Ask Liz Weston

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Health Insurance

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

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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

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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

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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

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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: Leaving the U.S. for cheap healthcare

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Dear Liz: Your column a few weeks ago suggested a couple consider leaving the country for healthcare benefits until they reach the age to receive Medicare. We are in a similar position, with enough money to retire early but profoundly worried about the future availability of health insurance. Which countries are considered good options for American ex-pats who want good, affordable healthcare?

Answer: Five countries with healthcare comparable to or better than the U.S. are Colombia, Costa Rica, Malaysia, Mexico and Panama, according to International Living, a site for living and investing abroad. These countries have both public and private healthcare systems, with out-of-pocket costs that are a fraction of what they are in the U.S.

In Mexico, for example, many doctors receive at least some of their training in the U.S. and speak English, according to International Living. The public healthcare system typically costs legal residents a few hundred dollars a year, while private services and prescription drugs cost 25% to 50% of their U.S. equivalents.
Some early retirees like their adopted countries enough to stay past age 65, but they should strongly consider signing up for Medicare when they are eligible, even if they can’t immediately use its services. Failure to sign up can lead to permanent penalties that will make Medicare more expensive if and when they do come back to the U.S.

Q&A: Healthcare costs could nix early retirement

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Dear Liz: Recently you included a letter from a retired person who was amused by the suggestion that early retirees may have to go abroad to find affordable healthcare. I was horrified by that letter and shared your article with several friends. Something is deeply wrong when a nation offers citizens who have contributed to its success so few options regarding decent medical care. It makes me very sad and angry. Thank you for focusing attention on this issue.

Answer: Currently early retirees do have an option before they’re old enough for Medicare, which is to buy insurance from Affordable Care Act exchanges. The future of that coverage is in doubt, though, which is why many financial planners are warning their clients who had planned on early retirement to continue working, if that guarantees them access to health insurance. Moving abroad is another option for the adventurous, but obviously won’t be a good solution for many.