Every September, several thousand insurance and reinsurance executives take over the hotels along the Monte Carlo waterfront for the “Rendez-Vous de Septembre” — the 68th edition ran from 5 to 9 September this year – and it remains the largest single gathering in the sector. Almost nobody in the room describes what they do as “healthcare.” Yet the conversations happening in those hotel bars this week will do more to shape the cross-border trade in medical services (“medical tourism”) over the next thirty-six months than any health ministry announcement, accreditation scheme, or medical tourism trade show.
If you build international patient programs, sell hospital capacity across borders, or advise ministries on medical services exports, as we do, it is worth understanding what was actually said at this event — and why it matters to you.
The headline: too much money, not enough places to put it
The mood this year in Monaco was one of ‘prosperous discomfort.’ Dedicated reinsurance capital (these are the big-money insurers of your insurance company) reached nearly $688 billion by mid-year 2026, while first-half insured losses came in at around $42 billion, against a ten-year average of $50 billion. Abundant capital plus moderately modest losses produces exactly one outcome: falling premiums.
S&P Global Ratings told delegates in Monaco that price softening will continue into the 2027 renewals, with rate reductions potentially matching those of 2026 even if losses hit full budget. Sector return on equity is forecast to fall from 19.1% in 2025 to 12%–15% in 2026 and 10%–13% in 2027. This was framed as a “controlled descent, not a fall off a cliff,” and one underwriter summarized the coming year as “soft but not reckless.”
Translated from trade-press dialect, it says something specific: the world’s risk capital is actively hunting for lines of business where it can earn a return that property & casualty insurance no longer offers. Specialty growth and diversification were the recurring refrain of the week.
At the same time that catastrophic risk is over-supplied, medical risk is repricing dramatically upward. Willis Towers Watson, a British advisory firm, projects global medical costs rising 10.3% in 2026, after increases of 10.0% in 2025 and 9.5% in 2024 — with Asia Pacific at 14.0%, Latin America at 11.9%, the Middle East and Africa at 11.3%, North America at 9.2% and Europe at 8.2%. Aon’s parallel forecast puts the global average trend rate at 9.8% across more than 100 countries. More telling than the headline number is that over half of insurers surveyed expect elevated medical cost trends to persist for more than three years, and respondents cite the decline of public health systems as a driver.
That second data point is the medical services export thesis in a single line, published by a global broker rather than a tourism board.
Medical reinsurance has historically been the bottleneck for cross-border medical services markets, where capacity is constrained. Three major reinsurers have withdrawn from US medical lines, and the shift is structural, not cyclical; one reinsurer describes it as a “course correction, not a crisis.” What are the likely effects? Certainly, greater pricing discipline, tighter underwriting, and a move toward captives and alternative risk transfer. The US insurance market is seeing a hard-market shift. The severity data behind that retreat is stark: almost half of plan sponsors reported claims above $1 million, more than double the share a year earlier, and stop-loss rates rose 8.8% to 10% in a single year.
So: soft property/casualty market, hard medical market, and capital looking for diversification. Cross-border care delivery sits precisely in that gap — and the flow is already large. Estimates vary widely by definition, but the medical tourism market is already between $84.5 billion and $109 billion in 2026, depending on how you count and whose numbers you trust. And almost everyone agrees that it will grow.
Three signals from Monaco worth acting on
Trade policy has become a driver of medical costs. Most insurers expect trade and related tariffs to raise healthcare costs over the next three years, with supply-chain disruptions to hospitals and provider operating costs as the leading concern. For those of us who have spent careers viewing healthcare as a traded service, this is the argument arriving from the other direction. If tariff regimes raise the cost of delivering care in Country A, the relative price advantage of Country B is no longer a marketing claim — it could be a line item in an underwriter’s model.
Underwriters are being asked to price things they still cannot measure (yet?). SCOR, a French reinsurer and one of the world’s tier-one reinsurance groups, used its Monaco briefing to warn about governance and liability challenges arising from AI, and S&P described the global protection gap as still “huge” even with third-party capital at $140 billion. Unpriceable risk is where reinsurers retreat — and where the party with credible data captures the attention. A destination hospital that can demonstrate infection rates, readmissions, complication rates, and lengths of stay at international benchmark standards is not making a quality argument. It is delivering the actuarial inputs that enable underwriting of cross-border trade in complex medical services.
Reinsurance is being repositioned as public infrastructure. Munich Re, one of the largest global reinsurers, told the audience in Monaco that “the value of reinsurance has never been more evident” as risks become more global and volatile, describing the industry as “society’s immune system.” Ministries of health negotiating international patient agreements should read that framing carefully. The counterparty that ultimately determines whether a cross-border care pathway scales is often not the referring payer — it is the reinsurer sitting behind that payer’s stop-loss barrier.
What this means if you sell medical services across borders
The strategic implication is not “market to insurers.” It is more focused and more challenging than that.
Sell predictability, not price. The major reinsurer’s perspective on the medical market is that insurers now favor providers offering underwriting clarity and multi-year stability. A bundled, fixed-price episode with a complication and readmission allowance is a fundamentally different product than a discounted fee schedule. The first can be risk-modeled. The second cannot.
Target severity, not volume. The pain in medical reinsurance is concentrated in million-dollar-plus claims, specialty pharmacy, oncology, cell and gene therapy, and complex neonatal care. High-volume elective orthopedics, cosmetics, and dental will always have a market, but the pathways that will attract institutional capital are the high-severity clinical pathways where a credible international center of excellence can mitigate or remove genuine cost variance.
Build the captive conversation into your commercial model. The Society of Actuaries has documented rapid growth and diversification in healthcare captives. Self-insured employers and provider-sponsored captives may finally become a more receptive first customer for cross-border pathways than traditional indemnity carriers, because they retain the savings. But you’ll need the data, and a really solid, risk-based pitch.
Assume the window is finite. If S&P is right that softening in property and casualty markets runs through 2027, the current appetite for diversification is a function of the cycle. When property catastrophe rates turn — and a genuinely large loss year would turn them — capital will go home to the line it understands best. The programs that survive that turn will be the ones already producing audited outcomes and cost data.
The uncomfortable conclusion
The international trade in medical services has spent two decades trying to legitimize itself through accreditation, patient testimonials, and government trade missions. There were some very small, and ultimately unproductive attempts to penetrate the self-insured employer market. The news from Monaco suggests a blunter route to legitimacy. The markets for cross-border trade in medical services become a real traded industry only when their outputs are predictable enough to be reinsured — and not one day sooner.
Big capital is looking. The question is whether the supply side can produce numbers worthy of underwriting.
Irving Stackpole advises hospitals, ministries, and investors on international healthcare strategy, medical services exports, and senior living markets. We’re building a benchmark of cross-border episode pricing and outcome data. If you’re assembling one, I’d like to compare notes.