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How to weigh Roth vs. traditional 401(k) for high earners in medicine

For Roth vs. traditional 401(k) for high earners, Annex Wealth Management compares the tax deduction today with the future tax on income draws, then tests the choice against retirement spending. On a hypothetical $24,500 contribution, a 35% assumed current tax rate creates an $8,575 tax difference; at an assumed 25% future rate, a $24,500 traditional income draw creates $6,125 of tax before growth and other income.

Annex Wealth Management wrote this for physicians and dentists with high income, often after a late start on saving and with student loans still open. The number that frames everything is the gap between your rate today and your rate on future income draws. Below you'll find the account rules, a five-year break-even table, the questions to put to your plan, and the timing errors that cost real dollars.

What does Roth versus traditional 401(k) actually change?

A traditional 401(k) contribution lowers your taxable income this year, and the money you draw later is generally taxed as ordinary income. A Roth contribution uses income you've already paid tax on, and qualified distributions later are generally tax-free. The choice moves the tax bill from one decade to another.

Reena (hypothetical) is 38, an anesthesiologist employed by a hospital and married to a public school teacher. They have two kids under six. She carries about $310,000 in federal loans, has $520,000 saved across a 403(b) and a 457(b), still holds a residency-era rollover IRA, and has four years left toward PSLF. Her plans aren't 401(k)s, but the Roth and traditional rules work the same way.

Her cash flow decides the question more than any brochure does. With $310,000 in loans and two small children, a deduction that frees cash this year can matter more than tax-free money decades from now. At Annex Wealth Management, the monthly spending plan comes first and the portfolio exists to fund it, so the tax choice is judged by what it does to that budget.

Ask the plan what it can really do

Before Reena touches her payroll percentage, she asks HR or the recordkeeper (the company that keeps the plan's account records) a short list of questions. Put them in an email so there's a record.

Some answers should slow her down. A vague reply about tax treatment is one. A statement with no source-account labels is another. So is a recordkeeper that can't show Roth and traditional balances on separate lines. Any of those means pause, and leave the election alone for now.

Most plans put the match in the traditional bucket. That surprises people who go all-in on Roth and then find a pre-tax balance growing right beside it.

  • Roth option offered in the plan
  • Employer match goes to traditional
  • Roth catch-up handling and start date
  • Separate Roth and traditional balances shown

How large is the tax difference in a back-of-the-envelope test?

Multiply the contribution by your tax rate. A $24,500 traditional contribution at an assumed 35% rate avoids $8,575 of tax this year. The same $24,500 drawn later at an assumed 25% rate costs $6,125. The gap is $2,450 before growth, which is why the next deduction deserves a test.

Here are the steps. The IRS limit for 2026 on employee deferrals in 401(k), 403(b) and governmental 457 plans is $24,500. Then $24,500 × 35% = $8,575 of assumed tax avoided now. Then $24,500 × 25% = $6,125 of assumed tax on the same dollars later. Finally $8,575 − $6,125 = $2,450 in favor of the deduction.

This is not a forecast. The gap moves with growth, future spending, filing status, deductions, state tax, and whether you invest the tax saving or spend it. If the $8,575 goes to a vacation, the deduction bought nothing. And investments can lose value, so the invested saving may end up worth less than you put in.

The test can't predict tax law or your exact retirement bracket. It also doesn't settle whether a rollover IRA, PSLF, the employer match or your state's rules change the answer.

The five-year move that looked smart

Reena earns enough that we assume a 35% marginal rate today, for illustration. Roth looks smart because future income draws would avoid tax. So she directs $24,500 to Roth for five years. Each year she pays $24,500 × 35% = $8,575 of assumed tax, which is $42,875 over five years. That's about $715 less in take-home cash each month, in a budget that already carries loan payments and child care.

Later, equal $24,500 traditional income draws at an assumed 25% would cost $24,500 × 25% = $6,125 a year, or $30,625 over five years. The difference is $42,875 − $30,625 = $12,250 before growth.

What does each year of the Roth choice cost against the future tax it avoids? The table keeps a running score.

By Year 5 the running cost sits $12,250 above the running benefit. Choosing Roth for five $24,500 contributions because future tax law feels uncertain costs $42,875 of assumed current tax against $30,625 of comparable future tax. Careful people make this move because 'tax-free' sounds safe.

The fix is partial. Reena can't relabel past Roth contributions. She can point her next payroll election at traditional and invest or set aside the tax difference, if cash flow permits. Changing the next contribution doesn't erase the earlier cost. Annex Wealth Management would check what the change does to her monthly take-home pay before she signs the form.

Decision rule: compare the rate on the next traditional deduction with the rate likely on those same dollars as income draws. If today's rate is clearly higher and you can invest the savings, traditional deserves the first test.

Hypothetical $24,500 annual contribution, 35% assumed current tax rate, 25% assumed future tax rate, no growth or state tax
YearRunning costRunning benefit
Year 1$8,575 tax now$6,125 future tax avoided
Year 2$17,150 tax now$12,250 future tax avoided
Year 3$25,725 tax now$18,375 future tax avoided
Year 4$34,300 tax now$24,500 future tax avoided
Year 5$42,875 tax now$30,625 future tax avoided

When does the tax break usually deserve priority?

The deduction deserves priority when your tax rate today is clearly higher than the rate you expect on those dollars later. A physician at an assumed 35% now who expects 25% on income draws should test traditional first. If retirement income stays high, or this year's income is unusually low, Roth earns a stronger case.

Take the employer match before either choice. Skipping a match is a separate error, and usually a bigger one than picking the less favorable tax bucket. Say a hospital matches 4% of $200,000 in pay: that's $8,000 each year left on the table.

Roth makes more sense in two spots. One is a big pension plus rental income in retirement. The other is a low-income year now, such as a sabbatical or a part-time stretch around a practice sale. Annex Wealth Management advisors run both rates against the spending plan before picking a side.

Check whether your plan applies the Roth catch-up rule

Newer plan rules make Roth treatment matter more for catch-up contributions. For 2026, the IRS says a worker whose prior-year FICA wages exceeded $150,000 must make the catch-up contribution as Roth, when the plan applies that requirement. The catch-up is $8,000 at age 50 and over, and $11,250 at ages 60 to 63. Reena is 38, so this lands in twelve years. If you've set payroll elections before, ask whether your plan has adopted the rule and whether it uses prior-year FICA wages, not this year's salary.

How do marriage, balance and retirement age move the answer?

Each factor changes the tax rate on your future income draws. A teacher's pension adds taxable income to a married couple's retirement, a large balance can force bigger required distributions, and an early retirement can create low-income years. Any of them can shrink or erase the gap between today's deduction and tomorrow's tax.

A single high earner with one income and no pension often faces a lower retirement bracket, so traditional wins more often. A married couple with a teacher pension has a floor of taxable income before the first draw, which pushes the other dollars higher.

Balance size matters too. A small balance with decades to grow can end up large, and a large balance faces required minimum distributions (RMDs) at age 73, or age 75 for anyone born in 1960 or later. Bigger RMDs mean bigger taxable income whether you want it or not.

Retire early and you may get low-income years that are good for Roth conversions. Retire late and a new Roth choice has little time to compound before the income draws begin.

Which timing errors deserve a dollar price?

Three timing errors cost real money: choosing Roth before capturing the employer match, waiting for the final payroll of the year to change the percentage, and ignoring the rollover IRA and PSLF cash flow. Each can shrink usable cash or close a tax opportunity you can't reopen.

The match error is easy to price. Skip a 4% match on $200,000 and you lose $8,000 that year. The last-payroll error is a cash squeeze: $24,500 over 24 paychecks is about $1,021 each, but crammed into two it's $12,250 each, and many plans cap or reject that.

The third error is context. Reena's rollover IRA affects later conversions, and her PSLF years make every dollar of monthly cash count. Check these four items before changing the percentage.

  • 403(b) and 457(b) election deadline
  • Year-end statement, by source
  • Last year's 1099-R, if any
  • Plan's payroll cutoff date

Bring Reena's paperwork to Annex Wealth Management

Reena can begin with her paystub, plan summary, year-end statements, rollover IRA statement, loan servicer details and PSLF paperwork. Annex Wealth Management compares the tax choice with the couple's spending plan and the loan decision, with fees set out in a written agreement before any work starts. Send a note through the request form, from anywhere in the country.

Questions about Roth vs. traditional 401(k) for high earners

Could my spouse's future pension or school income change the Roth decision?
Yes. A teacher's pension adds taxable income to the couple's retirement, which can push your traditional income draws into a higher bracket than you expected. If the pension is large, a Roth slice gives you tax-free dollars to draw in years when you want to stay in a lower bracket. Compare combined income, not yours alone.
What should I look for on the plan's annual statement before choosing Roth contributions?
Look for separate lines showing Roth and traditional balances, labels showing which source holds employer contributions, and your year's total deferrals against the IRS limit of $24,500 for 2026. If the statement lumps everything together, ask the recordkeeper for a source-level breakdown before changing anything. Keep the year-end copy with your tax paperwork.
If Roth contributions are tax-free later, why would a high earner choose traditional?
A high earner often pays the highest rate now and a lower rate on income draws later. At an assumed 35% today and 25% later, each $24,500 contributed to traditional avoids $2,450 more tax than it costs back, before growth. The deduction also frees cash now for loans and young children.
Does a rollover IRA make the Roth-versus-traditional choice unsafe for my employer plan?
No, but it adds a wrinkle. A rollover IRA holds pre-tax money, which matters for Roth conversions and the backdoor Roth pro-rata rule, not for your employer plan's Roth or traditional election. Check the IRA statement before any conversion. Annex Wealth Management reviews both accounts together so one doesn't surprise the other.
Is paying tax now worth it if I expect to retire with a smaller balance?
Often not on tax grounds alone. A smaller balance means smaller income draws and probably a lower bracket, so a deduction at a high rate usually beats tax-free money later. Paying tax now makes more sense if a pension or other income will keep your retirement bracket high. Annex Wealth Management tests this against the monthly spending plan.

Primary sources

This material is general information only and does not constitute investment, tax or legal advice tailored to your circumstances. Investing involves risk, including possible loss of principal. Before acting on any information here, speak with a financial advisor, tax professional or attorney about your specific situation.

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