain common reasons for medical tourism, along with bariatric weight-loss and elective plastic surgeries. Reconstructive dentistry is a growing market as well, considering that some Americans have limited or no dental benefits.

What impressed Michael Olesen of Plymouth wasn’t just the cost savings from his trip to Costa Rica for an overdue dental implant — but also the attention he received from the U.S.-trained specialist before the procedure.

“I talked to the oral surgeon down there for 40 minutes before he even looked in my mouth,” said Olesen, who works in health care.

Scaled-back projection

One of the most widely quoted projections of growth in medical tourism came in 2008 from the Deloitte Center for Health Solutions, which said 750,000 Americans traveled abroad for care in 2007, and predicted that 6 million would do so by 2010. But a year later, the consulting firm tempered its projection based on surveys showing more Americans interested in traveling domestically for care.

The outsourcing of American health care “never really blossomed,” said Leigh Turner, a bioethics professor at the University of Minnesota who has studied medical tourism. Recent projections of growth come from flimsy data or hospitals that “have a commercial interest in pumping up their numbers,” he added.

Technavio, a British market-research firm, recently predicted a doubling in global medical tourism spending in the next five years. But one-tenth of that business is expected to be foreigners traveling to the U.S. for care.

Maldonado said it’s difficult to promote medical tourism in Minnesota, which has lower-than-average medical costs and renowned providers such as the Mayo Clinic — which draws patients from more than 160 countries. Some of her clients are from other states.

Early predictions of a medical tourism boom were based on the theory that employers would revise their health plans to send workers to low-cost foreign hospitals. That hasn’t happened. Wisconsin-based Serigraph tried in 2005 to contract with an insurer to send workers to Bangalore, India, for joint replacements. The $10,000 travel package at the time was one-tenth to one-fourth the cost of orthopedic surgery alone in Milwaukee.

“It was attractive from a cost point of view,” said John Torinus, chief executive of the custom graphics company, “but we never got any takers.”

Torinus said he was further disappointed when he visited the hospital in India, and found the chief doctor unable to produce key data on hospital outcomes or infection rates.

Medical travel in U.S.

At the same time, a number of U.S. hospitals recognized that Americans are willing to travel for good medical care. Hospitals with histories of lower costs and higher quality seized on the trend by negotiating contracts with employers to exclusively provide care to their workers.

Wal-Mart, for example, now sends workers to Mayo in Rochester for heart, spine and transplant surgeries.

Serigraph similarly sends workers to top hospitals in Appleton and La Crosse for orthopedic care, Torinus said.

Torinus expects a rebound in international options, though, as foreign hospitals pair their rock-bottom costs with data showing good outcomes. American companies are getting involved as well; St. Louis-based Ascension Health helped open the $2 billion Health City hospital last year in the Cayman Islands.

Maldonado said the key to her business has been knowing the quality of hospitals and doctors before recommending them, and the hotels and communities that will be most supportive for patients during their recoveries.

The daughter of a Spanish surgeon, she managed Latin American business for Eden Prairie-based Starkey Hearing and researched medical tourism for Google Health.

Starting her agency two years ago seemed natural, and she has since been certified by the Medical Tourism Association. She hopes clients’ successes will compel employers to work with her on creating travel benefits.

“I like to call it medical travel,” she said. “It’s more professional [than medical tourism]. People don’t care where they go — if there is a beach or something like that. They’re just looking for a good outcome for their health issue.”

Janssen’s trip wasn’t without glitches. The hotel had a low bed that he couldn’t get out of, but the staff piled a second box spring on it to make it work. A night nurse didn’t speak English, but downloaded a phone app so she could ask about Janssen’s pain and needs.

But there’s no questioning the result. Renewed stability in his knees allowed Janssen to return to construction work and recently roof his house.

“Before I had this done,” he said, “it was to the point where I didn’t know what I was going to be able to do in my life. I couldn’t walk but I couldn’t sit.”