Back in the day, the big retirement locales for Americans were Florida and Arizona. These days, people have more exotic choices for spending their retirement years. How does Cuenca, Ecuador, or George Town, Malaysia, grab you? Or maybe Medellín, Colombia, or a region known as Panama City Beaches, Panama?

These four destinations received an overall “A” grade in the recent retirement index published by Live and Invest Overseas, an online resource for people interested in an offshore retirement.

The index identifies the top 21 retirement destinations based on 12 categories, including living expenses, health care, climate and friendliness to expats. The list spans Europe, Asia and Latin America (both South and Central America), and 17 countries (Belize, Malaysia, Panama and Thailand have two listings each).

Live and Invest Overseas publisher Kathleen Peddicord began writing about overseas retirement nearly 30 years ago as editor and publisher of International Living. “Back then, the idea of retiring overseas didn’t have much traction because why would an American want to retire anywhere but in the U.S.?” she says during a phone interview from Panama City, Panama, where she and her family live and where she runs her company, which was established in 2008. “But it’s no longer the nutty, fringy idea that it once was. Increasingly, it’s becoming a mainstream idea.”

She says the main reasons people consider relocating overseas for retirement are concerns about their living and health-care costs. “The average baby boomer at or approaching retirement is thinking seriously about the difficulty of maintaining their living standard while in retirement,” Peddicord says, noting that many investors approaching retirement saw their nest eggs damaged by the financial crash of ’08-’09. Others are worried by the rising costs of retirement communities, as well as the potential for escalating medical expenses.

“Baby boomers are the healthiest retirement generation ever, and they’re thinking about how to support themselves for 20 to 30 years,” she says. “They’re also the best educated and most traveled, so they’re more open to the idea [of retiring abroad].”

According to Live and Invest Overseas, the three most affordable international places for retirement are Cebu, the Philippines; Chiang Mai, Thailand; and Cuenca, Ecuador. This trio also topped the list for best health care. Cuenca and Medellín were also noted for having the best climate. In addition, Cuenca, which is recognized for its colonial architecture, cultural vibe and good food, ranks third behind Ambergris Caye, Belize, and Boquete, Panama, as the friendliest places for expats.

Finding cheap digs for retirement is one thing, but finding a place with good health care is another. “We tell people that depending upon your age and health, you might want to stick with a major population center where you’ll find acceptable health care, especially in Latin America and Asia,” Peddicord says. “In Europe, health care can be U.S. quality, even in tiny villages like in France.”

The Languedoc region in Southern France makes the Live and Invest Overseas list of the 21 best places for retirement.

An overseas retirement might be an adventure at first, but eventually a lot of people miss home. “That happens with a certain percentage of people,” Peddicord says. “As you get older, you remember your roots and want to be more in touch with your family and where you came from.”

She adds that the ideal situation for many overseas retirees who yearn to re-establish a U.S. presence is to divide their time between the U.S. and overseas.

That is, if they can afford it.