Q&A: Moving for cheaper foreign healthcare can be stressful

Dear Liz: My husband is 55 and we are hoping to retire in five years. That gives us time to clean up our outstanding debt (the house, car and credit card debt from medical bills). We have a little over $1 million saved. He was recently offered early retirement but didn’t take it because of our debt and my health problems. I have end-stage liver disease and recovered from liver cancer. I have been collecting disability for a while.

I’m doing relatively well for my condition. However, at any time my health can take a bad turn. So I was interested in what you said about living in other countries to get affordable healthcare. If we were to do that, how long would we need to live there to qualify for healthcare? Should we talk to a tax preparer and financial advisor?

Answer: Residency requirements to qualify for public healthcare vary by country, said Kathleen Peddicord, founder of the international living site Live and Invest Overseas. “In some cases it’s instant, in others it could take years,” she says.

In most countries, anyone who is employed or self-employed can instantly access the public system. Some countries allow non-workers to opt into this system by volunteering to pay into it, but there may be restrictions for those with pre-existing conditions. If you’re collecting Social Security disability, you probably have Medicare, but that coverage typically doesn’t extend abroad.

Expatriates in good health can use an international medical plan to bridge any gaps in coverage, but those policies also typically exclude preexisting conditions. You might have to settle for a more limited travel medical plan that would expire after six months and need to be renewed, she said. Given your serious health issues, that could be problematic.

Then there’s the potentially enormous stress of moving to a foreign country, adapting to a different culture and possibly learning a new language. Even in countries with excellent healthcare, finding specialists who can help you manage your condition, and who can communicate clearly with you, can be a hassle.

If you can find advisors familiar with life in the country of your choice, that could be helpful, but you’ll probably be doing a lot of research on your own. Before you decide to move, you should make at least one and preferably a few trips to the country to get a better idea of the challenges.

Q&A: The fat in your genes/jeans

Dear Liz: In one of your recent answers, you said “avoiding obesity” was part of choosing healthier lifestyles. The problem with that statement is that a large percentage of people cannot avoid obesity, because obesity is “wired” into their genes or otherwise into their personal biological makeup. People range all over the spectrum. I personally knew a guy who would normally eat four Double Double burgers plus fries when he ate at In-N-Out Burger, and he didn’t exercise, but he was trim as a telephone pole. But guys in my family have large lumps of extra fat on their bodies, even if we don’t eat that much.

Your casual mention unfortunately reinforced the false notion that people who have obese bodies always are that way because they eat poorly or too much, while people with trim bodies are always that way because they eat wisely and exercise. That false notion just makes life harder for those of us who have obesity regardless of how we eat. I’m sure you didn’t intend to make my life more difficult at all, but that’s the effect that such casual allusions have. It would be best to stick with unassailable phrases such as “eating wisely.”

Answer: Some people definitely are blessed with faster metabolisms, and research indicates that others have a genetic predisposition to packing on weight. But obesity is largely preventable, according to the World Health Organization and other medical authorities.

The WHO recommends that individuals limit the fats and sugars they eat, increase consumption of fruit and vegetables, as well as legumes, whole grains and nuts; and engage in regular physical activity (60 minutes a day for children and 150 minutes spread through the week for adults). Programs such as Weight Watchers or 12-step groups such as Overeaters Anonymous can help provide support. You may never be skinny, but you can definitely take steps to improve your health.

Q&A: Self insurance brings risk

Dear Liz: A letter writer in your column says that “self insurance,” or going without health insurance, “certainly reinforces healthy lifestyle choices.” My husband made all of those “right” choices for more than 60 years, which was absolutely no protection against being diagnosed with brain cancer. Your penny-pinching correspondent might currently be running marathons or doing daily yoga, but as Clint Eastwood put it: “You’ve gotta ask yourself one question: ‘Do I feel lucky? Well, do ya, punk?’”

Answer: As a nation, we could certainly lower our healthcare costs by choosing healthier lifestyles — exercising, avoiding obesity, not smoking and so on. But accident or illness can strike even the healthiest among us, which is why health insurance is a necessity not just to ensure we can get care but to protect against catastrophic medical bills.

Unfortunately, as human beings we often have the delusion that what’s happened in the recent past will continue indefinitely. If we’ve been lucky with our health, we may think that will always be the case. The reality is that everybody’s luck runs out at some point, and often does so at great expense.

Q&A: Going without health insurance isn’t wise

Dear Liz: You recently wrote about early retirees going abroad for their pre-Medicare years in order to get more affordable healthcare coverage. Why did you not bother to even mention the COBRA option that is often available to workers upon retirement? And by the way, some of us prefer to self-insure in our pre-Medicare years and even opt to not buy Part B coverage once we were eligible. Self-insuring is not for the sick, only the healthy, but there is a place for this never-mentioned option and it certainly reinforces healthy lifestyle choices.

Answer: COBRA was mentioned as an option in the original column, which addressed the retirement concerns of a woman 10 years younger than her husband. COBRA allows employees to continue their healthcare coverage for up to 18 months, so someone who is 63½ could use COBRA to bridge the gap until Medicare.

The coverage isn’t cheap because the retiree will have to pay the full premium without the employer subsidy, plus a 2% administrative fee. Anyone retiring earlier than 63½, including the younger spouse in the original column, still could face years without coverage once COBRA is exhausted.

And going without health insurance isn’t wise. Regardless of how healthy you currently happen to be, you’re one serious accident or illness away from disaster. Self-insuring can make sense for the smaller ongoing expenses of primary care. At a minimum, though, people should have a high-deductible plan that protects them from catastrophically high medical bills.

The decision to forgo Part B of Medicare may be an expensive one, as well. (For those who don’t know, Part A of Medicare is free for beneficiaries and covers hospital visits. Part B covers doctor visits, preventative care and medical equipment, among other expenses, and requires paying a monthly premium. Most people pay $134 a month for Part B coverage, although singles with incomes over $85,000 and married people with incomes over $170,000 pay higher amounts.) A permanent 10% penalty is tacked on to monthly premiums for every 12 months you were eligible for Part B but didn’t sign up.

Q&A: Beware of ‘junk’ medical insurance

Dear Liz: In response to your response to the retired couple about healthcare costs. I wish everyone else could be informed about this. Healthcare costs in the individual market before the ACA were anything but affordable. I had to quit my job because my husband got ill in 2000. I was healthy and was paying at first $350 a month. Every couple of years it went up because I entered a new age bracket. I had to drop my coverage when premiums went to $800. And that was for a junk policy. I was hit by a car and I realized what it didn’t cover. I almost went bankrupt, but was able to sue my own car insurance company so that I wouldn’t lose my house. I finally was able to get on Medicare when I turned 65.

Answer: Thank you for mentioning the issue of “junk” policies. Some of the cheaper alternatives to ACA policies offer far less coverage, something buyers may not discover until it’s too late. Any insurance policy worth the name should cover the kinds of catastrophically high expenses that could otherwise wipe out a retirement fund or lead to bankruptcy.

Q&A: Health sharing plans don’t work for everyone

Dear Liz: I read your column about healthcare options for couples planning for retirement today. I’ve recently learned about and signed up for health sharing. The benefits are closely comparable to traditional insurance and less expensive. If you haven’t heard about this, I think it’s worth looking into.

Answer: Christian health sharing plans are an alternative to traditional insurance, but they’re not actually health insurance. Members agree to pay each other’s medical bills, up to certain limits. Members typically must be Christians who attend church regularly and don’t use tobacco, among other restrictions. These plans often don’t cover preventive care such as mammograms or colonoscopies and may not cover mental health care, addiction treatment or other so-called “essential services” that are typically required of health insurance.

The plans can help with some healthcare costs, but the amounts that can be paid out are typically capped. That means that an accident or illness could still bankrupt you. In addition, the plans typically don’t cover preexisting conditions or limit the coverage they offer. Since few people reach their 50s and 60s without a preexisting condition or six, these plans aren’t a viable substitute for many people approaching retirement.

Q&A: Healthcare costs and retirement

Dear Liz: You usually don’t give me such a laugh, but today’s letter was from someone who’s 41 and her husband is 51. They now have $800,000 saved and want to retire early. You told them they might do better leaving the country since it will be so bad for them with health insurance.

My husband was a teacher in Los Angeles, with no Social Security. We have $60,000 in the bank and together we bring in $3,400 a month. We have Kaiser insurance that totals $2,400 a year for both. We have a house, a car, not so much money, but are happy. He’s 82, I’m 79. What planet do you live on? I guess people who have so much money can’t imagine people like us.

Answer: You’re living on Planet Medicare, so perhaps you can’t imagine what people are facing who don’t have access to guaranteed medical coverage.

Currently, those without employer-provided insurance can buy coverage on Affordable Care Act exchanges, but that option may soon be going away. Congress ended the ACA’s individual mandate, which requires most people to have insurance, so costs are expected to rise sharply.

In addition, the future of so-called “guaranteed issue” is in doubt. The ACA currently requires health insurers to accept people with preexisting conditions and limits how much people can be charged, something known as “community rating.” The U.S. Department of Justice recently announced it would not defend those provisions against a lawsuit filed by several states.

When health insurance is unavailable or unaffordable, it doesn’t matter if you have $1 million or more in savings. A hefty retirement fund can disappear in a few months without coverage.

Wednesday’s need-to-know money news

Today’s top story: Why brand loyalty makes some blind to retail cards’ flaws. Also in the news: The good, the bad and the budget of destination weddings, how to save on central air, and what to know about your insurance when you’re on vacation.

Why Brand Loyalty Makes Some Blind to Retail Cards’ Flaws
Your favorite store card could come with a whopping interest rate.

Destination Weddings: The Good, the Bad and the Budget
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The Cost to Install Central Air and 3 Ways to Save
Staying cool for less.

What to Know About Your Insurance When You’re on Vacation
What is and isn’t covered.

Q&A: Paying for a younger spouse’s health insurance until Medicare kicks in

Dear Liz: My husband and I have started discussing when he’ll retire. I’d like him to retire somewhere around 65 or 67. He thinks he’ll have to work until at least 70, if not longer, for health insurance coverage for me. (It’s possible that he could do so, since his is an intellectual job where experience is highly valued. Several of his colleagues are in their 70s now, and one retired last year in his 80s.) My husband is 51, and I will be 41 this year.

We’ve used retirement calculators, and even restricting the rate of return to 3% or 4%, we’ll have at least $800,000 in his 401(k) by the time he’s 67. If we use the historical return rate, we get well over $1 million. We then made a rough guess of what minimum distributions would be based on current IRS tables. This number alone will cover 70% or more of our retirement budget.

I think we can do this, even if we have to pay for my health insurance, and even if we have to start withdrawing from the 401(k) at 65. Is this a bad idea? If he gets there and wants to keep working, then no problem, but if he’s fed up at age 64 and 355 days, I want him to feel able to walk away.

Answer: That’s a wonderful goal, but you may be underestimating the cost and difficulty of securing health insurance for your future self.

Currently, people without employer-provided insurance can buy coverage on Affordable Care Act exchanges, but the future of those is in doubt. Congress ended the ACA’s individual mandate, which requires most people to have insurance, so costs are expected to rise sharply next year. If enough healthy people opt out, the exchanges will collapse.

It’s not hard to imagine a future that looks like the past, where people had to keep working at jobs that offered employer coverage until both they and their spouses were old enough for Medicare. Under current rules, that would mean your husband working until he’s 75 and you’re 65.

Your husband might be able to quit a bit earlier thanks to COBRA rules, which allow people to continue employer-provided coverage for 18 months if they can pay the full cost of the premiums, plus a 2% administrative fee. The average annual premium is $6,690 for single coverage and $18,764 for family coverage, according to the Kaiser Family Foundation. The cost is likely to be substantially more in the future if medical cost inflation isn’t brought under control.

If you really want to give your husband the option to quit at 65, you may need to look into employment for yourself that includes health insurance benefits. Another option is to move abroad to one of the many countries that offer affordable healthcare for expatriate retirees. Sites such as International Living at www.internationalliving.com and Live and Invest Overseas at www.liveandinvestoverseas.com can help you identify potential options. You could plan to return home once you’ve qualified for Medicare.

Tuesday’s need-to-know money news

Today’s top story: College degrees can be a bargain abroad. Also in the news: Open enrollment time, how to finance a car at 0% interest, and 3 ways to protect your retirement savings from a market crash.

College Degrees Can Be a Bargain Abroad
Considering international universities.

Open Enrollment at Work: Get Ready to Get Choosyst
Finding the best plan.

How to Finance a Car at 0% Interest
Getting the best rate.

401(k) uncertainty? 3 ways to protect your retirement savings from a market crash
Protecting your future.