Options for healthcare during FIRE (but before 65)?

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Kagord
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Re: Options for healthcare during FIRE (but before 65)?

Post by Kagord »

marcopolo wrote: Fri Jan 15, 2021 6:21 pm
MP123 wrote: Fri Jan 15, 2021 6:11 pm For comparison's sake an early 60s couple in the US making $69k/yr might pay $25k in unsubsidized premiums. That's the equivalent of a 35% "tax".
Currently, that couple could sign up for a HDHP HSA eligible plan on the ACA, contribute up to $9200 (at least enough to get their income below ~64k) to the HSA, and have their premiums capped at about $6k.
Thank you for this, obviously I knew about the traditional IRA which can be more beneficial than a Roth for cliff optimization. But I had no idea you can do an HSA yourself, that's huge for cliff planning.
ad2007
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Re: Options for healthcare during FIRE (but before 65)?

Post by ad2007 »

mushripu wrote: Fri Jan 15, 2021 1:04 pm This discussion brings me to my acceptance of the FI part and reluctance to the RE part. I would like to be financially independent and would prefer not to retire early. I personally think that there is something wrong with a 40-50 year retiring which I suppose is a more extreme position. The reason for saying that is not to comment on anyone's individual decision but to point at the loss of that person's productivity to the overall system. However considerations for retirement vary by individual and I would refrain from passing judgement on anyone's choice of retirement age. I tend to think that once FI is achieved, the sense of work pressure or burnout would subside. The sense of enjoyment in work would increase and you would be able to work on your terms. It shall make the retirement moot unless you get kicked out in the periodic megacorp purges.
This was not true for me.

Having enough money to retire did not make dealing with the crappy parts of my job any less painful. It was actually worse since I started asking myself "Why am I putting up with this?" and "What am I still doing here?"

Retiring magically took away all the work stress.

Yes, health insurance is a cost you'll notice more in retirement since your employer was subsidizing it.
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birdog
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Re: Options for healthcare during FIRE (but before 65)?

Post by birdog »

ad2007 wrote: Sat Jan 16, 2021 8:20 am This was not true for me.

Having enough money to retire did not make dealing with the crappy parts of my job any less painful. It was actually worse since I started asking myself "Why am I putting up with this?" and "What am I still doing here?"

Retiring magically took away all the work stress.

...
I noticed the same thing. Hitting FI made me less tolerant of the bad parts of my job because my need to work was removed. It was further compounded by the fact that the crappy parts of my job got even worse shortly after hitting FI. Healthcare for an early retiree in the U.S. is definitely a concern that requires investigation. Thankfully there are some options. It would be nice if the high cost of health services in the U.S. could be brought back into check a bit. The system is not only expensive but also hard to navigate as it is intentionally opaque.
JS-Elcano
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Re: Options for healthcare during FIRE (but before 65)?

Post by JS-Elcano »

tdmp wrote: Fri Jan 15, 2021 11:04 pm
JS-Elcano wrote: Fri Jan 15, 2021 12:44 pm
dziuniek wrote: Thu Jan 14, 2021 11:09 pm Find a state job which has retiree healthcare as part of benefits + allows early retirement.

Enjoy said healthcare.

My state allows retiree healthcare to start at 58. It does take 15 years to vest.....
Now, 58 is not really early - but atleast it bridges the gap from 58 - 65 and that's not insignificant. Additionally it becomes a kicker like program on top of medicare at 65.

I think most things have been mentioned.

Oh... You could get married to a citizen of a country where healthcare does not stink but is included in taxes. (no such thing as free healthcare)
So marry a Canadian or a European citizen + move there :) . Ha-ha.
The cost of health insurance in Germany is 8% of your gross income. The employer pays another 8%. Everybody pays it. It just comes out of your paycheck just like payroll taxes here. I have never quite understood why it would be such a big deal if we did something like this here. This notion that health care in European countries is somehow cheap or "free" always amazes me.
If we had something like Germany over here, I think many people would be willing to work part time or just FIRE or jump jobs for better pay or more willing to do "gig" work. Many people stay at their jobs or work full time is b/c Health Insurance is tied to the job. ACA makes this a little better but it is still not the same.
Agreed. I think it would be great in some many ways, and it would be more affordable paying a percentage of your income rather than a set premium, which is a much greater percentage of a small income than a big one. The ACA is basically that as it prescribes that you won't have to pay more than 9.83% of your gross.
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Re: Options for healthcare during FIRE (but before 65)?

Post by Carefreeap »

neb2020 wrote: Fri Jan 15, 2021 1:57 am I know health sharing ministries plan are not ACA complaint and have many loopholes, so how do you justify it? Or maybe I should hop into the other thread?

My biggest issue is that I balk at budgeting $24k/yr for healthcare. It's ridiculous. That's more than my rent!
Yep. When we were planning for FIRE I called it the new mortgage payment. But the cost for 2021 was going to be around $1850 for the two of us (ages 59 & 62) which exceeded our remaining mortgage by $600. We finally transitioned to the ACA for this year.
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mushripu
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Re: Options for healthcare during FIRE (but before 65)?

Post by mushripu »

birdog wrote: Sat Jan 16, 2021 8:46 am
ad2007 wrote: Sat Jan 16, 2021 8:20 am This was not true for me.

Having enough money to retire did not make dealing with the crappy parts of my job any less painful. It was actually worse since I started asking myself "Why am I putting up with this?" and "What am I still doing here?"

Retiring magically took away all the work stress.

...
I noticed the same thing. Hitting FI made me less tolerant of the bad parts of my job because my need to work was removed. It was further compounded by the fact that the crappy parts of my job got even worse shortly after hitting FI. Healthcare for an early retiree in the U.S. is definitely a concern that requires investigation. Thankfully there are some options. It would be nice if the high cost of health services in the U.S. could be brought back into check a bit. The system is not only expensive but also hard to navigate as it is intentionally opaque.
This information is useful to understand different scenarios that can evolve.

What healthcare option are you with after early retirement?

I sure am in favor of evolving a single payer option or making medicare enrollment available to people not working actively and below 65 as long as they have met some threshold.
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Re: Options for healthcare during FIRE (but before 65)?

Post by angelescrest »

JDCarpenter wrote: Thu Jan 14, 2021 10:16 pm We have been happy, as our biggest concerns are the hypothetical cost of being hit by an uninsured concrete truck (for example), and avoiding rack rate markups on everything else.
:shock: You don’t need health insurance for that, only life insurance.
jayk238
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Re: Options for healthcare during FIRE (but before 65)?

Post by jayk238 »

tdmp wrote: Fri Jan 15, 2021 11:04 pm
JS-Elcano wrote: Fri Jan 15, 2021 12:44 pm
dziuniek wrote: Thu Jan 14, 2021 11:09 pm Find a state job which has retiree healthcare as part of benefits + allows early retirement.

Enjoy said healthcare.

My state allows retiree healthcare to start at 58. It does take 15 years to vest.....
Now, 58 is not really early - but atleast it bridges the gap from 58 - 65 and that's not insignificant. Additionally it becomes a kicker like program on top of medicare at 65.

I think most things have been mentioned.

Oh... You could get married to a citizen of a country where healthcare does not stink but is included in taxes. (no such thing as free healthcare)
So marry a Canadian or a European citizen + move there :) . Ha-ha.
The cost of health insurance in Germany is 8% of your gross income. The employer pays another 8%. Everybody pays it. It just comes out of your paycheck just like payroll taxes here. I have never quite understood why it would be such a big deal if we did something like this here. This notion that health care in European countries is somehow cheap or "free" always amazes me.
If we had something like Germany over here, I think many people would be willing to work part time or just FIRE or jump jobs for better pay or more willing to do "gig" work. Many people stay at their jobs or work full time is b/c Health Insurance is tied to the job. ACA makes this a little better but it is still not the same.
Just curious how you would fire in germany? What wage are you expecting to do this?
jayk238
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Re: Options for healthcare during FIRE (but before 65)?

Post by jayk238 »

JS-Elcano wrote: Sat Jan 16, 2021 9:52 am
tdmp wrote: Fri Jan 15, 2021 11:04 pm
JS-Elcano wrote: Fri Jan 15, 2021 12:44 pm
dziuniek wrote: Thu Jan 14, 2021 11:09 pm Find a state job which has retiree healthcare as part of benefits + allows early retirement.

Enjoy said healthcare.

My state allows retiree healthcare to start at 58. It does take 15 years to vest.....
Now, 58 is not really early - but atleast it bridges the gap from 58 - 65 and that's not insignificant. Additionally it becomes a kicker like program on top of medicare at 65.

I think most things have been mentioned.

Oh... You could get married to a citizen of a country where healthcare does not stink but is included in taxes. (no such thing as free healthcare)
So marry a Canadian or a European citizen + move there :) . Ha-ha.
The cost of health insurance in Germany is 8% of your gross income. The employer pays another 8%. Everybody pays it. It just comes out of your paycheck just like payroll taxes here. I have never quite understood why it would be such a big deal if we did something like this here. This notion that health care in European countries is somehow cheap or "free" always amazes me.
If we had something like Germany over here, I think many people would be willing to work part time or just FIRE or jump jobs for better pay or more willing to do "gig" work. Many people stay at their jobs or work full time is b/c Health Insurance is tied to the job. ACA makes this a little better but it is still not the same.
Agreed. I think it would be great in some many ways, and it would be more affordable paying a percentage of your income rather than a set premium, which is a much greater percentage of a small income than a big one. The ACA is basically that as it prescribes that you won't have to pay more than 9.83% of your gross.
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TheGreyingDuke
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Re: Options for healthcare during FIRE (but before 65)?

Post by TheGreyingDuke »

I left working at 58, some years ago. This was all pre-ACA so not sure how relevant this is today.

But in the state I was living in I was able to join an association (Chamber of Commerce), register a trade name with the Secretary of State, and open a small business. I did one or two consulting jobs a year and was able to buy a high deductible plan from BCBS through the association. It was much cheaper than other options.
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Re: Options for healthcare during FIRE (but before 65)?

Post by goos_news »

Gattamelata wrote: Fri Jan 15, 2021 4:49 pm
jayk238 wrote: Fri Jan 15, 2021 7:38 am For your hypothetical german with excellent healthcare, their average taxes are 45% starting at wages of 65k. Is this ‘stinky’ enough?
Do you have a source for this? What I see for 2019 is that 45% is the highest tax bracket and starts at 265k income for single people and 530k for couples. Below that is the 42% bracket starting at 55k/111k. Below that is a 24% bracket, so there's definitely a high jump between brackets.

But marginal tax rate is very different than overall tax rate. What drives the average tax rate up to 45%?

In any case, the idea that you can retire to a country with socialized medicine funded by income taxes and participate in their health care scheme is one that should be researched. I know at least one European country doesn't allow you to free ride like that and requires securing private insurance. Otherwise their system would be destroyed by people not paying for their health insurance.
This is my understanding of how it works in France for non-EEA expats who no longer have earned income. After 3 months of residency, you become eligible for the national health care system (you must have private cover before then). The general charge is 6.5% of passive income (interest, dividends, capital gains) if more than roughly 20,400E and then up to a limit of roughly 320,000E. (These figures are per person). Those in receipt of a pension are currently excluded from any charges (currently even those before a formal retirement age -- this may change in the future). Many people than buy a low cost supplement coverage for about 1,200 to 1500E per year to eliminate copays.

Regarding earlier questions on other taxes, many foreign countries have a tax treaty with the US to address double taxation. In France, marginal tax rates are relatively high on earned income (45%@158K, per person). However, since US pension/annuity/401K/IRAs are not taxed via the Tax Treaty in France. Any other income is taxed in France (at various rates) but then can be credited against your US tax. Thus, a large majority of non-working people won't pay more than what they pay in the US . Property taxes and other taxes are relatively low, VAT is high.
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JDCarpenter
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Re: Options for healthcare during FIRE (but before 65)?

Post by JDCarpenter »

JoeJohnson wrote: Fri Jan 15, 2021 7:56 am
JDCarpenter wrote: Thu Jan 14, 2021 10:16 pm We have non-ACA policies through tennessee farm bureau (united healthcare runs them per contract). We have been happy, as our biggest concerns are the hypothetical cost of being hit by an uninsured concrete truck (for example), and avoiding rack rate markups on everything else.

...
What's the lifetime maximum benefit? If you develop a very serious condition, will you switch to Obamacare?
Sorry, we are in Puerto Rico for a few weeks, so I don't have the policies handy. But FWIW, we both (jd and md) had a lot of experience dealing with various insurance policies, laws, and companies during our careers and after working through the language didn't see anything that suggested we'd have to drop these for an ACA plan in the event of substantial claims.
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JDCarpenter
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Re: Options for healthcare during FIRE (but before 65)?

Post by JDCarpenter »

mkc wrote: Fri Jan 15, 2021 11:11 am ...

We looked at TN Farm Bureau health plans ourselves, but a few things gave us pause. ....

Any feedback on their underwriting process?
Was benign. We just had to permit review of medical records. Our policies had a 6 month preexisting illness exclusion. So we overlapped that period with COBRA just to be conservative. Once that period passed and we were enrolled in the system, no more worries.
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JDCarpenter
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Re: Options for healthcare during FIRE (but before 65)?

Post by JDCarpenter »

fortunefavored wrote: Fri Jan 15, 2021 11:15 am
mkc wrote: Fri Jan 15, 2021 11:11 am
JDCarpenter wrote: Thu Jan 14, 2021 10:16 pm We have non-ACA policies through tennessee farm bureau (united healthcare runs them per contract). We have been happy, as our biggest concerns are the hypothetical cost of being hit by an uninsured concrete truck (for example), and avoiding rack rate markups on everything else.
We looked at TN Farm Bureau health plans ourselves, but a few things gave us pause. The state doesn't consider their plans to be insurance so it doesn't regulate them, and won't help in the event of an issue. They also require underwriting, premiums depend on health history, and have a pre-existing condition exclusion (6 or 12 months, depending on plan type). That said, they do provide out-of-network coverage, which none of the BCBST EPO plans on ACA (the only coverage provider in our region) do, and they are potentially half the cost of our Bronze ACA plan.

Any feedback on their underwriting process?
Do these off-book plans have an out of pocket max? That's another previous gotchya in the bad pre-ACA days. $1 or 2M doesn't go very far these days. Similar thing to check around prescription coverage - cancer drugs can be 100s of thousands of dollars.

Until I hear otherwise, I'm assuming these plans are junk - but I'd love to be wrong.
Here you go. This confirms what I thought (but wasn't sure enough to post blindly). No lifetime caps, no kicking out if you come up with nasty chronic disease. https://www.statnews.com/2017/11/13/hea ... rm-bureau/ (an even handed pro/con analysis from a few years ago; can't find a more recent analysis, but this accords with my fallible memory).
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White Coat Investor
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Re: Options for healthcare during FIRE (but before 65)?

Post by White Coat Investor »

aristotelian wrote: Fri Jan 15, 2021 4:40 pm
White Coat Investor wrote: Fri Jan 15, 2021 11:23 am
neb2020 wrote: Thu Jan 14, 2021 9:01 pm For those who plan to FIRE, as in really retire and not just financially independent, how do you deal with health care costs from retirement until age 65 when medicare kicks in?

So far I've read/heard about the following options
- Not retire, and get a simple stress free job for the health insurance... so you're not really retired. Also known as barista FI.
- Have some kind of easy-to-manage business going into retirement and use that income to pay for healthcare premiums. So you're not really retired but self-employed.
- Game your income to be under 400% FPL to get ACA subsidies... but the premium still ain't cheap.
- Get a retirement visa / long-term-stay visa in another country, move there for cheaper healthcare, then come back at age 65.

Are there any better options?
Same way we deal with grocery costs. We buy it. If you don't have the money to buy it, you don't have the money to FIRE. Yes, there are ways to reduce the cost (PPACA subsidies, health sharing ministries) or pay for it with pre-tax dollars (start a little part-time business), but it's like every other expense so I'm not sure why people always single it out.
I think he knows he has to budget it, hence the question. Where do you buy it?
From the health insurance store. There are a bunch of them in your town, just like grocery stores. If you would like to find one, try googling: "Health insurance broker [name of your town]" If you are eligible for a PPACA subsidy, remember you need to go through your state exchange to get a plan that will qualify for it. How do you buy car insurance or property insurance or disability insurance or life insurance? You go to someone who sells it and you buy it from them.

I guess an above poster is right. The concept of buying health insurance on the open market is completely foreign to a large percentage of Americans because they've never done it. Thanks to bizarre WWII era government policies, their employers have taken care of this for them. I find it utterly fascinating how common this question is among incredibly intelligent people.
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incowtown
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Re: Options for healthcare during FIRE (but before 65)?

Post by incowtown »

leftcoaster wrote: Thu Jan 14, 2021 10:08 pm What are people paying out of pocket for employer retiree plans? My mega Corp has one for 55+ but I haven’t checked the cost.
I retired from my mega corp at 55 in 2018 with 31 yrs of service. Premium for the retiree health plan this year is 674/mo for one person (highest deductible/national network plan). In theory, the premium amount is reduced based on length of service - but of course I have no way to verify that.
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Re: Options for healthcare during FIRE (but before 65)?

Post by aristotelian »

White Coat Investor wrote: Sat Jan 16, 2021 7:42 pm
From the health insurance store. There are a bunch of them in your town, just like grocery stores. If you would like to find one, try googling: "Health insurance broker [name of your town]" If you are eligible for a PPACA subsidy, remember you need to go through your state exchange to get a plan that will qualify for it. How do you buy car insurance or property insurance or disability insurance or life insurance? You go to someone who sells it and you buy it from them.

I guess an above poster is right. The concept of buying health insurance on the open market is completely foreign to a large percentage of Americans because they've never done it. Thanks to bizarre WWII era government policies, their employers have taken care of this for them. I find it utterly fascinating how common this question is among incredibly intelligent people.
OP merely asked where people are buying theirs, just as there are dozens of threads on savings accounts and stock brokers. It does not mean the concept is foreign to him.
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Re: Options for healthcare during FIRE (but before 65)?

Post by ncbill »

Pandemic Bangs wrote: Thu Jan 14, 2021 9:16 pm Have you visited the healthcare ministry thread? :D

This in a nutshell is what is wrong with health insurance in the US. Many folks fail to recognize how much their employer underwrites the cost and negotiates the benefits on their behalf.

If you are rich enough to retire early but can not afford health insurance, then you are actually not rich enough to retire early imo.

The cheap countries you can retire to generally have poor health care. Someone will come along and trot out the infant mortality data and how awful the US is, etc., but those are public health metrics and have nothing to do with the bypass surgery or cancer care you or I will need.

I don't think anyone with less than an eight-figure net worth can "self-insure" for health care in the US. Ironically, I bet the self-insuring folks still have homeowner's insurance.

Spouse had enough years of service with her last employer that she could continue the same plan and group at an increased (i.e., unsubsidized) rate. Otherwise you will be looking at an individual plan, which is expensive.
South of the border you'll find plenty of doctors who trained at US medical schools.

If it's something that can't be treated there you can always come back...repatriating to the U.S. is a qualifying event for ACA signup.

One U.S. expat in Mexico I followed online returned for a transplant, though by that time they were over 65 so it was paid for by Medicare.
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Re: Options for healthcare during FIRE (but before 65)?

Post by rich126 »

My large company has self insured medical plans. The one I have is a PPO with HSA. For one person it runs $65 biweekly although they give you $600 for the hsa. If you use COBRA it is about $800 per month. $1600 for a couple.
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Re: Options for healthcare during FIRE (but before 65)?

Post by Pandemic Bangs »

ncbill wrote: Sun Jan 17, 2021 11:29 am
South of the border you'll find plenty of doctors who trained at US medical schools.
Again, if you expect it to be equivalent care, you are in for a surprise. A "US-trained" doctor is not the same as the US medical system. (Imperfect, I know, but there are none better when you are acutely ill.)

There are plenty of for-profit one-off "medical tourism" destinations around the globe where you can get your knee replacement, etc. That is a very different product than the place you go when you get severe COVID or have an acute MI.

I think there is a misconception that with a few dollars in a poor country, you can "self-insure" and simply buy top-notch care off the shelf.
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Re: Options for healthcare during FIRE (but before 65)?

Post by ncbill »

Pandemic Bangs wrote: Sun Jan 17, 2021 1:24 pm
ncbill wrote: Sun Jan 17, 2021 11:29 am
South of the border you'll find plenty of doctors who trained at US medical schools.
Again, if you expect it to be equivalent care, you are in for a surprise. A "US-trained" doctor is not the same as the US medical system. (Imperfect, I know, but there are none better when you are acutely ill.)

There are plenty of for-profit one-off "medical tourism" destinations around the globe where you can get your knee replacement, etc. That is a very different product than the place you go when you get severe COVID or have an acute MI.

I think there is a misconception that with a few dollars in a poor country, you can "self-insure" and simply buy top-notch care off the shelf.
Do you have any evidence to support your claims?

I would agree that most nationals, given lower income/assets, would likely be limited in their health care options, maybe to nothing more than that country's public option, but expats would normally have the means to access higher-end care, whether via "outside the U.S." health insurance or out-of-pocket.
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Re: Options for healthcare during FIRE (but before 65)?

Post by esteen »

wtfire wrote: Fri Jan 15, 2021 1:07 am
esteen wrote: Thu Jan 14, 2021 11:57 pm
Normchad wrote: Thu Jan 14, 2021 11:33 pm Then I will be on the ACA, and managing my MAGI to get optimal premium tax credits.
If I were retiring soon this would be my tactic as well. If you saved in Roth IRAs, taxable accounts, Roth 401(k)s etc you can have a lot of money for your expenses without having much "income".

Sadly my time horizon is more like ~15 years, and any number of things could happen to the ACA in that timeframe so I am not planning on any subsidy available no matter what my income. I'm saving for retirement as if I will have to pay high premiums and large OOP costs for any years before 65.
Don't you need to be over 59.5 years old to withdraw earnings from Roth IRA/401k? It won't help much on lowering the MAGI if poster is a lot younger than 60.
Earnings yes, contributions no. You withdraw the contributions before 59.5.
Pandemic Bangs
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Re: Options for healthcare during FIRE (but before 65)?

Post by Pandemic Bangs »

ncbill wrote: Sun Jan 17, 2021 4:29 pm
Do you have any evidence to support your claims?

I would agree that most nationals, given lower income/assets, would likely be limited in their health care options, maybe to nothing more than that country's public option, but expats would normally have the means to access higher-end care, whether via "outside the U.S." health insurance or out-of-pocket.
Do you mean an RCT of retirees randomized to US/Western Europe vs. those randomized to SE Asia? No, I do not.

But this is exactly the point I was making. The "surely a rich guy can find an iPhone in Vietnam" is precisely the wrong reasoning. Top-notch healthcare is a national ecosystem, or at least a regional one. You don't need that much to do a total knee, say, for medical tourism. But LVAD, ECMO, etc...?

A handful of one-off ex-pat dollars will not fund what you (may) need.

I have no need to try to convince you any further. I hear these arguments all the time. Family member got a hand x-ray for five bucks in rural Mexico and was amazed how much better this was than the US. But that's not the care you need in retirement. :D
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ncbill
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Re: Options for healthcare during FIRE (but before 65)?

Post by ncbill »

Pandemic Bangs wrote: Mon Jan 18, 2021 1:15 pm
ncbill wrote: Sun Jan 17, 2021 4:29 pm
Do you have any evidence to support your claims?

I would agree that most nationals, given lower income/assets, would likely be limited in their health care options, maybe to nothing more than that country's public option, but expats would normally have the means to access higher-end care, whether via "outside the U.S." health insurance or out-of-pocket.
Do you mean an RCT of retirees randomized to US/Western Europe vs. those randomized to SE Asia? No, I do not.

But this is exactly the point I was making. The "surely a rich guy can find an iPhone in Vietnam" is precisely the wrong reasoning. Top-notch healthcare is a national ecosystem, or at least a regional one. You don't need that much to do a total knee, say, for medical tourism. But LVAD, ECMO, etc...?

A handful of one-off ex-pat dollars will not fund what you (may) need.

I have no need to try to convince you any further. I hear these arguments all the time. Family member got a hand x-ray for five bucks in rural Mexico and was amazed how much better this was than the US. But that's not the care you need in retirement. :D
For the highest-level care like organ transplants (or LVAD), sure, you'd need to return to the U.S.

But only a tiny fraction of retirees will ever need such in their entire lifetime.

Most would instead be facing chronic conditions as they age, managed mostly via medications...which are likely to be cheaper outside the U.S.
EnjoyIt
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Re: Options for healthcare during FIRE (but before 65)?

Post by EnjoyIt »

ncbill wrote: Mon Jan 18, 2021 4:32 pm
Pandemic Bangs wrote: Mon Jan 18, 2021 1:15 pm
ncbill wrote: Sun Jan 17, 2021 4:29 pm
Do you have any evidence to support your claims?

I would agree that most nationals, given lower income/assets, would likely be limited in their health care options, maybe to nothing more than that country's public option, but expats would normally have the means to access higher-end care, whether via "outside the U.S." health insurance or out-of-pocket.
Do you mean an RCT of retirees randomized to US/Western Europe vs. those randomized to SE Asia? No, I do not.

But this is exactly the point I was making. The "surely a rich guy can find an iPhone in Vietnam" is precisely the wrong reasoning. Top-notch healthcare is a national ecosystem, or at least a regional one. You don't need that much to do a total knee, say, for medical tourism. But LVAD, ECMO, etc...?

A handful of one-off ex-pat dollars will not fund what you (may) need.

I have no need to try to convince you any further. I hear these arguments all the time. Family member got a hand x-ray for five bucks in rural Mexico and was amazed how much better this was than the US. But that's not the care you need in retirement. :D
For the highest-level care like organ transplants (or LVAD), sure, you'd need to return to the U.S.

But only a tiny fraction of retirees will ever need such in their entire lifetime.

Most would instead be facing chronic conditions as they age, managed mostly via medications...which are likely to be cheaper outside the U.S.
Most medications are pretty cheap. This excludes some rare drugs as well as drugs like epi-pens and insulin. Blood pressure meds, cholesterol meds, aspirin, are all pretty inexpensive.

The high costs are hospital stays, procedures, less common chronic treatments such as cancer, rheumatoid arthritis, HIV that treatment isn’t cheap.

And yeah, imaging is very expensive in the US compared to Mexico.
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ncbill
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Re: Options for healthcare during FIRE (but before 65)?

Post by ncbill »

EnjoyIt wrote: Tue Jan 19, 2021 11:47 am
ncbill wrote: Mon Jan 18, 2021 4:32 pm
Pandemic Bangs wrote: Mon Jan 18, 2021 1:15 pm
ncbill wrote: Sun Jan 17, 2021 4:29 pm
Do you have any evidence to support your claims?

I would agree that most nationals, given lower income/assets, would likely be limited in their health care options, maybe to nothing more than that country's public option, but expats would normally have the means to access higher-end care, whether via "outside the U.S." health insurance or out-of-pocket.
Do you mean an RCT of retirees randomized to US/Western Europe vs. those randomized to SE Asia? No, I do not.

But this is exactly the point I was making. The "surely a rich guy can find an iPhone in Vietnam" is precisely the wrong reasoning. Top-notch healthcare is a national ecosystem, or at least a regional one. You don't need that much to do a total knee, say, for medical tourism. But LVAD, ECMO, etc...?

A handful of one-off ex-pat dollars will not fund what you (may) need.

I have no need to try to convince you any further. I hear these arguments all the time. Family member got a hand x-ray for five bucks in rural Mexico and was amazed how much better this was than the US. But that's not the care you need in retirement. :D
For the highest-level care like organ transplants (or LVAD), sure, you'd need to return to the U.S.

But only a tiny fraction of retirees will ever need such in their entire lifetime.

Most would instead be facing chronic conditions as they age, managed mostly via medications...which are likely to be cheaper outside the U.S.
Most medications are pretty cheap. This excludes some rare drugs as well as drugs like epi-pens and insulin. Blood pressure meds, cholesterol meds, aspirin, are all pretty inexpensive.

The high costs are hospital stays, procedures, less common chronic treatments such as cancer, rheumatoid arthritis, HIV that treatment isn’t cheap.

And yeah, imaging is very expensive in the US compared to Mexico.
Treatment for cancer, rheumatoid arthritis, HIV isn't confined to the U.S...there are plenty of expats being treated for those without having to return to the U.S. & the meds are usually much cheaper.

I can only assume the previous poster must have very ill family members to believe rare treatments like LVADs are what an average retiree would need.
EnjoyIt
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Re: Options for healthcare during FIRE (but before 65)?

Post by EnjoyIt »

ncbill wrote: Wed Jan 20, 2021 1:12 pm
EnjoyIt wrote: Tue Jan 19, 2021 11:47 am
ncbill wrote: Mon Jan 18, 2021 4:32 pm
Pandemic Bangs wrote: Mon Jan 18, 2021 1:15 pm
ncbill wrote: Sun Jan 17, 2021 4:29 pm
Do you have any evidence to support your claims?

I would agree that most nationals, given lower income/assets, would likely be limited in their health care options, maybe to nothing more than that country's public option, but expats would normally have the means to access higher-end care, whether via "outside the U.S." health insurance or out-of-pocket.
Do you mean an RCT of retirees randomized to US/Western Europe vs. those randomized to SE Asia? No, I do not.

But this is exactly the point I was making. The "surely a rich guy can find an iPhone in Vietnam" is precisely the wrong reasoning. Top-notch healthcare is a national ecosystem, or at least a regional one. You don't need that much to do a total knee, say, for medical tourism. But LVAD, ECMO, etc...?

A handful of one-off ex-pat dollars will not fund what you (may) need.

I have no need to try to convince you any further. I hear these arguments all the time. Family member got a hand x-ray for five bucks in rural Mexico and was amazed how much better this was than the US. But that's not the care you need in retirement. :D
For the highest-level care like organ transplants (or LVAD), sure, you'd need to return to the U.S.

But only a tiny fraction of retirees will ever need such in their entire lifetime.

Most would instead be facing chronic conditions as they age, managed mostly via medications...which are likely to be cheaper outside the U.S.
Most medications are pretty cheap. This excludes some rare drugs as well as drugs like epi-pens and insulin. Blood pressure meds, cholesterol meds, aspirin, are all pretty inexpensive.

The high costs are hospital stays, procedures, less common chronic treatments such as cancer, rheumatoid arthritis, HIV that treatment isn’t cheap.

And yeah, imaging is very expensive in the US compared to Mexico.
Treatment for cancer, rheumatoid arthritis, HIV isn't confined to the U.S...there are plenty of expats being treated for those without having to return to the U.S. & the meds are usually much cheaper.

I can only assume the previous poster must have very ill family members to believe rare treatments like LVADs are what an average retiree would need.
And frankly, I would no be getting my LVAD in Mexico.

I figure, if I need very expensive medicine I would do what Utah does for its state employees. They travel to Mexico and get those prescriptions filled there.

https://abcnews.go.com/Health/wireStory ... s-68861516
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boglegirl
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Re: Options for healthcare during FIRE (but before 65)?

Post by boglegirl »

EnjoyIt wrote: Wed Jan 20, 2021 1:26 pm ...
And frankly, I would no be getting my LVAD in Mexico.

I figure, if I need very expensive medicine I would do what Utah does for its state employees. They travel to Mexico and get those prescriptions filled there.

https://abcnews.go.com/Health/wireStory ... s-68861516
Wow. I had heard of insurers paying for patients to travel across the border for surgeries such as knee replacements. But it's shocking that they save so much on drugs to pay for patients to travel several times a year for a refill!
Pandemic Bangs
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Re: Options for healthcare during FIRE (but before 65)?

Post by Pandemic Bangs »

ncbill wrote: Mon Jan 18, 2021 4:32 pm
For the highest-level care like organ transplants (or LVAD), sure, you'd need to return to the U.S.
Agreed.

But then who pays since you have no US insurance? The flight alone could be six figures.
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birdog
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Re: Options for healthcare during FIRE (but before 65)?

Post by birdog »

EnjoyIt wrote: Wed Jan 20, 2021 1:26 pm ...

I figure, if I need very expensive medicine I would do what Utah does for its state employees. They travel to Mexico and get those prescriptions filled there.

https://abcnews.go.com/Health/wireStory ... s-68861516
Interesting article. Another example of America’s overly expensive healthcare system.
EnjoyIt
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Re: Options for healthcare during FIRE (but before 65)?

Post by EnjoyIt »

birdog wrote: Thu Jan 21, 2021 7:42 am
EnjoyIt wrote: Wed Jan 20, 2021 1:26 pm ...

I figure, if I need very expensive medicine I would do what Utah does for its state employees. They travel to Mexico and get those prescriptions filled there.

https://abcnews.go.com/Health/wireStory ... s-68861516
Interesting article. Another example of America’s overly expensive healthcare system.
What amazes me the most is that the meds are exactly the same, coming from the same manufacturer but cost 10x, 100x, more in the US compared to outside. To me that is theft and ridiculous.
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bltkmt
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Re: Options for healthcare during FIRE (but before 65)?

Post by bltkmt »

I am in this precise boat currently. DW and I just went onto ACA and plan to keep our income below the threshold. Our subsidized premium is $18 per month.
7eight9
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Re: Options for healthcare during FIRE (but before 65)?

Post by 7eight9 »

EnjoyIt wrote: Thu Jan 21, 2021 10:24 am
birdog wrote: Thu Jan 21, 2021 7:42 am
EnjoyIt wrote: Wed Jan 20, 2021 1:26 pm ...

I figure, if I need very expensive medicine I would do what Utah does for its state employees. They travel to Mexico and get those prescriptions filled there.

https://abcnews.go.com/Health/wireStory ... s-68861516
Interesting article. Another example of America’s overly expensive healthcare system.
What amazes me the most is that the meds are exactly the same, coming from the same manufacturer but cost 10x, 100x, more in the US compared to outside. To me that is theft and ridiculous.
It can be even worse than that ...

The Same Pill That Costs $1,000 in America Sells for $4 in India
https://www.bloomberg.com/news/articles ... g-in-india
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gatorking
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Re: Options for healthcare during FIRE (but before 65)?

Post by gatorking »

This article is from 2016. Will such planning still work?
https://www.cnbc.com/2016/01/27/theyre- ... idies.html
ncbill
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Re: Options for healthcare during FIRE (but before 65)?

Post by ncbill »

Pandemic Bangs wrote: Wed Jan 20, 2021 3:27 pm
ncbill wrote: Mon Jan 18, 2021 4:32 pm
For the highest-level care like organ transplants (or LVAD), sure, you'd need to return to the U.S.
Agreed.

But then who pays since you have no US insurance? The flight alone could be six figures.
Returning to the US is a qualifying event for ACA coverage.

Medjet, AirMed, etc. offer insurance plans covering repatriation to the U.S.
random_walker_77
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Re: Options for healthcare during FIRE (but before 65)?

Post by random_walker_77 »

gatorking wrote: Sat Jan 23, 2021 8:26 am This article is from 2016. Will such planning still work?
https://www.cnbc.com/2016/01/27/theyre- ... idies.html
Yes, I believe so. ACA subsidies and cost sharing are entirely based on income. When you're retired, taxable income can be controlled, keeping in mind that withdrawals != income.
EnjoyIt
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Re: Options for healthcare during FIRE (but before 65)?

Post by EnjoyIt »

random_walker_77 wrote: Sat Jan 23, 2021 10:36 am
gatorking wrote: Sat Jan 23, 2021 8:26 am This article is from 2016. Will such planning still work?
https://www.cnbc.com/2016/01/27/theyre- ... idies.html
Yes, I believe so. ACA subsidies and cost sharing are entirely based on income. When you're retired, taxable income can be controlled, keeping in mind that withdrawals != income.
Taxable income can be controlled. The math I figure is that for every $1k in taxable income, one loses about $100 or 10% of ACA subsidies. This keeps going until one reaches 400% of poverty and the subsidy drops off.

Disclaimer: This is a ballpark figure I got when playing with healthcare.gov website. One’s actual results may vary.
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fds2
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Re: Options for healthcare during FIRE (but before 65)?

Post by fds2 »

EnjoyIt wrote: Sat Jan 23, 2021 10:45 am Taxable income can be controlled. The math I figure is that for every $1k in taxable income, one loses about $100 or 10% of ACA subsidies. This keeps going until one reaches 400% of poverty and the subsidy drops off.

Disclaimer: This is a ballpark figure I got when playing with healthcare.gov website. One’s actual results may vary.
Wow! For Seattle, with 2 people in their 50's, you get an $800/month subsidy at a $67K MAGI - and it drops to $0 at $68K.
That really is a cliff
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Re: Options for healthcare during FIRE (but before 65)?

Post by marcopolo »

EnjoyIt wrote: Sat Jan 23, 2021 10:45 am
random_walker_77 wrote: Sat Jan 23, 2021 10:36 am
gatorking wrote: Sat Jan 23, 2021 8:26 am This article is from 2016. Will such planning still work?
https://www.cnbc.com/2016/01/27/theyre- ... idies.html
Yes, I believe so. ACA subsidies and cost sharing are entirely based on income. When you're retired, taxable income can be controlled, keeping in mind that withdrawals != income.
Taxable income can be controlled. The math I figure is that for every $1k in taxable income, one loses about $100 or 10% of ACA subsidies. This keeps going until one reaches 400% of poverty and the subsidy drops off.

Disclaimer: This is a ballpark figure I got when playing with healthcare.gov website. One’s actual results may vary.

The change in subsidy depends on where you are in income relative to Federal Poverty Level. At various levels, you are expected to pay a certain percentage of income in premiums (loss of subsidy as income increases).

Here is an article explaining the details. There is a table that gives the exact percentages at various FPL ranges.

https://thefinancebuff.com/aca-premiu ... ges.html
Once in a while you get shown the light, in the strangest of places if you look at it right.
EnjoyIt
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Re: Options for healthcare during FIRE (but before 65)?

Post by EnjoyIt »

fds2 wrote: Sat Jan 23, 2021 12:29 pm
EnjoyIt wrote: Sat Jan 23, 2021 10:45 am Taxable income can be controlled. The math I figure is that for every $1k in taxable income, one loses about $100 or 10% of ACA subsidies. This keeps going until one reaches 400% of poverty and the subsidy drops off.

Disclaimer: This is a ballpark figure I got when playing with healthcare.gov website. One’s actual results may vary.
Wow! For Seattle, with 2 people in their 50's, you get an $800/month subsidy at a $67K MAGI - and it drops to $0 at $68K.
That really is a cliff
The way I see it, ACA subsidy is a tax. 10% tax up to $68k and then a huge cliff. With that in mind. If I know I’m going to hit the cliff then it may be worthwhile to do Roth conversions right up to the top of the 24% tax bracket so that the next few years you qualify or subsidies again. I believe this is what we will be doing based on our expected expenses in retirement.
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EnjoyIt
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Re: Options for healthcare during FIRE (but before 65)?

Post by EnjoyIt »

marcopolo wrote: Sat Jan 23, 2021 12:47 pm
EnjoyIt wrote: Sat Jan 23, 2021 10:45 am
random_walker_77 wrote: Sat Jan 23, 2021 10:36 am
gatorking wrote: Sat Jan 23, 2021 8:26 am This article is from 2016. Will such planning still work?
https://www.cnbc.com/2016/01/27/theyre- ... idies.html
Yes, I believe so. ACA subsidies and cost sharing are entirely based on income. When you're retired, taxable income can be controlled, keeping in mind that withdrawals != income.
Taxable income can be controlled. The math I figure is that for every $1k in taxable income, one loses about $100 or 10% of ACA subsidies. This keeps going until one reaches 400% of poverty and the subsidy drops off.

Disclaimer: This is a ballpark figure I got when playing with healthcare.gov website. One’s actual results may vary.

The change in subsidy depends on where you are in income relative to Federal Poverty Level. At various levels, you are expected to pay a certain percentage of income in premiums (loss of subsidy as income increases).

Here is an article explaining the details. There is a table that gives the exact percentages at various FPL ranges.

https://thefinancebuff.com/aca-premiu ... ges.html
Awesome. Thanks for the link. It very nicely explains why I was seeing about 10% when I was playing around on healthcare.gov
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gatorking
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Re: Options for healthcare during FIRE (but before 65)?

Post by gatorking »

Comments in the TFB article are most interesting, especially this link:
https://www.forbes.com/sites/carolynmcc ... 472ebb1f53
It is a detailed explanation of how to get tax credits AND reduce out of pocket expenses.
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