The Real Cost of Health Care in Retirement

Health care can be one of the biggest costs in retirement, yet it is notoriously dif fi cult to estimate—and too often people assume Medicare1老年和殘障健康保險，由美國聯(lián)邦政府依據(jù)1965年的社會保障修正案建立，服務(wù)對象是65歲以上的老人或者符合一定條件的65歲以下的殘疾人或晚期腎病患者。will cover either everything or nothing, neither of which is true. Understanding Medicare is like learning about the birds and the bees: Until they experience it themselves, most people base their assumptions on anecdotes and misinformation,which means there can be some uncomfortable surprises ahead.

[2] “Medicare covers a lot less than people usually think. People are just not informed; health-care costs aren’t on the radar2on the radar受人關(guān)注； 引起注意。until they have a crisis,” says Heather Evans, a fi nancial advisor with Merrill Lynch3美林證券，世界最大的證券零售商和投資銀行之一，總部位于美國紐約市。outside of Washington.“It can be a huge surprise cost—and your quality of life is going to depend on what you can afford.”

在美國，醫(yī)療可能是退休后最大的開銷之一，其成本卻難以估量——人們往往認為，老年和殘障健康保險（以下稱Medicare）要么什么都包，要么什么都不包，但這兩種看法都不對。了解Medicare就像學習基礎(chǔ)的性知識，除非親身經(jīng)歷過，否則大多數(shù)人會根據(jù)奇聞異事和錯誤信息對其臆斷，這就意味著可能會遇到一些令人不適的意外情況。

[2]華盛頓郊區(qū)的美林證券金融顧問希瑟·埃文斯稱：“Medicare的承保范圍遠比通常想象的要窄。人們根本不了解，只有出現(xiàn)危機時才會意識到醫(yī)療的成本。該成本之大可能令人瞠目——一個人的生活質(zhì)量將取決于可負擔的那部分?！?/p>

The fi rst line of expense: Medicare

[3] Even retirees satis fi ed with Medicare’s coverage will still spend an average of $260,000 (per couple) on health care from age 65 on, according to Fidelity Investments4美國跨國金融服務(wù)公司。. About a third of that is for Medicare premiums5premium保險費。; the rest goes to co-payments, deductibles6deductible 自付扣除金，接受合乎條件的醫(yī)療服務(wù)時，在健康保險計劃開始支付前由患者先行負擔的自付額。, and drug and medical costs.

[4] But affluent retirees especially may find health-care costs far exceed that estimated $260,000. Married couples with income of more than$170,000, for instance, will pay an additional $134 to $742 every month for their Parts B (medical visits and tests)and D (prescription drug) coverage7Medicare分為四大類：住院保險（Part A），即聯(lián)邦政府對住院治療或護理費用的醫(yī)療保險；補充性醫(yī)療保險（Part B），由職工選擇投保，主要保障住院保險沒有覆蓋到的門診項目；醫(yī)保優(yōu)勢計劃（Medicare Advantage，簡稱MA計劃，Part C），經(jīng)政府特許的保險公司為醫(yī)保受益人設(shè)計的一些額外醫(yī)療服務(wù)保險； 處方藥計劃（Part D），政府補貼的藥物福利計劃，參加此計劃的受益人支付額外的保險費，可以低價購買處方藥。.

[5] Medicare covers the basics, and there’s no reason not to use it. But it doesn’t cover everything retirees may want—such as newer drug treatments,state-of-the-art medical equipment, or more personalized care. And it doesn’t cover long-term care at all.

基本開支：Medicare

[3]富達投資稱，即便那些對Medicare服務(wù)感到滿意的退休人士，自65歲開始，（每對夫妻的）平均醫(yī)療開支也高達26萬美元。其中約三分之一用于支付Medicare的保險費，其余款項用于支付共付額、自付扣除金以及藥品和醫(yī)療費用。

[4]但尤其是生活富裕的退休人士可能發(fā)現(xiàn)，醫(yī)療保健的費用遠超上文估測的26萬美元。例如，年收入超過17萬美元的夫婦，每月需為Medicare B部分（門診和檢查）和D部分（處方藥）額外支付134至742美元不等。

[5] Medicare覆蓋基本項目，沒有理由不參保，但它不覆蓋退休人士可能需要的所有項目，比如較新的藥物治療、最先進的醫(yī)療設(shè)備或者更具個性化的護理，也根本不包括長期護理。

[6] Ken Dychtwald, head of Age-Wave8一家專注于人口老齡化問題研究的美國公司。, a consulting firm focused on aging trends, likens health care to air travel. “Everyone will have a seat.Some will buy coach, which will be OK but not terribly comfortable, while others will pay up for business class and better health care,” he says. “The fi rstclass travelers will want the best medical treatment, second and third opinions9second opinion二次診療，與原診（primary diagnosis）相對應(yīng)，指個人在某疾病已獲得初次診療醫(yī)生的診斷后，通過向權(quán)威機構(gòu)/人士進行第二次診斷咨詢，從而獲得更為完善的診斷意見的做法。, and doctors available 24/7. You can wind up10wind up（使自己）陷入，卷入，落得。spending a lot of money for that Four Seasons-level care.”

[7] There are a few main categories for which retirees should plan on paying higher out-of-pocket costs.

[8]Drugs and similar treatments.Medicare Part D prescription plans vary in the drugs they cover, as well as what portion of the cost they assume. To add to the complexity, the lists—known as formularies11formulary 每年各家醫(yī)療保險公司都會綜合考慮藥品的療效和價格來制定自己的報銷目錄?！猚an change annually.Retirees can also be on the hook12on the hook陷入（困境）。for as much as a third of the cost of specialized treatments. More patients are taking biologics, which are treatments derived from living organisms, and specialized drugs because they can make a significant change in patient care,especially in areas like cancer, multiple sclerosis, and hepatitis C. But that can lead to significantly higher costs.

[6] AgeWave是一家專注于老齡化趨勢研究的咨詢公司，其總裁肯·戴奇沃迪把醫(yī)療服務(wù)比作航空旅行：“每個人都有座位。有的人買經(jīng)濟艙，雖然能坐，但是不太舒適，有的人則加錢買商務(wù)艙和更好的醫(yī)療服務(wù)。頭等艙的乘客想要獲得最好的治療，享受二次診療和三次診療服務(wù)，希望隨時能看醫(yī)生。這種五星級醫(yī)療服務(wù)價格不菲。”

[7]退休人士應(yīng)做好為一些主要項目自付更高費用的打算。

[8]藥物和類似治療。不同類型的Medicare處方藥計劃在承保藥物種類及報銷比例上差別很大。此外，藥品清單，即藥品報銷目錄，每年都可能更改，這讓情況愈加復雜。退休人士還可能需要自付高達三分之一的專業(yè)治療費用。如今，更多的患者服用生物制劑（源于活生物體）和專業(yè)藥物，因為它們可以顯著改善患者治療質(zhì)量，在癌癥、多發(fā)性硬化癥和丙型肝炎等領(lǐng)域尤其如此。但這會導致費用大幅提高。

[9]Testing and physical treatments.Medicare limits the amount of diagnostic testing it will cover. Medicare also limits physical-therapy and speech-pathology expenses each year to $1,980—an amount that seniors can hit quickly.If not deemed medically necessary,Medicare will deny payment.

[10]Services not covered by Medicare. Cataract surgery is one of the most common procedures for retirees, and modern medicine has greatly reduced the invasiveness13invasiveness侵襲性。of the surgery and patient-recovery time by using lasers,rather than a scalpel14scalpel解剖刀；手術(shù)刀。, to remove the cataract. But Medicare will pay only for procedures using a scalpel, and not the extra cost of laser surgery, which typically runs an additional $1,500 an eye.

[11] Costs can also add up for routine dental work. Medicare doesn’t cover typical dental costs but will step in if a hospital stay is needed. A dental implant can cost as much as $3,000, with the crown and possible bone grafts15graft〈醫(yī)學〉移植。costing another $4,150.

[9]檢查和物理治療。Medicare對其承保的診斷檢查有數(shù)量限制，并將物理治療和言語病理學治療的報銷額度限定在每年1980美元，這一額度老年人很快便會用完。如果采取的措施并非醫(yī)療必須，Medicare不予報銷。

[10] Medicare未承保服務(wù)。白內(nèi)障手術(shù)是退休人士最常做的手術(shù)之一。現(xiàn)代醫(yī)學通過激光而非手術(shù)刀來切除白內(nèi)障，大大降低了手術(shù)造成的創(chuàng)傷，縮短了患者恢復時間。但Medicare僅報銷手術(shù)刀手術(shù)的費用，而不報銷激光手術(shù)的額外費用。選擇激光手術(shù)，通常每只眼睛需另付1500美元。

[11]常規(guī)牙齒護理也會增加費用。Medicare不報銷一般的牙齒護理費用，但如果患者需住院治療，則予以報銷。植一顆牙的費用可能高達3000美元，牙冠和骨移植物需另付4150美元。

[12] Medical concierge services and health-care consultants. According to a 2015 Kaiser16= Kaiser Family Foundation凱澤家庭基金會。survey, 2% of doctors nationally won’t take Medicare at all,but other reports find it can be higher in places such as Washington and New York, though the problem is worse in rural areas overall.

[13] Retirees can negotiate the price with doctors who don’t take insurance,often paying 15% to 20% more than they would under Medicare. But the hassle leads some retirees to more personalized concierge or direct primarycare doctors. Most limit the size of their practice, charging a membership fee for access to a doctor who offers the physicals, sick visits, and preventative17preventative預防的。care that primary-care doctors typically provide. The attraction is more personalized care, as well as longer—and easier to get—appointments.

[14] Memberships average $110 a month, but some can charge several thousand dollars a year. While most do not accept insurance, patients can still file their own paperwork to get some reimbursement from Medicare. Some practices include basic labs and diagnostic tests, but most do not; in that instance, Medicare will help cover those.

[12]醫(yī)療管家服務(wù)和醫(yī)療顧問。2015年凱澤調(diào)查顯示，全美有2%的醫(yī)生根本不接受Medicare醫(yī)保報銷。其他報告還發(fā)現(xiàn)，在華盛頓和紐約等地區(qū)，這一數(shù)字可能更高，而這一問題在整個農(nóng)村地區(qū)更為嚴重。

[13]對于不接受保險報銷的醫(yī)生，退休人士可與其商議價格，費用通常比Medicare高出15%到20%。為避免這一麻煩，部分退休人士會選擇服務(wù)更為個性化的醫(yī)療管家或直接找初級保健醫(yī)生。此類醫(yī)生大多會限制其接診人數(shù)，患者需繳納會員費才能看醫(yī)生，獲得初級保健醫(yī)生通常提供的體檢、病訪和預防性保健服務(wù)。此類診所的吸引人之處在于治療更為個性化，更易約診且診療時間更長。

[14]會員費平均每月110美元，但有些診所會員費可高達每年數(shù)千美元。雖然大部分不接受保險，但患者仍可遞交文件，從Medicare中報銷部分費用。有些診所還提供基本的化驗和診斷性檢查，但大多數(shù)診所不提供這些；這種情況下，Medicare會報銷這些檢查的費用。

[15]人生規(guī)劃伙伴公司財務(wù)顧問卡羅琳·麥克拉納漢曾當過醫(yī)生，她說：“如果你很少看病或者身體相對健康，這可能是浪費錢。但如果你有疑難雜癥，這倒是個好辦法?！?/p>

[15] “If you rarely go to the doctor or are relatively healthy, it’s probably a waste of money,” says Carolyn McClanahan, a medical doctor turned fi nancial advisor at Life Planning Partners18一家金融咨詢公司，位于美國佛羅里達州。. “But if you have a complicated illness, it’s a good way to go.”

[16]Chronic conditions, including dementia19dementia癡呆癥。. Chronic conditions are costly. Having five or more chronic conditions—like diabetes, cancer, heart disease, or Parkinson’s—raised the median20median中位數(shù)的。annual out-of-pocket expenses by 75%, according to Kaiser.

[17] Dementia is the black swan21black swan黑天鵝，指非常難以預測，且不尋常的事件。of health care planning, substantially boosting costs primarily because it could require much longer long-term care services compared with the average of two to three years.

[18] Medicare will pay for cognitive assessments and care-planning services,but it doesn’t help with some of the biggest costs, such as daily care. Dementia can progress over a 20-year period,making care managers especially helpful in mapping out22map out規(guī)劃。the types of services needed over time.

[16]癡呆癥等慢性病?？绰圆r格昂貴。凱澤調(diào)查顯示，患5種或5種以上慢性?。ㄈ缣悄虿?、癌癥、心臟病或帕金森?。┑幕颊撸淠曜愿夺t(yī)療費中位數(shù)增加了75%。

[17]癡呆癥是醫(yī)保計劃中的“黑天鵝”，會大幅抬高醫(yī)療費用，主要是因為癡呆癥需要時間更長的長期護理服務(wù)，而其他慢性病的平均護理時間為兩到三年。

[18] Medicare可報銷認知評估和護理規(guī)劃服務(wù)費用，但不報銷日常護理等一些成本最高的服務(wù)費用。癡呆癥的持續(xù)時間可長達20年，因而特別需要護理管理人員為患者規(guī)劃所需的服務(wù)類型。

[19]退休人士通常在確診癡呆癥前便需要幫助，例如需要人協(xié)助準備餐食、開車或跑腿。成人日托服務(wù)可提供安全環(huán)境下的社交互動，并讓護理人員得到急需的歇息機會，但這通常不在Medicare的承保范圍內(nèi)。據(jù)最新的展維護理成本調(diào)查顯示，全美聘請家庭護工的月平均成本約為3800美元，而成人日托服務(wù)的月平均成本為1473美元。

[19] Often, retirees need help even before a formal diagnosis of dementia,such as assistance in preparing meals,driving, or running errands. Adult daycare services offer social interaction in a safe environment, and give caregivers much-needed respite. But none of this is typically covered by Medicare. The national average cost for a home companion is about $3,800 a month, while adult day care averages $1,473 a month,according to the latest Genworth23= Genworth Financial展維金融集團，長期護理保險領(lǐng)域的領(lǐng)軍企業(yè)。Cost of Care survey.

[20]Long-term care. Long-term care is perhaps the biggest expense not covered by Medicare, and therefore insuring for it is one of the most highly debated fi nancial decisions.

[21] Costs vary widely depending on location. The median annual cost of a private room in a nursing home is$155,125 on Long Island, N.Y.; $182,318 in San Francisco; and almost $126,000 in Naples, Fla.—far pricier than the median$74,000 in the Dallas area. Sought-after facilities cost more.

[22] Home-based care is vastly preferable for most people. But it can cost four times as much as assisted living24assisted living贍養(yǎng)院；安養(yǎng)照護。,with the national average at $180,000 a year, according to HealthView25= HealthView Services一家提供退休醫(yī)療成本數(shù)據(jù)的公司，位于馬薩諸塞州。. That’s on top of costs incurred to modify the home—such as wider doorways and ramps to accommodate wheelchairs,or grab-bars in the shower—as well as whatever additional help is needed to maintain the home.

How to pay for it all

[23] All of these costs can add up to a sizable sum, but it’s not a lump sum26lump sum一次總付的錢款。. Starting early makes these costs easier to digest. For example, a healthy 55-year-old couple retiring at 65 needs to set aside $199,000 invested today, or $25,507 annually for the next decade assuming a 6% return, to cover healthcare expenses, according to HealthView founder Ron Mastrogiovanni.

[20]長期護理。長期護理或為Medicare未承保項目中費用最高的服務(wù)，因此是否將其納入保險項目是爭議最大的財務(wù)決策之一。

[21]各地長期護理的成本差異巨大。一間養(yǎng)老院私人看護房的年中位價格在紐約長島為155125美元，在舊金山為182318美元，在佛羅里達州那不勒斯市則近126000美元，遠高于達拉斯地區(qū)的74000美元。熱門養(yǎng)老院的費用更高。

[22]大多數(shù)人更青睞家庭護理。但HealthView稱，家庭護理的費用可高達養(yǎng)老院的4倍；全美家庭護理的年平均成本為18萬美元，這還不包括改造房屋（如加寬門道和坡道以方便輪椅通過，或在浴室安裝扶手）和請人維護房屋所需的費用。

如何支付醫(yī)療費用

[23]所有費用加到一起數(shù)額巨大，但并非一次性付款。及早規(guī)劃可讓費用更易消化。HealthView的創(chuàng)始人羅恩·馬斯特羅喬瓦尼稱，假設(shè)一對55歲的健康夫婦將于65歲退休，那么現(xiàn)在需儲備199000美元，或者在未來10年里每年存25507美元（假設(shè)年收益率為6%），將來用以支付醫(yī)療費用。

[24] Health savings accounts are often championed27champion支持，擁護。as a great way to save money for medical expenses before retirement because contributions go in tax-free, grow tax-free, and withdrawals are tax-free, no matter what your age,so long as the money is used for medical care. That triple-tax-free treatment is advantageous, but there are caveats28caveat防止誤解的說明； 知會備忘。.First, HSAs must be paired with a highdeductible health plan, which means you could incur higher health-care costs the years you’re contributing. Because contributions have an annual limit—$3,400 for a single person; $6,750 for a family; those 55 and older can add another $1,000—it’s best to get started early and leave the money to compound tax-free for as long as possible.

[25] Ultimately, the best way to deal with the uncertainty of health-care costs is fl exibility. “Figuring out the course of health care policy is tough,” McClanahan says. “We quit trying to predict the future, and instead build resiliency into our plans.” ■

[24]健康儲蓄賬戶通常被認為是退休前攢下醫(yī)療費用的一個絕佳辦法，因為只要賬戶里的錢用來付醫(yī)療費，無論開戶人多少歲，往賬戶里存錢、賺取利息和取款都無須繳稅。這種三重免稅待遇雖然有利，但也有一些限制條件。首先，建立健康儲蓄賬戶必須捆綁購買一種自付扣除金很高的健康保險，這意味著，在你繳存的這些年里可能要承擔更高的醫(yī)療費用。由于健康儲蓄賬戶對年存款額度有限制——個人為3400美元，家庭為6750美元，55歲及以上的老人可多存1000美元——因此存款越早越好，盡可能久地享受免稅復利。

[25]最后，應(yīng)對不確定醫(yī)療開銷的最佳方法是靈活應(yīng)變。麥克拉納漢稱：“醫(yī)療政策的走向難以揣測。我們不再試圖預測未來，而是讓自己的健康保險計劃更有彈性?！?□