Author Topic: How to plan for possible nursing home/long term care expenses during FIRE?  (Read 2893 times)

Toronto.poutine

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How do you financially prepare for unexpected and expensive contingencies, for example possibly needing costly long term care/nursing home care in old age? I am afraid we could quickly blow through our nest egg if one or both of us needed this. Iíve been reading a little about long term care insurance but it doesnít seem very popular and also seems expensive.

Rob_bob

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I have heard it said that if you can't afford LTC insurance then you can't afford to not have it.  I have heard there are some type of life ins. policies that have a LTC option but I'm not knowledgeable of such things.

Being single and no real heirs I will self fund as long as I can. 

wenchsenior

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There's no good answer to this...we're trying to play the statistical odds that nursing home stays typically average only 1-2 years, but that's such a crapshoot (all three of my g-parents who survived to old age were in full time care much longer than that, and my father who is actively trying to kill himself right now and requires 3/4 time care, is still alive and burning through his fairly substantial nest egg at a rate of 13K/month, so hopefully he doesn't outlive it).

We bought LTC insurance worth about 300K for my husband, but I don't qualify for that type of insurance so am planning on continuing to work until I have the equivalent saved up. Beyond that, we'll just have to spend down assets like the vast majority do until we're broke and can qualify for Medicaid. We're kicking around the idea of trying to get into a continuing care community, but honestly I doubt my husband would agree to it until he was too impaired to be accepted. So if he dies first and I'm still in a state where they'd accept me and I could afford it, I'd consider it then.

But yeah, it's tough.

LightStache

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You can never reduce your probability of failure to zero, even with insurance. So you just have to make a reasonable plan considering the risks you're willing to take.

For me I look at the cost in my HCOL area, which was $135K/yr for a private room in 2021 dollars. Assuming markets continue to perform on historical averages, I should be able to cover that expense indefinitely (adjusted for inflation of course) by the time I'm 70.

If I were to need LTC for 20 years, from 45-65 y/o, that would probably wipe me out financially. But then again I'd much rather die than be in a nursing home that long, so it's a risk I'm willing to accept in exchange for FIRE'ing sooner. Hopefully FIRE'ing sooner will reduce my probability of ending up in long term care so the risk will be a wash.

reeshau

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How do you financially prepare for unexpected and expensive contingencies,

Just to stop you right there:  this is what insurance is for.  To take a small, known cost, and address a cost you would not be able to (comfortably) afford yourself, by pooling the risk.  Whether loss of house, health, car, etc.

The old saw was that you needed LTC if you had $2.5M to $5M in assets.  Less than that, and LTC could eat up your whole nest egg, leaving you on Medicaid anyway.  More than that, and you could "self insure." (afford to pay out of pocket)

But costs have gone up a lot: cost of care has, and so therefore has the insurance.  This is both a matter of the "unit cost" of care, and the fact that many people are living longer.  In fact, there was some controversy a few years ago about policies that only paid up until 100 years old, and a large number of people hitting that limit.

Other than that, many of the usual financial suspects have articles about getting it.  Most agree the sweet spot is to consider it in your 50's, so that you are healthy enough to be approved, but young enough not to cost a fortune.  (OK, a larger fortune)  Of course, FI folks will want to work some number into their plans, but that's research for planning purposes at this time.  Getting a plan when you are under 50 commits you to the annual cost increases, whatever they are.  And you won't be reimbursed for your sunk cost, if you decide to cancel later because it wasn't worth it,

https://www.investopedia.com/articles/personal-finance/052014/whats-best-time-get-longterm-care-insurance.asp

Catbert

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What's your paid off house worth?  If push came to shove, I'd sell it or if *healthy * wanted to stay take out a reverse mortgage.  Generally if you're going into assisted living bc of old age you won't live too long (single digits rather than decades) so 4% rule doesn't apply.

reeshau

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Generally if you're going into assisted living bc of old age you won't live too long (single digits rather than decades) so 4% rule doesn't apply.

This is true, but I had a grandma who was in assisted living for almost 20 years.  My stepfather has been in one after a bad motorcycle accident. (TBI)  He may well be in one for four decades.

Shit happens.  You still plan for what's likely, and what you can handle.  And through it all, everyone here will do better than the average population.  If something worse than average happens, your old age won't be what you imagined, but you will likely survive, as these services operate in support of that average population.

BeanCounter

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We plan to self insure. I'm honestly not sure LTC insurance is worth it anymore. My mother had one of the better policies, and had paid a lot of premiums over the years. But when she became ill enough to need it, the amount of paper work and days we had to self pay before the policy kicked rendered the policy nearly useless. She became eligible for hospice and then died before the policy kicked in. She got nothing for her thousands of dollars worth of premiums (maybe $35k IRC).
She might be the extreme case because she had cancer, but I've seen similar things with my grandparents. Because they were in their late 80s their nursing home stays were relatively short before they died.
There maybe a few exceptions, like dementia. Anyone with Alzheimer's seems to have very long nursing home LTC needs.
Anyway as a high NW couple, I think we are going to roll the dice and self pay for anything that comes up. In the extreme case of disease it will just mean less inheritance for our heirs.

simonsez

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There's no good answer to this...we're trying to play the statistical odds that nursing home stays typically average only 1-2 years, but that's such a crapshoot (all three of my g-parents who survived to old age were in full time care much longer than that, and my father who is actively trying to kill himself right now and requires 3/4 time care, is still alive and burning through his fairly substantial nest egg at a rate of 13K/month, so hopefully he doesn't outlive it).
@wenchsenior Sorry if this comes off as insensitive and naive but I'm genuinely curious.  The part at the end of the parentheses (the bolded) sounds like you would be okay with your father passing away before poverty sets in.  But the earlier line (the italicized) sounds like if your father had his wish, he wouldn't outlive it and thus would not be outliving his nest egg.

Does the facility he stays at not view right-to-die as a valid choice for someone to make?  Suicide/right-to-die can be tricky and nuance is important but it is a human right and even if it's one I do or do not agree with.  I.e. I can be against something for me personally but that doesn't mean I actively pursue avenues to strip away the freedom from someone else who thought differently.  I don't know much about LTC facilities and I get that they wouldn't be (or at least, most would not be, I'm not aware of any laws/regulations) actively assisting, but it just strikes me as a freedom being taken away (again, devil is in the details - is mental illness involved, any pain or suffering, affairs set in order, etc.). 

Still, either way what happens at the end of life whether it be the actual end or a LTC facility for years, it's not fun.  My extended families are largely within the same geographic area and no one has been in a LTC facility since my great grandfather in the 90s for a spell after his wife passed.  There has been some palliative care at home for some loved ones dealing with advanced stages of the big C but no one permanently in a facility.  This is partially by design (i.e. moving away for a career/relationship for a time but most who leave do return and most never move outside the metro area to begin with) to have a robust kith and kin network to check in on people, socialize, help out here and there, etc.  So this area is pretty foreign to me but I want to be prepared and one day I hope to effectively balance proper care along with the wishes of a loved one.

If this isn't appropriate, please let me know and I can edit to delete the above and only leave the sentences below.

Sounds like self-insuring is the play for those that didn't retire too lean.  Perhaps safety really is an expensive illusion.

wenchsenior

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There's no good answer to this...we're trying to play the statistical odds that nursing home stays typically average only 1-2 years, but that's such a crapshoot (all three of my g-parents who survived to old age were in full time care much longer than that, and my father who is actively trying to kill himself right now and requires 3/4 time care, is still alive and burning through his fairly substantial nest egg at a rate of 13K/month, so hopefully he doesn't outlive it).
@wenchsenior Sorry if this comes off as insensitive and naive but I'm genuinely curious.  The part at the end of the parentheses (the bolded) sounds like you would be okay with your father passing away before poverty sets in.  But the earlier line (the italicized) sounds like if your father had his wish, he wouldn't outlive it and thus would not be outliving his nest egg.

Does the facility he stays at not view right-to-die as a valid choice for someone to make?  Suicide/right-to-die can be tricky and nuance is important but it is a human right and even if it's one I do or do not agree with.  I.e. I can be against something for me personally but that doesn't mean I actively pursue avenues to strip away the freedom from someone else who thought differently.  I don't know much about LTC facilities and I get that they wouldn't be (or at least, most would not be, I'm not aware of any laws/regulations) actively assisting, but it just strikes me as a freedom being taken away (again, devil is in the details - is mental illness involved, any pain or suffering, affairs set in order, etc.). 

Still, either way what happens at the end of life whether it be the actual end or a LTC facility for years, it's not fun.  My extended families are largely within the same geographic area and no one has been in a LTC facility since my great grandfather in the 90s for a spell after his wife passed.  There has been some palliative care at home for some loved ones dealing with advanced stages of the big C but no one permanently in a facility.  This is partially by design (i.e. moving away for a career/relationship for a time but most who leave do return and most never move outside the metro area to begin with) to have a robust kith and kin network to check in on people, socialize, help out here and there, etc.  So this area is pretty foreign to me but I want to be prepared and one day I hope to effectively balance proper care along with the wishes of a loved one.

If this isn't appropriate, please let me know and I can edit to delete the above and only leave the sentences below.

Sounds like self-insuring is the play for those that didn't retire too lean.  Perhaps safety really is an expensive illusion.

No it's fine. My father is a bit of a particular case and I'm not making any judgements about him when I describe him, simply stating facts. He's a miserable addict; he wants to die, but not enough to actually actively kill himself (although he has the means to do). He is choosing to drink himself to death, which is his right, of course. He's not in a facility, which he is 100% opposed to ever going to (and thus we desperately hope he won't outlive his money and leave himself no option), but is being cared for 3/4er time at home by hired caregivers. Even if he were interested in assisted suicide, it is not legal in the state he's in (nor in most states in the U.S. AFAIK).

Our concern is not whether he leaves an estate, it's more that the one remaining thing in his life that he still can take pride in is the land and money he's accumulated to pass on to us, and if he lives more than another year or two, he will be forced to sell it to help fund care. If that were to happen, I would hope to hell his mental state would be such that he wouldn't truly understand that it were happening. He went through his life simultaneously convinced (via a lot of magical thinking) that he 1) would never live to be old but would die around 50 of a quick heart attack; 2) didn't need life or LTC insurance (see number 1); 3) would always be able to pay for his own care no matter how expensive it was; and 4) that he'd always have someone available to help him out. Unfortunately, 1 and 2 combined with his addiction and his systematic alienation from everyone in his life took care of 3 and 4. 

His situation is not that illustrative of most peoples' situation, other than ...quite a few people need care a lot longer than they want to believe they will. This has certainly been true in my family, unfortunately.
« Last Edit: April 26, 2022, 12:18:16 PM by wenchsenior »

LightStache

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There's no good answer to this...we're trying to play the statistical odds that nursing home stays typically average only 1-2 years, but that's such a crapshoot (all three of my g-parents who survived to old age were in full time care much longer than that, and my father who is actively trying to kill himself right now and requires 3/4 time care, is still alive and burning through his fairly substantial nest egg at a rate of 13K/month, so hopefully he doesn't outlive it).
@wenchsenior Sorry if this comes off as insensitive and naive but I'm genuinely curious.  The part at the end of the parentheses (the bolded) sounds like you would be okay with your father passing away before poverty sets in.  But the earlier line (the italicized) sounds like if your father had his wish, he wouldn't outlive it and thus would not be outliving his nest egg.

Does the facility he stays at not view right-to-die as a valid choice for someone to make?  Suicide/right-to-die can be tricky and nuance is important but it is a human right and even if it's one I do or do not agree with.  I.e. I can be against something for me personally but that doesn't mean I actively pursue avenues to strip away the freedom from someone else who thought differently.  I don't know much about LTC facilities and I get that they wouldn't be (or at least, most would not be, I'm not aware of any laws/regulations) actively assisting, but it just strikes me as a freedom being taken away (again, devil is in the details - is mental illness involved, any pain or suffering, affairs set in order, etc.). 

Still, either way what happens at the end of life whether it be the actual end or a LTC facility for years, it's not fun.  My extended families are largely within the same geographic area and no one has been in a LTC facility since my great grandfather in the 90s for a spell after his wife passed.  There has been some palliative care at home for some loved ones dealing with advanced stages of the big C but no one permanently in a facility.  This is partially by design (i.e. moving away for a career/relationship for a time but most who leave do return and most never move outside the metro area to begin with) to have a robust kith and kin network to check in on people, socialize, help out here and there, etc.  So this area is pretty foreign to me but I want to be prepared and one day I hope to effectively balance proper care along with the wishes of a loved one.

If this isn't appropriate, please let me know and I can edit to delete the above and only leave the sentences below.

Sounds like self-insuring is the play for those that didn't retire too lean.  Perhaps safety really is an expensive illusion.

No it's fine. My father is a bit of a particular case and I'm not making any judgements about him when I describe him, simply stating facts. He's a miserable addict; he wants to die, but not enough to actually actively kill himself (although he has the means to do). He is choosing to drink himself to death, which is his right, of course. He's not in a facility, which he is 100% opposed to ever going to (and thus we desperately hope he won't outlive his money and leave himself no option), but is being cared for 3/4er time at home by hired caregivers. Even if he were interested in assisted suicide, it is not legal in the state he's in (nor in most states in the U.S. AFAIK).

Our concern is not whether he leaves an estate, it's more that the one remaining thing in his life that he still can take pride in is the land and money he's accumulated to pass on to us, and if he lives more than another year or two, he will be forced to sell it to help fund care. If that were to happen, I would hope to hell his mental state would be such that he wouldn't truly understand that it were happening. He went through his life simultaneously convinced (via a lot of magical thinking) that he 1) would never live to be old but would die around 50 of a quick heart attack; 2) didn't need life or LTC insurance (see number 1); 3) would always be able to pay for his own care no matter how expensive it was; and 4) that he'd always have someone available to help him out. Unfortunately, 1 and 2 combined with his addiction and his systematic alienation from everyone in his life took care of 3 and 4. 

His situation is not that illustrative of most peoples' situation, other than ...quite a few people need care a lot longer than they want to believe they will. This has certainly been true in my family, unfortunately.

Dang @wenchsenior thanks for sharing. Makes me glad I cut back on the sauce, but there are still many decades ahead.

Dicey

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We are 100% self funding. We've seen first hand what a rip-off these policies can be. Even if someone, somewhere has a decent policy, they still only cover a small portion of your actual costs.

It's a yet another benefit of choosing a mustachian lifestyle. We spend less than our investments earn, thanks to the miracle of compound interest.

Abe

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My plan is having long term care insurance with the idea of engaging in physician-assisted suicide before Iím dependent on others for daily living.
If I develop a neurodegenerative condition, thatíll preclude me taking that option when I need it (I.e. Alzheimerís or Parkinsonís dementias). In that case itís a bit tricky, but a living will should help. If I canít figure out how to eat, then itís time to go.

 If itís plain old canít take care of myself because my bodyís too frail, I would probably just go with PAS when Iíve done all I planned to do on my bucket list. No plan on going to assisted living unless itís for convenience of not having to take care of a house, bills, etc. Keep in mind there are different gradations of care needed, and LTC insurance will pay for cases even where one isnít completely disabled. For me, anything other than the minimal care would be a sign to pull the plug before I deteriorate.

FWIW almost all my friends and family (including my wife) who are also physicians have the same plan. Youíre not going to find any of us in high-level assisted living.
« Last Edit: April 27, 2022, 08:12:25 PM by Abe »

Cassie

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A few people I know have the policies and now that they are in their 70ís the cost keeps increasing.

gooki

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I just assume 40+ years of growth above the 4% safe withdrawal rate will take care of it.

herbgeek

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We are self funding.  My dad lived until 90, in his own house.  His parents were 87 and 93 when they died, also fully in control of their functions at home.  So I have some reasonable genes on that side.   My mom has vascular dementia (from multiple strokes) and has been in assisted living for the last year.  Mom never took care of her health, and ignored seeing the doctor after strokes because she could still walk.  Her mother died from stroke complications in her 70s, and she has a brother who also has vascular dementia due to strokes.  I'm doing what I can to address that part of my DNA by an active exercise program all through my adult life.  Yes, I know its not fool proof and bad stuff could still happen, but I am doing the things under my control through a diet with lots of veggies, exercise and stress reduction and continual learning to keep the brain engaged.  If/when my spouse dies, I might look for a continuing care community or at least an over 55 community, so that someone would likely notice if I didn't get my mail at my usual time or the like.

Sibley

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My plan is having long term care insurance with the idea of engaging in physician-assisted suicide before Iím dependent on others for daily living.
If I develop a neurodegenerative condition, thatíll preclude me taking that option when I need it (I.e. Alzheimerís or Parkinsonís dementias). In that case itís a bit tricky, but a living will should help. If I canít figure out how to eat, then itís time to go.

 If itís plain old canít take care of myself because my bodyís too frail, I would probably just go with PAS when Iíve done all I planned to do on my bucket list. No plan on going to assisted living unless itís for convenience of not having to take care of a house, bills, etc. Keep in mind there are different gradations of care needed, and LTC insurance will pay for cases even where one isnít completely disabled. For me, anything other than the minimal care would be a sign to pull the plug before I deteriorate.

FWIW almost all my friends and family (including my wife) who are also physicians have the same plan. Youíre not going to find any of us in high-level assisted living.

Great plan.... until its illegal, or you get to that point and don't want to die. Emotions are not rational. Just keep that in mind.

wenchsenior

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My plan is having long term care insurance with the idea of engaging in physician-assisted suicide before Iím dependent on others for daily living.
If I develop a neurodegenerative condition, thatíll preclude me taking that option when I need it (I.e. Alzheimerís or Parkinsonís dementias). In that case itís a bit tricky, but a living will should help. If I canít figure out how to eat, then itís time to go.

 If itís plain old canít take care of myself because my bodyís too frail, I would probably just go with PAS when Iíve done all I planned to do on my bucket list. No plan on going to assisted living unless itís for convenience of not having to take care of a house, bills, etc. Keep in mind there are different gradations of care needed, and LTC insurance will pay for cases even where one isnít completely disabled. For me, anything other than the minimal care would be a sign to pull the plug before I deteriorate.

FWIW almost all my friends and family (including my wife) who are also physicians have the same plan. Youíre not going to find any of us in high-level assisted living.

Great plan.... until its illegal, or you get to that point and don't want to die. Emotions are not rational. Just keep that in mind.

Yeah, it's illegal in all but 10? states right now; and with the coming massive sweep of Congress/State legislatures by the GOP, it isn't likely to get more legal.  My dad (discussed above) always ALWAYS for years and years used to tell us that he wanted us to transport him to one of the states where it is legal to do it when he could no longer function without assistance. Well, we reached that point about 6 months ago, and he freely admits he's totally miserable and  'wants to die, but just not right now'. He also wants nothing to do with that plan of seeking out a state with assisted suicide, despite that being his longstanding plan leading up to the actual crunch point.

The human will to eke out another week, day, or minute, even in absolutely miserable circumstances, does not usually bow to reason. And it's often a narrow window of time that the person has to actually make the decision and carry it out. I mean, the time for my Dad to decide to take action maybe lasted a month or two. Since then, he's passed the point where he could reasonably make that decision for himself in terms of mental competence, nor could he physically handle the travel to a state where PAS is legal.  It's the most common thing to hear people SAY they want to do it and dismiss long term care b/c they are convinced they will do it, but it's actually very uncommon for people to ACTUALLY do it. Thus, I don't think that's a very realistic plan for most people (doctors might the exception).

Catbert

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My plan is having long term care insurance with the idea of engaging in physician-assisted suicide before Iím dependent on others for daily living.
If I develop a neurodegenerative condition, thatíll preclude me taking that option when I need it (I.e. Alzheimerís or Parkinsonís dementias). In that case itís a bit tricky, but a living will should help. If I canít figure out how to eat, then itís time to go.

 If itís plain old canít take care of myself because my bodyís too frail, I would probably just go with PAS when Iíve done all I planned to do on my bucket list. No plan on going to assisted living unless itís for convenience of not having to take care of a house, bills, etc. Keep in mind there are different gradations of care needed, and LTC insurance will pay for cases even where one isnít completely disabled. For me, anything other than the minimal care would be a sign to pull the plug before I deteriorate.

FWIW almost all my friends and family (including my wife) who are also physicians have the same plan. Youíre not going to find any of us in high-level assisted living.

Does anyone remember the Julianne Moore movie "Still Alice"?  She played a college professor with early onset Alzheimer's.  She had a plan to kill herself when she could no longer remember her daughters' names.  Unfortunately by then she could no longer follow the directions she had written down (e.g., go upstairs, open the top dresser drawer, etc.)  Easy to say you'd kill yourself in those circumstances. 

cannotWAIT

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Every PAS scheme I know about in the US requires you to have a terminal illness with a prognosis of no more than 6 months to live. They won't help you die just because you want to.

mozar

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I did a lot of research on suicide when I was planning to do so. You have to over ride your natural self preservation instincts. I realized I was too much of a wuss to do that so I would have to figure out how to cope with being alive.
If you remember/ and have the ability to feed your self you can live on your own for a long time. Once you canít feed yourself it doesnít take that long to die of starvation. I doubt Iíll be able to afford fancy assisted care.And At 40 I already have a lot of medical issues. I canít imagine a Medicaid paid  assistance facility that will feed me a gluten free vegan diet. My aunt who lives in assisted living facility (schizophrenic) is always complaining about the food.
So Iím going to focus on living in my house until I die. My mothers mother paid 40k a year (3ish years) for someone to cook for her and bathe her every day. Thatís a lot cheaper than 125k a year for assisted living.
And maybe I am full of myself but I think I am less stubborn than my parents and grandparents. My grandmother refused to clean up the puddle of water in her garage so she slipped in it and broke her hip then refused to do the strength training to get better. I plan to be less ridiculous when Iím old.

Abe

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Every PAS scheme I know about in the US requires you to have a terminal illness with a prognosis of no more than 6 months to live. They won't help you die just because you want to.

Thatís correct. Someone with dementia severe enough that they canít feed themselves meets that criteria, but as others point out cannot necessarily advocate for themselves. Laws in other countries are not quite as stringent and take this scenario into account. Also agree for most people this would be difficult to carry out, especially those less exposed to death and end-of-life planning as part of their daily work.

 I would not recommend this strategy for most people, but it is a valid strategy in many cases. Neurodegenerative disorders is one of the difficult gaps, though.

BeanCounter

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I once worked at a very old, old "blue blood" country club. One of the older ladies threw a gigantic birthday party for herself with all her friends and family. A few weeks later she was found in her big, 100 year old estate, in the bathtub with classical music on and an empty bottle of booze and an empty bottle of pills. She left a note to her family. Which said something to the effect that she had enjoyed a long and wonderful life, she loved each one of them dearly, but it was only downhill from age 90.
I often think of her. She wasn't wrong.

getsorted

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How do you financially prepare for unexpected and expensive contingencies, for example possibly needing costly long term care/nursing home care in old age? I am afraid we could quickly blow through our nest egg if one or both of us needed this. Iíve been reading a little about long term care insurance but it doesnít seem very popular and also seems expensive.

There's just not a good answer to this unless you are able to accumulate enough wealth to generate $7,000-$15,000 in monthly income. Personally, I would be spending down my assets until I qualified for Medicaid. If Medicaid-compliant annuities still exist at that point, I would probably purchase one so that I could cover additional small expenses.

Beyond that, it's just - keep strength training into old age, keep engaged and active with other people, eat well, and be extremely nice to my child. Life is going to end somehow or other.

Kris

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Like others here I'm on the Smith and Wesson plan (if I am able). Not married (divorced)  and don't have kids or really any family or strong relationships (younger BF doesn't count) so that part isn't an issue. Until then my plan is to first set myself up in an easy to care for condo or apt near whatever it is I need. If I need a caregiver or need to go i to a nursing home I will self fund that as long as my money lasts then probably have to go on Medicaid if I outlive my assets. After that - well hopefully there won't be an "after that". If terminal the mr. S & W can help..

I could never use Mr. S&W, personally (I know myself well enough to know I could never pull the trigger) but I am a member of the Hemlock Society, and I will be thinking and planning more as I get older about ways to remove myself if need be.

That said, I am aware of what others have said in this thread regarding intentions vs. reality.

Kris

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Like others here I'm on the Smith and Wesson plan (if I am able). Not married (divorced)  and don't have kids or really any family or strong relationships (younger BF doesn't count) so that part isn't an issue. Until then my plan is to first set myself up in an easy to care for condo or apt near whatever it is I need. If I need a caregiver or need to go i to a nursing home I will self fund that as long as my money lasts then probably have to go on Medicaid if I outlive my assets. After that - well hopefully there won't be an "after that". If terminal the mr. S & W can help..

I could never use Mr. S&W, personally (I know myself well enough to know I could never pull the trigger) but I am a member of the Hemlock Society, and I will be thinking and planning more as I get older about ways to remove myself if need be.

That said, I am aware of what others have said in this thread regarding intentions vs. reality.
Yeah I don't know if I can either  but something short and sweet if possible. I also hope I am both mentally and physically able to figuratively pull the trigger as you can't really depend on assisted suicide in some cases.

I saw a documentary a couple of years ago about this - people with severe terminal illnesses who planned to off themselves once "ready" in one form or another. Almost no one could do it. As mentioned above they clung to life to the bitter end or until unable to do it physically or mentally. Only one women did it with PAS and she was only allowed to do it because she was still able to self-administer her own lethal dose. It was all pretty heart wrenching seeing what people with end-stage diseases had to go thru. So I know that while I (all of us) say we'll pull the trigger while we can, I know it's going to be unlikely for many  emotionally to end it.

My biggest fear though is not being about being  brave(?) enough but lacking the opportunity or ability. Or,  as a person without kids or younger relatives (younger sister but only by a few years),  I won't have anyone advocate for me. I do have a living will stating what I want and my Dr. has a copy, but lots of things can mess up your own choices. Or you get Dementia and no one realizes it and you give away all your assets and are found wandering the streets nekkid in search of our Alien Overlords.  Next thing you know you're "locked up" in the old folks mental ward of the nursing home tied to a bed for a decade or 2.

Yeah, this is kind of the seedy underbelly of modern medicine. We're a lot better at keeping people alive and so the diseases and accidents that used to take people out when they got older aren't as fatal anymore. So now we get to stare down the possibility of suffering for years in a body that we probably should have let give up the ghost a while ago. It's really a sad situation.