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老年和残障健康保险，由美国联邦政府依据1965年的社会保障修正案建立，服务对象是65岁以上的老人或者符合一定条件的65岁以下的残疾人或晚期肾病患者。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受人关注； 引起注意。until they have a crisis,” says Heather Evans, a fi nancial advisor with Merrill Lynch3美林证券，世界最大的证券零售商和投资银行之一，总部位于美国纽约市。outside of Washington.“It can be a huge surprise cost—and your quality of life is going to depend on what you can afford.”

在美国，医疗可能是退休后最大的开销之一，其成本却难以估量——人们往往认为，老年和残障健康保险（以下称Medicare）要么什么都包，要么什么都不包，但这两种看法都不对。了解Medicare就像学习基础的性知识，除非亲身经历过，否则大多数人会根据奇闻异事和错误信息对其臆断，这就意味着可能会遇到一些令人不适的意外情况。

[2]华盛顿郊区的美林证券金融顾问希瑟·埃文斯称：“Medicare的承保范围远比通常想象的要窄。人们根本不了解，只有出现危机时才会意识到医疗的成本。该成本之大可能令人瞠目——一个人的生活质量将取决于可负担的那部分。”

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美国跨国金融服务公司。. About a third of that is for Medicare premiums5premium保险费。; the rest goes to co-payments, deductibles6deductible 自付扣除金，接受合乎条件的医疗服务时，在健康保险计划开始支付前由患者先行负担的自付额。, 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分为四大类：住院保险（Part A），即联邦政府对住院治疗或护理费用的医疗保险；补充性医疗保险（Part B），由职工选择投保，主要保障住院保险没有覆盖到的门诊项目；医保优势计划（Medicare Advantage，简称MA计划，Part C），经政府特许的保险公司为医保受益人设计的一些额外医疗服务保险； 处方药计划（Part D），政府补贴的药物福利计划，参加此计划的受益人支付额外的保险费，可以低价购买处方药。.

[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.

基本开支：Medicare

[3]富达投资称，即便那些对Medicare服务感到满意的退休人士，自65岁开始，（每对夫妻的）平均医疗开支也高达26万美元。其中约三分之一用于支付Medicare的保险费，其余款项用于支付共付额、自付扣除金以及药品和医疗费用。

[4]但尤其是生活富裕的退休人士可能发现，医疗保健的费用远超上文估测的26万美元。例如，年收入超过17万美元的夫妇，每月需为Medicare B部分（门诊和检查）和D部分（处方药）额外支付134至742美元不等。

[5] Medicare覆盖基本项目，没有理由不参保，但它不覆盖退休人士可能需要的所有项目，比如较新的药物治疗、最先进的医疗设备或者更具个性化的护理，也根本不包括长期护理。

[6] Ken Dychtwald, head of Age-Wave8一家专注于人口老龄化问题研究的美国公司。, 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二次诊疗，与原诊（primary diagnosis）相对应，指个人在某疾病已获得初次诊疗医生的诊断后，通过向权威机构/人士进行第二次诊断咨询，从而获得更为完善的诊断意见的做法。, 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 每年各家医疗保险公司都会综合考虑药品的疗效和价格来制定自己的报销目录。—can 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是一家专注于老龄化趋势研究的咨询公司，其总裁肯·戴奇沃迪把医疗服务比作航空旅行：“每个人都有座位。有的人买经济舱，虽然能坐，但是不太舒适，有的人则加钱买商务舱和更好的医疗服务。头等舱的乘客想要获得最好的治疗，享受二次诊疗和三次诊疗服务，希望随时能看医生。这种五星级医疗服务价格不菲。”

[7]退休人士应做好为一些主要项目自付更高费用的打算。

[8]药物和类似治疗。不同类型的Medicare处方药计划在承保药物种类及报销比例上差别很大。此外，药品清单，即药品报销目录，每年都可能更改，这让情况愈加复杂。退休人士还可能需要自付高达三分之一的专业治疗费用。如今，更多的患者服用生物制剂（源于活生物体）和专业药物，因为它们可以显著改善患者治疗质量，在癌症、多发性硬化症和丙型肝炎等领域尤其如此。但这会导致费用大幅提高。

[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侵袭性。of the surgery and patient-recovery time by using lasers,rather than a scalpel14scalpel解剖刀；手术刀。, 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〈医学〉移植。costing another $4,150.

[9]检查和物理治疗。Medicare对其承保的诊断检查有数量限制，并将物理治疗和言语病理学治疗的报销额度限定在每年1980美元，这一额度老年人很快便会用完。如果采取的措施并非医疗必须，Medicare不予报销。

[10] Medicare未承保服务。白内障手术是退休人士最常做的手术之一。现代医学通过激光而非手术刀来切除白内障，大大降低了手术造成的创伤，缩短了患者恢复时间。但Medicare仅报销手术刀手术的费用，而不报销激光手术的额外费用。选择激光手术，通常每只眼睛需另付1500美元。

[11]常规牙齿护理也会增加费用。Medicare不报销一般的牙齿护理费用，但如果患者需住院治疗，则予以报销。植一颗牙的费用可能高达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凯泽家庭基金会。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预防的。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]医疗管家服务和医疗顾问。2015年凯泽调查显示，全美有2%的医生根本不接受Medicare医保报销。其他报告还发现，在华盛顿和纽约等地区，这一数字可能更高，而这一问题在整个农村地区更为严重。

[13]对于不接受保险报销的医生，退休人士可与其商议价格，费用通常比Medicare高出15%到20%。为避免这一麻烦，部分退休人士会选择服务更为个性化的医疗管家或直接找初级保健医生。此类医生大多会限制其接诊人数，患者需缴纳会员费才能看医生，获得初级保健医生通常提供的体检、病访和预防性保健服务。此类诊所的吸引人之处在于治疗更为个性化，更易约诊且诊疗时间更长。

[14]会员费平均每月110美元，但有些诊所会员费可高达每年数千美元。虽然大部分不接受保险，但患者仍可递交文件，从Medicare中报销部分费用。有些诊所还提供基本的化验和诊断性检查，但大多数诊所不提供这些；这种情况下，Medicare会报销这些检查的费用。

[15]人生规划伙伴公司财务顾问卡罗琳·麦克拉纳汉曾当过医生，她说：“如果你很少看病或者身体相对健康，这可能是浪费钱。但如果你有疑难杂症，这倒是个好办法。”

[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 Partners18一家金融咨询公司，位于美国佛罗里达州。. “But if you have a complicated illness, it’s a good way to go.”

[16]Chronic conditions, including dementia19dementia痴呆症。. Chronic conditions are costly. Having five or more chronic conditions—like diabetes, cancer, heart disease, or Parkinson’s—raised the median20median中位数的。annual out-of-pocket expenses by 75%, according to Kaiser.

[17] Dementia is the black swan21black swan黑天鹅，指非常难以预测，且不寻常的事件。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规划。the types of services needed over time.

[16]痴呆症等慢性病。看慢性病价格昂贵。凯泽调查显示，患5种或5种以上慢性病（如糖尿病、癌症、心脏病或帕金森病）的患者，其年自付医疗费中位数增加了75%。

[17]痴呆症是医保计划中的“黑天鹅”，会大幅抬高医疗费用，主要是因为痴呆症需要时间更长的长期护理服务，而其他慢性病的平均护理时间为两到三年。

[18] Medicare可报销认知评估和护理规划服务费用，但不报销日常护理等一些成本最高的服务费用。痴呆症的持续时间可长达20年，因而特别需要护理管理人员为患者规划所需的服务类型。

[19]退休人士通常在确诊痴呆症前便需要帮助，例如需要人协助准备餐食、开车或跑腿。成人日托服务可提供安全环境下的社交互动，并让护理人员得到急需的歇息机会，但这通常不在Medicare的承保范围内。据最新的展维护理成本调查显示，全美聘请家庭护工的月平均成本约为3800美元，而成人日托服务的月平均成本为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展维金融集团，长期护理保险领域的领军企业。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赡养院；安养照护。,with the national average at $180,000 a year, according to HealthView25= HealthView Services一家提供退休医疗成本数据的公司，位于马萨诸塞州。. 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一次总付的钱款。. 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]长期护理。长期护理或为Medicare未承保项目中费用最高的服务，因此是否将其纳入保险项目是争议最大的财务决策之一。

[21]各地长期护理的成本差异巨大。一间养老院私人看护房的年中位价格在纽约长岛为155125美元，在旧金山为182318美元，在佛罗里达州那不勒斯市则近126000美元，远高于达拉斯地区的74000美元。热门养老院的费用更高。

[22]大多数人更青睐家庭护理。但HealthView称，家庭护理的费用可高达养老院的4倍；全美家庭护理的年平均成本为18万美元，这还不包括改造房屋（如加宽门道和坡道以方便轮椅通过，或在浴室安装扶手）和请人维护房屋所需的费用。

如何支付医疗费用

[23]所有费用加到一起数额巨大，但并非一次性付款。及早规划可让费用更易消化。HealthView的创始人罗恩·马斯特罗乔瓦尼称，假设一对55岁的健康夫妇将于65岁退休，那么现在需储备199000美元，或者在未来10年里每年存25507美元（假设年收益率为6%），将来用以支付医疗费用。

[24] Health savings accounts are often championed27champion支持，拥护。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防止误解的说明； 知会备忘。.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]健康储蓄账户通常被认为是退休前攒下医疗费用的一个绝佳办法，因为只要账户里的钱用来付医疗费，无论开户人多少岁，往账户里存钱、赚取利息和取款都无须缴税。这种三重免税待遇虽然有利，但也有一些限制条件。首先，建立健康储蓄账户必须捆绑购买一种自付扣除金很高的健康保险，这意味着，在你缴存的这些年里可能要承担更高的医疗费用。由于健康储蓄账户对年存款额度有限制——个人为3400美元，家庭为6750美元，55岁及以上的老人可多存1000美元——因此存款越早越好，尽可能久地享受免税复利。

[25]最后，应对不确定医疗开销的最佳方法是灵活应变。麦克拉纳汉称：“医疗政策的走向难以揣测。我们不再试图预测未来，而是让自己的健康保险计划更有弹性。” □