"[...] the resort picks them up at the airport, them and their spouse, takes them to the hotel, puts them in a nice room overlooking the lake," Rasmussen said. Valorie Crooks, a health geographer at Simon Fraser University in British Columbia, said Canadians are often heading across the border to avoid the wait lists of their national healthcare system. "The practice of Canadians going to the United States for these sort of out-of-pocket payment health care arrangements raise some of the similar types of questions as Canadians going to any other country in the world, including sort of lesser developed nations," Crooks said. She said since patients are doing this outside their normal health care system, they have to pay — and do all their own research. [...] Crooks said even when the procedure goes as planned, the patient's recovery becomes the responsibility of the Canadian health care system. Jeffries had had knee problems for over a decade, but wouldn't receive approval from his doctor in Canada for knee replacement until he was 55. [...] with a few years to go and the pain medications no longer working, Jeffries and his wife consulted with a orthopedic surgeon in north Idaho.