Medical tourism
I’ve been an occasional “medical tourist” for as long as I can remember. Until roughly 2010, I had no US medical insurance, from ~age 16 until age 30. As such, US medical care was prohibitively expensive, and I avoided it to the extent possible. I also lived outside the US for the majority of that (Caribbean, Europe, and then Iraq/Afghanistan), so it was easy. Fortunately, being young, I never really got sick, and I was careful to not get injured. I paid out of pocket for maybe a bi-annual health screening, but that’s about it.
In a lot of cases, I would fly to specific countries for dental or medical care, based on quality, cost, and accessibility. Thailand is excellent — historically Bumrungrad Hospital was an excellent deal, and while it’s still good quality, services have decreased and prices have probably tripled. I’m interested in trying Japan for medical imaging at some point — they make extensive use of MRI in screenings and it is a good place to get scans for low cash prices.
I got LASIK (wavefront!) in 2005 when I’d gotten tired of “you can’t wear contact lenses in Iraq due to eye injury risk (trauma as well as infection), so you must wear glasses” and the prescription eyeglasses being kind of shitty compared to the sunglasses I’d otherwise want to wear, plus being annoyed by not being able to see well when I first woke up, such as being woken up by incoming fire alarms. I stayed at a 5-star hotel next to the US Embassy (Le Royal Meridien), in a suite, and used the hotel limo to take me to and from the TRSC International LASIK Center (highest volume in Asia, and high volume = excellent results), as I didn’t want to navigate a taxi while blind, and was pretty much back to acceptable vision the next day, and totally fine and back to Iraq a week later. I believe the cost was approximately $2000 all-in for both eyes, back when surgery was generally more expensive than it is today. Very happy with the results, and this was really the only expensive medical procedure I’ve had.
At some point I got a High Deductible Health Plan for $60-150/yr, with a $5000 (?) deductible. This got discounted insurance-negotiated prices for various things, and in Washington State included checkups; this was pretty amazing coverage and perhaps underpriced from an actuarial basis, or at least not overpriced. HDHPs were one of the best innovations in medical costs in the US, and one of the few good things George W. Bush accomplished. Unfortunately, increasing state mandates on what would be covered, and then finally Obamacare, killed the HDHP as an option for anyone >30 years old, so I again went without insurance except for a couple years where I worked for a large company. My “health insurance plan” was basically to quickly apply to Google (known for having great insurance and benefits, including life insurance) if I had a serious medical diagnosis; I assumed I’d be able to get a role there or at a similar tech company quickly (at least unless the medical diagnosis was immediately disabling, like being hit by a truck).
Since 2019 I have had ~$200/mo “gold” insurance now as a Puerto Rico resident through SSS, but I’ve never actually used it successfully. They only cover emergency care outside Puerto Rico, and the Puerto Rico medical system is “difficult to access” in a lot of ways. I mainly have it in case I’m injured or sick here, since it’s an insignificant cost. I also have $500k+ policies on various credit cards for accident/etc. coverage, and have medical evacuation insurance through Medjet Horizon which covers transportation from a foreign hospital back to a hospital near my residence — I’d probably use it for transportation back to the US and possibly to Puerto Rico, depending on the situation, and it’s another thing discounted through Founderscard.
Now, there are popular medications which are not yet on formularies for the insurance I do have, and which would cost >$1k/mo out of pocket. It is far cheaper for me to use an online telehealth service in Canada (there are many, I used Maple), get a prescription from that doctor, and have it sent to a regular Canadian pharmacy, pay cash at the Canadian pharmacy, and pick up the medication. For a 90 day supply, with cheap flights from New York, this is an easy win (especially as I love Montreal, Toronto, and Vancouver, and often visit those cities anyway). You’re allowed to bring a 90 day supply into the US, and I have valid Canadian and US Rx for the medication (and it’s not a scheduled narcotic/etc. anyway). If you go to Mexico, many medications can be purchased directly at pharmacies without an a local Rx, either using a US Rx or the Andrew Jackson prescription (i.e. a $20 bill for “a prescription as required”) or just out of the kindness of staff (I went to ~8 pharmacies in one part of CDMX to find something in relatively low stock, and half were out, and of those who had stock, most had qty 1, so I purchased 1, 1, 2, 1, and only one store actually required the $20 prescription.)
I would probably still consider the US the best for many forms of intensive, cutting edge medical care, but for every medical issue I’ve had to date, I’m comfortable with the level and quality of care I’ve received elsewhere. To be honest, 95% of everything I’ve ever needed I could diagnose myself given access to lab tests, the Internet, and basic medical knowledge (moderate to good at non-medical-provider level gunshot trauma management as a TCCC graduate and living/working in a hospital in war zone for years; reasonably good at basic medical knowledge and evaluating information online, friends with a sufficient number of doctors). Doctors gatekeep access to facilities, medications, and testing to some degree (although this is falling away), but outside of surgery. emergency care, or ortho, very little of medicine requires physical contact with a patient.
For elective and non-emergency care which isn’t extremely sensitive, I’d be quite comfortable with medical tourism to most of the “designed for medical tourism” facilities worldwide. Some of these have specialties, others (like Thailand) are fairly broad spectrum. To some degree the length of recovery would matter, as I’d sure rather spend a month recovering in a 5-star hotel in Bangkok than in London. The US (and maybe some specific global specialty centers) still win for very specialized care, stuff which I hope to not need, at least for a long time. The sweet spot for commercial medical tourism is probably “things not covered by insurance anyway”, like cosmetic surgery, dental care, vision, etc. Emergency care and urgent care are probably not good markets (although cash-only care for tourists and others is very useful for those).
Medical tourism for chronic conditions, high-importance non-elective care, etc. have a few difficulties. A lot of people are covered by insurance (Medicare/medicaid in the US, employer-provided care, national health systems, etc.), so they may be price insensitive. In many markets, cost of providing care itself is subsidized heavily by the State and others (and in the poorest countries, by high PPP anyway). Many people with chronic conditions are not economically able to pay anywhere near the actual costs of delivering care internationally (even just transport, let alone the care), so without insurance, there’s no market for medical tourism for them. The relatively small population of people without local access to affordable-to-them care, or who have exposure to price such that they want to search for value, care enough about health to get care, etc. is non-zero, but isn’t currently a huge market. It’s probably best for those who already travel extensively, people in the uninsured demographic of the US (mostly, men over 26 years old, reasonable income, such that there’s no subsidy, and penalized 4x+ over the actuarial rates for market insurance), and a lot of that care starts to overlap with “elective.” There are ways to do cost-reduction with medical tourism as well (volume, automation, systems, and probably some intellectual property related arbitrage or non-compliance). Another market are people working remotely in places without good medical care/access to the local system, but who don’t necessarily work for an employer with in-house care or repatriation-based care — I knew lots of oil and gas folks in the Middle East who also went to Thailand for medical care.
The other markets for medical tourism are probably “not yet approved by FDA” type care. This ranges from experimental drugs not yet approved, to things not recognized by FDA generally (ketamine or other treatments for depression and addiction, some other psychedelic medications used in medical treatment), to pretty amazing science like biophages (used in the former Soviet Union and I think still available in Georgia, and which might be more relevant in an antibiotic-resistant world.) There’s also the whole market of “human performance enhancement” rather than just fixing deficiencies, and we might see some truly amazing transhumanist care at some point. A market of 100k people worldwide who would be willing to pay $1k to $1mm+ for treatments not available elsewhere is likely attractive.
I’m not a doctor or medical technology investor, but have been a user and beneficiary of this trend for much of my adult life, as well as a general advocate of regulatory and jurisdictional arbitrage, so I’m excited to see where it goes.