Ok. Wasn't intending to address any of the other issues you raised, but I can because on further reflection there are many issues with your points:
(1) This generally isn't true for most companies. You must be in healthcare? Otherwise there are a bunch of state-level data protection laws which to my knowledge do not prevent access to PII by persons not within the US.
(2) Partially covered with my first comment about South America. I'll also note that asynchronous work seems to be more productive for a lot of people, and practically everyone in the corporate world complains about too many meetings – so maybe making it harder to constantly have meetings is a feature, not a bug (even if your org isn't great at async).
(3) Shared context might be helpful, but the design part is nonsense. Obviously non-Americans can design for the US market. Suggesting otherwise is just so ludicrous I don't know where to start.
(4) This is just a skill issue. You can definitely filter for quality in off-shore roles just as well as you can for on-shore roles. If you're bad at it, that's on you, not intrinsic to the off-shore labor or their circumstances.
(5) Saving money isn't the only reason to off-shore roles. Believe it or not there are actually more talented people you have access to if you consider all 8 billion of the world's population rather than only looking at 4% of it. Or for example with your first point where off-shoring can actually be a huge boon because diff timezones means all of your employees can work a 9-5 without needing people to work graveyard shifts. Also there are solutions like Deel which are less expensive than your average contracting middleman, but still allow you to hire people globally without needing to deal (pun intended by them I guess) with all the local tax etc issues. So even if money is your only concern, there is plenty of room left in the market for labor arbitrage.
